Healthcare services face vast challenges that will increase in the years to come, partly due to demographic changes including ageing populations [
1,
2]. Welfare technology is viewed as one important means to meet these challenges. Implementation of digital night surveillance technologies in nursing homes and home care services has emerged as a potentially efficient way of meeting the need for monitoring persons for healthcare and safety reasons. This is an alternative to calling in on, for example, patients with dementia or intellectual disabilities, and potentially waking them up at night. However, the application and use of digital surveillance technologies in the care for vulnerable individuals generates considerable ethical debate [
3‐
5]. Implementation of welfare technology also implies innovation and organizational change, which is often met by different kinds of resistance. Resistance can be found on individual, organizational, and institutional levels, and these levels are often inter-connected [
6‐
8]. This paper explores if and how resistance occurs on different levels in the initial phase of digital surveillance technology implementation in municipal nursing homes and home care services.
Implementation of innovation
Innovation has been defined as “the intentional introduction and application within a role, group, or organization, of ideas, processes, products or procedures, new to the relevant unit of adoption, designed to significantly benefit the individual, the group, or wider society” [
9,
10]. This definition has become widely accepted among researchers [
11,
12]. It captures many aspects of the innovation process under study, as it aims at implementing new technologies and developing new ways of working in order to benefit the individual service user and the healthcare organization. Implementation is seen as one of the four stages of innovation: dissemination, adoption, implementation and continuation [
13]. The implementation stage is according to Rogers “that which occurs when an individual puts an innovation into use” ([
14]:474).
Implementation of technology initiates a change process and has the potential to alter the way we work, how we organize work and the power relations in an organization. However, a large number of change initiatives fail due to unfocused and insecure management and lack of systematic project management [
15,
16] or are slow to be implemented (e.g. [
17‐
19]). The implementation phase is increasingly becoming a phase where the technology developers and the customers cooperate closely, and in the business literature it is coined as co-development of the product [
20] or co-creation of value [
21]. The concept of co-creation implies close and continuous interaction in the implementation phase between the innovators and developers of the technology and the customers. The technology developers may lack knowledge about the market and the users, while customers often also lack familiarity of technological language and technology proficiency. In the implementation phase of, for example, welfare technology, several knowledge spheres or epistemic cultures meet [
22].
Resistance to technology implementation
Resistance is inherent to organizational life [
23,
24], and the literature on resistance stretches across several disciplines [
25]. According to a recent review of research on resistance to healthcare information technologies, resistance is under-researched and multifaceted, and relatively little attention has been paid in understanding it [
26]. Resistance to change has mainly been seen as an effort to maintain status quo and research has traditionally seen resistance as a negative force that must be overcome [
23], and as a restraining force “that leads employees away from supporting changes proposed by managers” [27:784]. Resistance to technology implementation is ‘expected’ and can be seen as the flip side of success factors for innovation which has been emphasized in research on technology implementation in the Information Systems (IS) field (see for instance [
26,
28]).
Change processes like the implementation of technology are met by several types of resistance. Resistance is found at individual, organizational and institutional levels [
6‐
8], and these levels are inter-connected. Previous research has for instance shown that traditional organizational constellations may change as a result of technology implementation [
29,
30]. Increased use of technology may change the work pattern, the division of labour and the interaction pattern. Previous research also indicates that the implementation is complicated by a lack of training and lack of interest from employees [
31,
32].
Within the IS field, research on resistance concentrates on the negative paradigm, focusing on subordinates' unwillingness to implement decisions made by the management [
33,
34]. Resistance occurs if threats are perceived from the interaction between the object of resistance and initial conditions [
33]. Resistance creates friction, which has negative connotations and may complicate the implementation process. Friction is however also an antecedent to change [
35]. As the implementation process proceeds, the users are likely to make moderations to the set of initial conditions or the subject of resistance, based on their experience with the technology. Hence the nature of the resistance will change through the implementation process [
33], and resistance is not considered as purely harmful. A further example is the notion of productive resistance [
23]. Productive resistance builds on the notion of resistance as a way of coproducing change and “refers to those forms of protest that develop outside of institutional channels” [23:801].
In this study, we investigate how resisters think, how they understand their own resistance and what resisters do “rather than seeing resistance as fixed opposition between irreconcilable adversaries” [23:801]. This resistance behaviour is categorized by Coetsee [
36] as apathy, passive resistance, active resistance and aggressive resistance.
Resistance to technology implementation in healthcare
Resistance to increased use of technology in healthcare is still considered to be under-researched [
26,
29]. Lluch states in a review article on health information technologies (HIT) that “more information is needed regarding organizational change, incentives, liability issues, end-users’ HIT competences and skills, structure and work process issues involved in realizing the benefits from HIT” [31:849].
Furthermore, the healthcare field is not
one field, and healthcare technology consists of a wide range of technology. Within the healthcare field, hospitals have often been the preferred empirical setting (see for example [
33,
37,
38]), and physicians are the preferred actors under study (see for example [
18,
37]). The municipal healthcare setting differs from that of a hospital, especially due to the organizational and structural elements of the municipality itself. The municipality is more complex and consists of several organizations, weakly tied and embedded in the larger municipal organization. Still, the levels and the various actors and units within the greater municipal organization are linked through the tasks and the users of the services. Further, the focus on patients’ interests in healthcare in general and concerning the increased use of technology, in particular, has led to focus on the groups who need to collaborate in order to implement technology [
39].
Based on their studies of the implementation of information technology (IT) in hospital settings, Lapointe and Rivard [
33] identified five basic components of resistance: Resistance behaviours (from passive uncooperative to aggressive), the object of resistance (the content of what is being resisted), perceived threats (negative consequences that are expected implications of the change), initial conditions (such as established distributions of power or established routines) and finally the subject of resistance (the entity, individual or group, that adopts resistance behaviours). They propose a dynamic explanation for resistance to the implementation of technology. The resistance behaviours result from the nature of perceived threats on various points in the implementation process. Depending on what triggers the resistance behaviours, new threats and consequently, new resistance behaviour emerges. The perceived threats and the resistance behaviour can be found at an individual and group level. In this article, we recognize the five basic components of resistance identified by Lapointe and Rivard, and define resistance descriptively as behaviours (attitudes, acts and omissions) that obstruct or interfere with the process of co-creation and organizational change.
The case of Digital Night Surveillance
The innovation project at hand is called “Digital Night Surveillance”, which is a government funded project where five municipalities, both rural and urban, work with a network of technology developers to develop and implement the use of sensors and digital communication in nursing homes and home care services.
The project entailed service development and technology development in a co-creation process [
21,
40] within a triple-helix inspired network [
41], consisting of (1) a network of small- and medium-size technology enterprises (SMEs), (2) municipal health and care services, and (3) a university research group [
42]. The overall aim was to develop and implement the best possible solution to the challenges of night surveillance, in order to enhance security and quality of care for the service users within the municipalities’ limited resources [
29,
43]. The co-creation and implementation process was facilitated by a professional manager or “orchestrator” [
42].
The technology to be implemented included sensors on doors and in electronic security blankets (on mattresses) used during the night. A web-based portal facilitated communication via traditional PCs as well as mobile devices, such as tablet computers and smartphones. Most of the municipal services already had some welfare technology installed, such as alarm systems. The novelty of the new system was tied to the web-based portal into which different technological applications could be connected and administered. In this way, technology in different categories and from different producers could function together and be programmed and adjusted to the individual patients’ needs. Alterations could be made based on for instance variations in needs during the day or due to the progression of a disease. An alarm went off when an incident happened. The system was programmed to send alarm messages to dedicated personnel, and they received the alarm on either a smartphone, pad or PC, or a combination of these. They ‘signed out’ the alarm as they checked on the patient.
The implementation project involved a large number of stakeholders, and the study of resistance involved exploring some of these. Data in this study comes mainly from the healthcare providers on the night shift, managers on various levels in the municipalities and healthcare institutions, and the technology developers, who also installed the equipment and trained the healthcare providers. Furthermore, the following stakeholders were involved and/or affected by the project: IT service staff, patients and families.
The home care services and the nursing homes included in the project had primary users in need of night supervision. The residents of the nursing homes suffered from dementia, and tended to get up at night and wander around, which has been described as one of the most challenging behaviours to manage [
44]. Night surveillance in one form or another (face-to-face or technology based) was necessary to detect “night wanderers” and guide them back to bed in order to avoid confusion and anxiety, avoid the risk of falling and injuries, and protect other residents from being disturbed and frightened at night. In the Digital Night Surveillance project, sensors in blankets and on doors detected and sent a signal if the patient left the room. The patients did not actively use the technology; rather the users were the healthcare providers.
The participating municipalities identified a need for innovation in order to ensure safety at night for the service users. Then entered into a contract with a network orchestrator, a network of technological SMEs and a science centre for health and technology in a university, in order to run an implementation project, which included both municipal home care services and nursing homes. The initiative came from the empirical field itself.