This study explored hospital staffs’ perceptions of using an EFS program to engage patients in their nutrition care. Three themes emerged from interview data: 1) Enacting patient participation in practice; 2) Optimising nutrition care; and 3) Considerations for implementing an EFS program in practice. Staff generally expressed positive views of the program and spoke about how it could contribute to better nutrition care and enable patient participation. Most staff described a hands-on approach to nutrition care, especially nurses. Staff promoted patient participation in their practice and liked the idea of using the EFS to involve patients in care. Importantly, staff discussed a number of considerations for implementing the program in practice; perspectives that will be invaluable to the design of the program itself and its implementation and evaluation strategies. These findings will also be useful for others looking to develop and implement patient participatory HIT in the hospital setting.
Technology for patient participation in care
The patient-centred EFS program evaluated in this study has a strong focus on engaging patients in their own care, which is becoming inherent in many HIT programs now and into the future. As such, the program was seen by staff to facilitate participation in several ways, many of which aligned with the dimensions of patient participation as identified in a concept analysis [
28]. Staff thought the program could improve information access and management, for both patients and for staff providing nutrition care. Information sharing, that is, a meaningful exchange of information and knowledge between patient and HCP is one of the four dimensions of patient participation [
28]. The EFS program was seen to improve patients’ knowledge and awareness of nutrition by providing access to information such as their personal nutritional needs, intake and dietary options. For staff, access to patient-specific information could help plan care and was a medium for education. A realist review of studies using technology to engage hospitalised patients in their care found that technology-based interventions employed this strategy (i.e. information and knowledge exchange) through information sharing, assessment and feedback, and tailored education [
7].
Another dimension of participation is active mutual engagement in intellectual and/or physical activities [
28]. In this study, dietitians spoke about engaging patients in intellectual activities such as educating them about their nutritional needs vs. intake (goal setting) and nurses spoke about physically helping patients use the EFS to engage in the program. Patients often require the support of staff when engaging with technology-based interventions, and they wish to maintain relationships with HCPs in using them [
12]. That is, patients do not want technology to replace HCPs, but prefer it as a tool to support staff in providing care [
7].
A third dimension, that is surrendering of some power or control by HCPs is required to enable participation [
28]. Interestingly in this study, some staff were less willing to surrender control of certain tasks (MST and intake tracking) than others. Staff spoke about giving patients responsibilities in their current practice (such as keeping their own fluid balance or food charts), but some were hesitant to pledge control to patients over tasks within a system that was not yet implemented.
Finally, a trusting, mutual and respectful relationship between patient and HCP an important dimension of participation [
28]. In this study staff spoke about knowing their patient, building trust, and empowering and supporting them to participate. They discussed how patients relied on them when they were unable to participate, and how understanding their patient allowed them to tailor activities to accommodate for differing abilities to participate.
Technology-based decision aids
The EFS program could also be seen as a decision aid for both patients and HCPs, to promote participation. That is, it is a tool that can be used to facilitate informed and shared decision-making between patients and practitioners [
34]. The information provided by the EFS program can be used by HCPs to plan care and enable patients to understand more about their nutrition whilst in hospital. The proposed goal-setting function can be used by patients and HCPs together, to provide information and options about potential avenues for nutrition care. Studies have found that decision aid systems providing advice for both patients and HCPs are more likely to be successful [
35].
A Cochrane review found that compared with standard care, decision aids resulted in improved knowledge, more accurate risk perceptions and lower decisional conflict among patients; more patients choosing options aligning with their values; and less patients being passive in decision making [
36]. These benefits are reflected in staff perceptions of the EFS program in the current study. Staff believed the program may improve patients’ knowledge, awareness and perceived importance about nutrition, which could help them make decisions about what to order or eat. This was seen to allow patients to be more active and in control of the nutrition they received, in order to improve health outcomes.
Uptake of new technologies
Staff were generally very accepting of the EFS as a means of involving patients in their care, and welcomed its adoption for various reasons. Uptake of new innovations is complex, and several theories are used to understand how and why new technologies are (or are not) adopted in practice. According to Rogers, the uptake of new innovations can depend on characteristics of the innovation, individual adopters and the organisation [
37]. In this study, staff perspectives were particularly focused on characteristics of the EFS program.
Rogers suggests relative advantage, low complexity, compatibility, observability and trialability of new innovations are likely to influence their adoption [
37]. When discussing how the program could be implemented in practice, staff in this study highlighted the importance of it being easy to use (low complexity/ease of use) and linking in with existing electronic systems in the hospital (compatibility). They spoke about being able to use a tailored, individualised approach when engaging patients with the EFS, as ‘every patient is different’ (trialability). Finally, staff thought they would be able to see the impact the program had on their nutrition care practices through the benefits outlined above (observability). An interpretive review of 13 systematic reviews of issues surrounding HIT implementation in health organisations also found that the majority of end-users are accepting of technology, and successful uptake depended on characteristics of the technology itself, social aspects and organisational factors [
38]. Characteristics of technologies were consistent with the current study and included usefulness and relative advantage over existing practices, ease of use, compatibility with existing systems and processes, demonstrable benefits and adaptability [
38].
Similarly, the Technology Acceptance Model postulates perceived usefulness and ease of use affect adoption of new technologies [
39]. A systematic review of factors influencing HCPs’ adoption of HIT concluded perceived usefulness/benefits was the most common facilitating factor, followed by perceived ease of use [
40]. Others reporting staff perceptions of clinical information systems found perceived ease of use and usefulness impacted on staff attitudes, satisfaction and behavioural intention towards systems [
41,
42]. In our study, staff found the EFS program acceptable when they saw benefits to using it; for example, they thought it could reduce time and paperwork, improve information access and management, and enable patient participation in care. That is, they perceived the program to be superior to current nutrition-related practices (relative advantage/usefulness).
Staff frequently spoke about how they thought the EFS program could be implemented into routine practice. Their perspectives aligned with Normalisation Process Theory, which is used to understand how new technologies are integrated into systems to become usual or ‘normal’ practice [
43]. The theory consists of four main constructs (coherence, cognitive participation, collective action, reflexive monitoring), each with a number of components. Interestingly, staff were fairly optimistic about the program and focused on overcoming barriers and facilitating implementation. Staff made sense of the program (coherence) by considering how using it would differ from current practice (differentiation); by describing their own specific tasks, roles and responsibilities in operationalising it (individual specification) and how the multidisciplinary team should work together to achieve success (communal specification); and by recognising the value, benefits and importance of the program to patients and staff providing nutrition care (internalisation). Nurses were forward in accepting responsibility for a number of tasks and saw many benefits to using the EFS program in their practice. Throughout interviews, staff displayed cognitive participation in the program; they ‘bought into it’ as they thought it was acceptable (enrolment), discussed responsibilities for leading/driving it (initiation), expressed how they would contribute personally (legitimation) and described the actions needed to sustain its use in practice (activation). Staff also gave in-depth explanations of the operational work needed to enact practices relating to its implementation (collective action). They spoke about the interactional work between staff, the EFS and nutritional practices that would be needed to operationalise the system in routine care, as well as allocation of tasks and resources. Reflexive monitoring was not applicable as the program was not yet implemented. Other studies have also found constructs of Normalisation Process Theory explain why nutritional [
44] or technology-based [
45] innovations were (or were not) successfully adopted into routine practice.
Interestingly, some of the concerns and benefits of the EFS program staff perceived in the current study are comparable to previous research [
46,
47]. A systematic review of HCPs’ perceptions of engaging patients in care using electronic portals found that in prospective studies (i.e. when portals had not yet been implemented), HCPs were concerned with the accuracy of patient-entered data, the potential increase in workload, and the liability and roles around tracking and acting on clinical information in the system [
46]. However, the review found that in retrospective studies, these concerns were not justified and in fact portals were perceived by patients and staff to be very useful [
46]. In our study, staff raised the same concerns. However, despite this being a prospective study exploring staffs’ perceptions of a program not yet implemented, staff were overwhelmingly accepting of the program. Any issues or barriers were outweighed by perceived benefits and were seen as manageable, with staff suggesting ways to facilitate the program’s implementation and use. The benefits of the EFS program staff perceived were comparable with another study on staffs’ perceptions on the use of electronic dietary assessment tools in primary care [
47]. In that study, staff thought patient-generated dietary intake monitoring would increase patients’ awareness of what they were eating and motivate them to improve their dietary habits [
47], consistent with staff perceptions in our study. Staff in both studies also perceived electronic dietary assessment tools would be more efficient, would improve the quality and quantity of dietary information available to HCPs, and would enable them to provide individually tailored education [
47].
Limitations
While there are a number of strengths to this study such as sampling a wide variety of hospital staff and undertaking a rigorous analytic process, it has several limitations. This was a relatively small study of 19 staff from one hospital in Queensland, Australia on their views of an EFS program. Whilst staffs’ perceptions are specific to this particular EFS program, which is not currently widely available, the findings may be important for the future (when it does become available) and may have applicability for the use of technology-based interventions to engage patients in care more broadly. It is possible that some views were not represented in our sample, however we used purposive sampling to improve generalisability and continued data collection until saturation was reached, which may have increased the relevance of our findings for other similar settings. Finally, nurses’ views emerged most strongly from the data, which may reflect the larger sample of nurses (n = 10), but may also be due to the active approach they expressed in providing nutrition care.