Co-creating digital transformation in care of older persons: A longitudinal mixed-methods study

Abstract

Norwegian authorities emphasize use of welfare technology in order to meet the increasing demand for healthcare services to the population of older persons. Implementation of welfare technology is considered beneficial to increase the quality of municipal care services, support the independence of persons receiving care services and improve the care providers’ workflow. However, welfare technologies challenge established workflows and competence, as well as perceptions of good care. Furthermore, recommended implementation strategies such as co-creation of services and outcome measurements such as benefit - and value realization represent novelties in the care services. Digital transformation of the care services thus calls for innovative approaches, as well as research. This thesis had a longitudinal mixed-methods design, and explored and evaluated implementation of digital monitoring services based on welfare technologies that promoted safety in municipal residential care facilities. The thesis belonged to a person-centred healthcare PhD program, and theories on innovation, implementation, co-creation, resistance and networks guided the research. Three sub-studies were included, presented by four research papers. In the first sub-study, paper 1 aimed to identify and describe forms of resistance that emerged during the first year (2013-2014) of the digital monitoring implementation in five residential care facilities. Paper 2 aimed to identify the facilitators and barriers during the full four-year (2013-2017) implementation of digital monitoring in eight residential care facilities, and to explore co-creation as implementation strategy and practice. Both were longitudinal qualitative case studies where we observed and elicited the experiences of care providers, healthcare managers and vendors. Paper 2 also included managers and staff in information technology (IT) support services. Data analyses in paper 2 started with a deductive analysis based on a determinants of innovation framework, and both papers included inductive content analysis of interviews, process- and observation data. Four main categories of resistance could be identified in paper 1: Organizational, cultural, technological and ethical. Each included several subcategories, which emerged as the participants perceived threats to stability and predictability in their workflow; to their role and group identity; and to their basic healthcare values. The resistance was primarily subtle, and changed over time. IT infrastructure and –support was identified as the most prominent resisting factor. Importantly, resistance contributed as a productive force during co-creation processes. Paper 2 identified five categories of facilitators and barriers: Pre-implementation preparations, implementation strategy, technology stability and usability, building competence and organisational learning, and service transformation and quality management. Each category encompassed several subcategories that affected the early-, mid and late phases of the implementation to varying degrees. The implementation resulted in a sustained digital monitoring service in all the residential care facilities, indicating success. The co-creation methodology was in itself identified as the most prominent facilitator. The reluctance of the IT support service to contribute in the co-creation activities, in combination with persistent IT infrastructure instability, was the principle barrier. In the second sub-study, paper 3 aimed to describe how a measurement instrument for determinants of innovation could be contextually adapted to evaluate welfare technology implementation in municipal care services. We performed an iterative evaluation of our adaptations of the instrument (questionnaire) during 2013-2019 and identified the chronological order of the most relevant informants and settings to adapt and verify the instrument. We described the operationalization of items detailing the 29 instrument determinants and linked the determinants to a sequence of welfare technology implementation strategies used in municipal care services. In the third sub-study, paper 4 aimed to evaluate facilitators for and barriers to implementation of wireless nurse call systems as measured by the adapted determinant instrument. Paper 4 had a quantitative cross-sectional descriptive design and we collected questionnaire data from care providers (n=98) during the first year of wireless nurse call system implementations in five residential care facilities (2017-2019). The greatest facilitators were the normative belief of unit managers and the care providers’ perceptions of the nurse call systems contributing to prompter call responses and increased safety for residents and families. The care providers’ lack of prior knowledge, and how they initially found the systems difficult to learn, constituted the most prominent barriers, rapidly solved through training and skill acquisition. The major finding of the thesis is that digital transformation in the form of successful implementation of digital monitoring is a complex, resource intensive and time-consuming process in municipal residential care facilities, and more so when it represents radical innovation with respect to technology novelty, disruption of care relationships and workflows, moral values, and the need for competency. All the implementations studied were successful in establishing new services that are still sustained, even though the implementations represented a high degree of complexity. Alignment of actors and agencies’ self-efficacy, their trust in the technology, and in other actors’ competence and support represented a tipping-point in the implementation processes, where the resistance decreased and safe, person-centred practices were established. Co-creation had a strong facilitating effect on resource-integration between actors, as well as on the development of competency and new workflows. However, both the implementations and co-creation represented novelty and depended on facilitation. The findings point to the importance of how the implementation of digital monitoring was conceptualized; as a straightforward “just do it” process, or as a complex and innovative endeavor. The thesis contributed with substantial empirical evidence for digital monitoring implementations, including resistance, co-creation, facilitators and barriers, implementation strategies, complexity, conceptualization of digital monitoring implementation, and development of competency, capacity and capability for digital monitoring in residential care facilities. Further, it contributed methodologically with detailed descriptions of co-creation practices for dual implementation and research projects, as well as an adapted version of a measurement instrument for determinants of innovation for welfare technology implementation. Clinical implications are in line with the major findings: Digital monitoring implementation will be safer if conceptualized as digital transformation, rather than incremental change. The implementations benefit from good planning and persistent management focus. The prior level of digital competency among care managers and care providers needs to be addressed appropriately. Practical training and co-creation processes facilitate implementation efforts and contribute to competence building and an implementation climate characterized by benevolence. The measurement instrument offers valuable means to evaluate welfare technology implementation. Moreover, digital transformation of care services challenges the current silo organization of municipal IT support services. This is ultimately a threat to patient safety and will need to change over time. More research is needed into patients’ perspectives, safety aspects and organizational capacity building as more welfare technologies are introduced into the care services, either as new entities or as new parts and functionalities expanding such innovative digital systems as described in this thesis. A compilation of welfare technology implementation strategies has been suggested, and more research is needed into the differentiation and cause effect relationship between barriers, facilitators, implementation strategies, intermediate implementation outcomes and long term service- and patient outcomes, in order to realize benefits and a sustainable digital care service. Keywords: co-creation, digital transformation, welfare technology, digital monitoring, innovation, implementation, facilitators, barriers, service design, residential care, patient safety, competency building, resource integration, ethical resistance, complexity