Background
Digital monitoring has become an increasingly important application among the health information technologies (IT) in long-term care, such as residential care facilities for persons with dementia [
1,
2]. Implementation of monitoring technologies potentially reduces staff burdens and enhances safety, increases resident freedom and prevents elopements and wandering behaviour in persons with dementia [
3‐
9]. This includes persons referred to as night wanderers. Sleep disturbances and wandering upon awakenings in combination with night-time agitation pose severe challenges in caring for these persons [
10‐
12].
The research literature provides recommendations as to how implementation of monitoring technologies can be facilitated (e.g. [
4,
13,
14]). However, many healthcare professionals (HCPs) and service organisations are reluctant to introduce such technologies [
2,
15]. There are multiple causes for this reluctance, including ethical considerations, fear that technology will cause attenuation of the care relationship, lack of appropriate infrastructure, and a general lack of knowledge and skills in relation to digital health [
3,
16‐
21]. In a recent literature review, Granja et al. [
22] found quality of healthcare to be the major facilitator and shortage of finance the major barrier in the implementation of eHealth interventions, including monitoring technologies. The intervention’s influence on existing workflow was the single most important factor to predict success or failure. There is a need for further identification of facilitators and barriers to ensure that all factors are considered when defining the development and implementation strategy of specific eHealth interventions [
22].
Intelligent assistive technologies (IATs) [
23] are monitoring technologies with computation capability and the ability to communicate information through a network. These are complex technologies that require new skill sets and perspectives, and their development must be responsive to the needs of their users and simultaneously be commercially viable [
24]. A high number of the more recently introduced IATs lack clinical validation; i.e. technical feasibility and usability have predominately been tested through simulations [
15]. Therefore, study designs involving multiple stakeholders in technology development processes are recommended [
4,
16,
24,
25]. New technologies transform services, including contexts, service provision and experiences with respect to organisations, employees and users. Therefore, there is a need for research into service innovation by leveraging service design and understanding value creation in this context [
26]. These are time-consuming processes, but most implementation studies report retrospectively from early phases and there are few innovations studies in the field that cover long periods of time [
27].
The current article is a longitudinal case study of the implementation of digital monitoring technology over a four-year period. The article explores the barriers and facilitators during the implementation and the strategic role of co-creation processes to overcome resistance, improve functionality and ensure quality of care. In a previous article from the first year of these processes, four main forms of resistance to the implementation were identified: i.e. organisational, cultural, technological and ethical resistance [
20]. Resistance was triggered by perceived threats to stability and predictability, role and group identities and basic healthcare values.
Conceptual framework: innovation and implementation through co-creation
Innovation in health service delivery and organisation has been defined as “a novel set of behaviors, routines, and ways of working that are directed at improving health outcomes, administrative efficiency, cost effectiveness, or users’ experience and that are implemented by planned and coordinated actions” [
28]. This definition captures many aspects of the innovation processes under study, as novel technologies and new ways of working were developed and implemented to benefit service users and healthcare organisations. Service innovations are usually categorised according to the degree of change, type of change, novelty and means of provision [
29]. Most innovations in the public sector are incremental, but still disruptive, i.e. they are changes that potentially cause improvement [
27,
30]. Radical innovations usually refer to products, such as breakthrough technologies, that their intended users perceive as novel, disruptive and hard to adopt, disturbing prevailing habits and behaviour [
31]. Radical innovations rely on a series of incremental innovations to be fitted into a system or context in a form that is acceptable to the intended users [
32]. Regarding the type of change, discussions of product and process innovations are predominant in the literature. Other types include position, strategic, governance and rhetorical innovation [
30].
The innovation process is traditionally described by the stages of dissemination, adoption, implementation and continuation [
33]. The transformative nature underpins the need for learning and development of new knowledge as an organisation implements an innovation e.g. [
27,
28]. The more radical the innovation, the more necessary it is to teach the users how to adopt and use it [
34]. The organisation’s absorptive capacity includes capabilities for problem solving and learning new knowledge generated externally, as well as technological infrastructure, leadership, internal knowledge sharing and relational capability [
35‐
37]. The absorptive capacity builds cumulatively on the existing base of skills and knowledge [
27,
35], including tacit knowledge [
38]. Absorptive capacity is an antecedent and strong predictor for innovation and knowledge transfer [
28,
37].
Implementation of innovative technology within complex organisational systems, such as healthcare, involves various cycles of iteration as technological, social and organisational dimensions gradually align (or not) over time [
18]. Interacting influences known as determinants of innovations [
39] and determinants of healthcare professional practice [
40] contribute to the multidimensionality of the innovation process, and enable or prevent the improvement, or change, in the specific context or practice. Information about such barriers and facilitators is useful for controlling the implementation strategy and a determinant of innovation framework helps to focus this study on the essential processes of behavioural change, which are complex in clinical settings [
41,
42].
The triple-helix model [
43] is an innovation strategy where public sector organisations, private sector companies and academia collaborate and co-create. This strategy allows its intended users to be involved in design and development processes of products, processes and services, and involvement is likely to improve adoption and post-implementation satisfaction [
28,
44]. Resources can be accessed from other actors through absorption, acquisition, sharing and resource co-creation [
45].
Co-creation is an interaction where actors jointly produce a mutually valued outcome based on assessments of the risks and benefits of proposed courses of action and decisions based on dialogue, access to information and transparency [
46]. Cutting through a broad variety of concepts and theories regarding co-creation [
47‐
52], its central elements include defining and creating value through iterative processes including value propositions, resource integration and learning processes. Public sector services are suitable for co-creation because they are discreet and intangible, focusing on the users consuming the service as it is produced or delivered [
53]. Traditionally, the value-creation process is said to occur as the user consumes or uses a product or service [
54]. According to Oertzen et al. [
49], co-creation in services “manifests itself in different forms depending on the phases of the service process (co-ideation, co-valuation, co-design, co-test, co-launch, co-production and co-consumption) and is influenced by a contextual, multi-actor network”. Co-creation includes creative collaboration connected to design processes as well as the usage or delivery of a service [
55]. Actively involving intended users through participatory design processes has traditionally been emphasised in IT design [
56]. Service design processes aim to develop services that are useful, usable and desirable from the service users’ perspective [
57]. Service design applies to all parts of a service, including planning and organising people, infrastructure, communication and material components [
55].
Methods
Aim and study design
The overall aims of this article are a) to identify facilitators and barriers, and b) to explore co-creation practices as an innovation strategy during four years of implementation of a digital monitoring technology in long-term residential care for persons with dementia who were night wanderers. The study had a longitudinal case study design [
58] with elements of transformational action research [
59]. Action research elements included researcher participation in the project design and planning activities, participation in and facilitation of knowledge-sharing and reflection processes during workshops and meetings, and presentation of preliminary research findings to the steering group and during workshops, which informed the iterative innovation activities.
The case: a digital night surveillance intervention
The present study is based on the Digital Night Surveillance Innovation Project, which was a combined innovation and research project initiated by a triple-helix-inspired network that developed digital technologies for municipal healthcare services. Between 2009 and 2012, vendors from a small-sized enterprise had developed a distributed IAT system, i.e. the digital monitoring technology system used in this study, which potentially offered increased safety for persons with dementia who were night wanderers. To access the immature market of municipal healthcare organisations, the vendors organised a project for implementation utilising public sector-sponsored incentive programs to minimise economic risk for the municipalities. Based on their access to funding, the vendors and three municipalities initiated the implementation in 2013, and successively recruited more partners and established a formal consortium of eight municipalities and two technology companies for the main project from 2014 to 2017. A group of nine researchers from two universities, including the authors of this paper, participated in the consortium.
The implementation strategy encompassed a variety of co-creation activities combining human-centred and service designs, as well as participatory design methodologies. Workshops constituted a major arena for co-creation during the implementation, as detailed below. An orchestrator managed the implementation project in co-operation with a project group comprised of the local project managers and vendors. Within the municipalities, local politicians made formal decisions to enter the project based on preparations by municipal top management. The organisational units of adoption, one per municipality, were dementia care wards in nursing homes within the municipal healthcare organisations. Healthcare workers and registered nurses, i.e. care providers, working on the night shift were anticipated to be the main group of users to adopt the monitoring technology.
Sixty-seven installations of the monitoring technology system were implemented. The system consisted of an Internet-based portal built on a platform solution that included novel Internet-of-Things (IOT) middleware, which could handle and unify data from multiple hardware protocols and allowed integration of e.g. bed-exit or door sensors from different manufacturers. Thus, the system offered a unique feature where the care providers could operate multiple technologies simultaneously via a personal computer (PC), tablet or smartphone of their choice. A short message service (SMS)-mediated alarm alerted care providers when predefined scenarios occurred, such as a resident leaving their bed. The portal allowed adjustments of settings at any time to match the needs, behaviour and progression of dementia of individual residents, including the sequence and timing of input from a variety of sensors. No other monitoring technology systems available on the market at the time offered these affordances. Upon installation, the final stages of designing user interfaces on the applications and operating systems chosen by each municipality, as well as integration of suitable sensor technology, would take place. The monitoring technology was in compliance with regulations of data protection and privacy, as well as the legal framework for monitoring persons with dementia using sensors. According to the Norwegian Patients Rights’ Act, municipal health and care services may decide on the use of technology for notification and localization as part of services to patients over the age of 18 who do not have capacity to consent. The measure must prevent or limit the risk of injury to the patient, be in reasonable proportion to the relevant risk and appear to be the least invasive option. It should be likely that the patient would have given permission for the measure. The provision does not apply if the patient opposes the measure.
Participants and data
Data collection took place between June 2013 and September 2018. The data included 23 interviews, strategic documents, participatory observations and process data from seven workshops, as well as observations of local training sessions and numerous meetings. The meetings were steering group meetings, project group meetings, local staff meetings, information meetings for residents and relatives, meetings between vendors and single municipalities, and meetings between IT and healthcare services. Data was not collected in care settings, and not from residents or relatives. All participants in research settings consented to participation in the research study. The study complied with the tenets of the Declaration of Helsinki.
Workshops
Data from workshops were collected between November 2014 and September 2016. The workshops (not including the final dissemination seminar) were attended by participants (n = 172) from municipal healthcare service staff (n = 89) and IT service staff (n = 8), vendors (n = 30), research institutions (n = 14), non-governmental organisations (n = 3), other public sector organisations (n = 5), innovation and funding agencies (n = 20) and external experts (n = 3).
The orchestrator and researchers facilitated workshops, where the researchers and other experts initially would introduce a theme predetermined by the project group. Then all participants engaged in co-creational activities related to the theme and thus contributed to the progress of the implementation. The researchers documented the results of such activities and made them available to the participants in a reasonable time. In addition, the vendors and the local project managers presented updates during workshops and the researchers presented preliminary research results. There were opportunities for generating and prioritising ideas, discussions and exchanges of experiences. The workshops usually lasted for two days, from lunch to lunch, with a social event during the evening. Workshop locations were close to the participating municipalities and one took place in Sweden in co-operation with a corresponding triple-helix network.
Interviews
The sample consisted of 21 individual interviews (
n = 16) and two focus group interviews, i.e. one with HCPs (
n = 9) and one with the vendors (
n = 4) (Table
1). Fifteen interviews were performed between August 2013 and April 2016, and informants were interviewed up to three times. Individual interviews were performed at a place of the informants’ choice, normally at their workplace. The focus group interviews took place in co-creation activity settings. The interviews started with a “grand tour” question (around the table if in a focus group) to elicit the informants’ perception of the implementation and their own participation in the project. Two main topics were then discussed with the informants: i.e. if any need for new competence had emerged and how it had been dealt with; and if there had been changes to the job situation or organisation of HCPs. The interviews were semi-structured, recorded and transcribed verbatim. Please c.f. Nilsen et al. [
20] for the interview guide. Purposeful selection assured inclusion of informants representing the enterprises (
n = 4) as well as the initial three municipalities (n
1 = 6, n
2 = 5 and n
3 = 6) that participated throughout the entire project period from 2013 to 2017. As a validation of information regarding the municipal planning and preparation process, JD interviewed the orchestrator, three local project managers and two vendors over the phone in April–September 2018. These interviews lasted for 10 to 45 min and were documented by notes.
Table 1
Overview of interviews and informant characteristics
1 | x | x | | | RN | 2 | |
2 | x | | | | RN | 2 | |
3 | x | | | | RN | 2 | |
4 | | x | | | RN | 1 | 1 |
5 | | x | | | RN | 2 | |
6 | | x | | | RN | 1 | 1 |
7 | x | | x | | RN | 2 | 1 |
8 | | | x | x | RN | | 1 |
9 | | | x | x | RN | 1 | |
10 | | | x | x | HCW | 1 | 1 |
11 | | | x | x | HCW | 1 | 1 |
12 | | | | x | HCW | 1 | |
13 | | | | x | RN | | 1 |
14 | | | | x | RN | 1 | |
15 | | | | x | RN | | 1 |
16 | | | | x | RN | | 1 |
17 | | | | | T | 1 | 1 |
18 | | | | | T | 1 | 1 |
19 | | | | | T | | 1 |
20 | | | | | T | | 1 |
21 | | | | | IT | 1 | |
22 | | | | | O | 1 | |
Data analyses
Data from qualitative interviews were analysed by content analysis [
60], followed by an inductive phenomenological hermeneutical analysis inspired by Lindseth and Norberg [
61]. The first step consisted of deductive qualitative analysis and mapping of the transcribed interviews [
60] against the constructs in the measurement instrument for determinants of innovation (MIDI) framework [
62]. JD and HE did the analysis. The MIDI framework [
62] encompasses the innovation process and strategy, and captures four broad categories of essential determinants, as evaluated by healthcare professionals, who are considered to be the adopting users during the implementation of innovations in larger healthcare organisations. The category associated with the innovation includes determinants such as correctness, complexity and compatibility. The adopting user category encompasses benefits, professional obligations, knowledge and perceived satisfaction of patients. The category for organisational attributes includes determinants such as management involvement, staff capacity, resources, and information and performance feedback. Legislation and regulations constitute the final socio-political category.
The second step consisted of an inductive analysis of the same material by putting the MIDI framework in parenthesis to grasp the essence of the meanings of the informants’ expressions of their experiences of the innovation processes. JD and TE performed several iterations of the inductive exploration, the latter without any knowledge of the results of step 1. The aim was to group facilitators and barriers into themes. JD performed the initial inductive coding and then condensed the data excerpts. The data were complex; therefore, physical organising and structuring was needed. Thus, the data excerpts were printed and cut into separate units. JD and TE sorted and reorganised the data and this analysis resulted in the main structure of themes.
In the third and final step, observational data, process data and strategic documents were examined to enrich the exploration of processes that were found to be essential during implementation. Therefore, the data from interviews, observations and text analysis were integrated. Utilising a phenomenological hermeneutical approach [
61], JD and TE interpreted the data excerpts in an iterative manner by reading and critiquing each other’s texts. We abstracted the data to form subcategories in the form of facilitators and barriers. The subcategories were then further condensed into categories and reviewed in a timeline perspective. JD, TE, HE and EN contributed in finalising the themes, categories and timeline.
Threats to validity were met by co-operating within the research team in all phases of the research project, which ensured open discussion and deep knowledge of the context. The reliability of the study was strengthened through researcher triangulation. A further layer of discussion and reflexivity about the data and their interpretation with consortium members complemented the interdisciplinary reflections and discussions. Detailed descriptions of the research approach were included to meet threats to reliability.
Discussion
This article aims to identify facilitators and barriers, and explore co-creation practices as an innovation strategy during a four-year implementation of digital monitoring technology in long-term residential care for persons with dementia who are night wanderers. The study shows that the implementation of monitoring technology in nursing homes implies radical innovation and digital transformation. The main finding – which is not previously identified – is that the complex process of digital transformation of healthcare services can be successfully facilitated by recognizing the inherent slowness of radical change and by applying co-creation methodology across roles and professions. This will be discussed in the following.
Factors that proved to facilitate the implementation when completed or impede the implementation when not completed can be categorised as: 1) Pre-implementation preparations; 2) Implementation strategy; 3) Technology stability and usability; 4) Building competence and organisational learning; and 5) Service transformation and quality management. The co-creational methodology was the most prominent facilitator and the combination of IT infrastructure instability and the reluctance of the IT support service to contribute in the co-creation of values was the most persistent barrier throughout the implementation. In combination with the project initiation followed by the pre-implementation activities, identification of three phases during implementation is in line with the five-stage model of innovation processes in organisations proposed by Rogers [
33].
The foundation for digital transformation
The implementation represented a radical and transformative innovation process in contrast to the incremental changes that all levels of management and the IT and healthcare services were prepared for. The political decision to kick-start a digital transformation of the healthcare services by implementing monitoring technology in nursing homes formed the foundation for radical innovation. The decision was in itself a strategic innovation in line with Hartley’s [
30] description of long-term perspectives for restructuring responsibilities between the public care sector, the population and the private sector. The municipal managements’ initiative to enter a project with a set timeframe and a formal consortium based on the triple-helix network structure was essential. The interactions within the consortium added value to the implementation processes almost regardless of settings, participants and activities, which supports the proposition by Sørensen and Torfing [
63], i.e. cross-disciplinary collaboration enriches the generation, selection and implementation of ideas, in addition to the dissemination of new practices.
Co-producing radically new technology
The monitoring technology fulfilled the three criteria defining technological radicalness according to Dahlin and Behrens [
64], i.e. novelty, uniqueness and impact on future inventions and practices, as well as the definition proposed by Chandy and Tellis [
65], which includes incorporation of substantially different technology that can fulfil key customer needs better than existing products. In contrast to most technological innovations that reconfigure known technologies [
66], this system was unique because it included novel IOT middleware that allowed one application to operate a variety of technologies based on different technical protocols. The care providers had experience with and could easily manage some of the sensor technologies in line with the findings of Hall et al. [
4], whereas smartphones had not yet been adopted by the majority of intended users.
Norman and Verganti [
32] suggested that advances in technology and change in the meaning of existing products instead of human-centred design drove radical product innovation. In this case, the vendors had entered a not-yet-existing market, which can be considered as position innovation [
30] and relied on close interaction with the care providers, that took the position as the lead users [
67] of the novel technology. The vendors developed deep knowledge of the services, residents and care providers through dialogue, translation and co-creation, thus minimising the potential clash described by Coiera [
68] between anticipations forming the basis for software coding and the real clinical practices. These final stages of the product innovation [
30] represented a paradox. The adaptability of the technology was found attractive by the care providers and managers and is considered a promoting factor in implementation [
27,
69,
70], whereas the lack of completeness, which truly frustrated the care providers, is a known barrier [
39] that had to be overcome. The vendors aligned their processes with those of the care services (i.e. their customers) through the co-creation activities [
52] and actively planned, tested, prototyped and implemented value co-creation opportunities. The gap in competence and difference in terminology between vendors and care providers was dealt with by translation by project managers and co-creational methodology as visualisation and prototyping, in line with the recommendations by Ünsal et al. [
71]. Furthermore, the vendors explored potential technological solutions and then presented a moderate number of options, which enabled the managers, project managers and care providers to make decisions, as discussed by Bratteteig and Wagner [
56].
Knowledge conversion as a mediator for service innovations
Care providers acquired skills and adopted routines that initially were perceived as incompatible and inconsistent with existing workflows. This breach is traditionally considered to be a major barrier to implementation [
22,
39]. In contrast to the incremental improvements of existing practices, most of the service and process innovations represented new ways of structuring and performing tasks and responsibilities, which supports the notion of radical innovation described by Norman and Verganti [
32]. The service design methodology engaged all actors during the workshops by offering them a voice in the co-creation processes and lending them an ear during the collective prioritisation of recommendations. Co-creation efforts included sharing experiences, integrating resources and learning, and resulted in mutual betterment [
72]. The methodology facilitated conversion of tacit knowledge to explicit knowledge through externalisation [
38], initially in the form of critiques and concerns. Little by little, the externalisation processes resulted in written material, routines and organisational learning. Organisational learning also included recognition of all the efforts and smaller tasks constantly performed without prior mentioning in written routines. This “hidden work” [
73], relied on an expert level of competence because they required a trained eye and overview to be recognised and dealt with.
Building capacities for digital transformation
The implementation brought together groups of actors with strong internal uniformity in their knowledge base, but with thick knowledge boundaries [
74] between the groups, as expressed by differences in language, interpretation and motivation. Digital transformation represented a novel domain to care providers, with a prediction that learning would be more difficult and expertise would develop incrementally [
35]. An array of strategies and practices promoted competence building that was radical in the sense that it elevated most care providers from expressing almost no technological knowledge to becoming experts in intuitively using the technology, which allowed them to focus on their residents. The first learning strategy was skill acquisition, which is in line with the model introduced by Dreyfus and Dreyfus [
75]. The care providers’ problem-solving capability developed through the high availability of support from and interaction with the vendors. Other learning strategies included access to training, supervision, practical experience over time and collective reflections, which are known to facilitate a positive implementation climate [
76]. Discontinuity in practicing newly acquired skills inhibited the development of competence, in line with the perpetual novice syndrome described by Wilson et al. [
77].
Orchestration and translation was essential for the development of absorptive capacity, including communication with external organisations, between actors in the consortium and within internal subunits [
35]. As HCPs, the middle managers are expected to be able to take key roles in the implementation [
78], with the capability to mediate between the innovation strategy and day-to-day activities, and translate and facilitate implementation processes [
77]. Their delegation of responsibility for implementation activities to project managers and professional practice advisors without delegation of authority over the nursing staff impeded the problem-solving capacity at times when it was difficult to maintain momentum during the implementation [
28]. Further, it complicated the coordination between the implementation and other organisational priorities, which is a known barrier to implementation [
18,
39]. Transformational leadership has been found to support innovation and readiness for change in residential aged care settings [
79]. From a long-term perspective, the nursing homes lost essential leadership competence related to digital transformation upon completion of the implementation because the project managers had held temporary positions and returned to the larger municipal healthcare organisations after the implementation completed.
In a co-creation of value perspective, the interaction between service systems such as the healthcare and IT services should optimally be based on a relationship that promoted integration of mutually beneficial resources [
51]. The support and services from the IT service was an integrated part of the healthcare service ecosystem [
80] because the services provided by the healthcare service (i.e. their value propositions) strongly relied on deliveries from the IT service. However, in line with traditional bureaucratic silos [
63], the established practices and routines of the IT services were to a large extent ignorant of the essential traits and needs of the healthcare services. During implementation, the IT services were reluctant to participate in co-creation activities and contribute to internal knowledge transfer [
35], which diminished the absorptive capacity of the municipal organisations that relied on their expertise. This recurrent infrastructure instability, which is a substantial barrier in implementations of e-health applications [
19,
81], impeded the implementation during all phases. The reluctance to change IT operating routines [
82] and unwillingness to solve system slowdown and downtimes, which are among the major causes for negative attitudes toward health IT among nurses [
44], compromised the provision of care and had a negative reinforcing effect. As most IT support staff did not actively involve themselves in the implementation, the nursing staff and vendors joined forces as a compensating measure. Consequently, the vendors filled the supporting role [
83] and thus contributed to a trustful implementation climate conducive to change and characterised by benevolence.
Trust, risk and safety across the colliding worlds of health and technology
Trust in the monitoring technology, the infrastructure, their colleagues and their own safe use of the technology was crucial for the care providers, which supports the concept that a trustful working environment contributes to the care providers’ basis for providing quality care [
17] and specifically to their confidence in caring for residents with dementia [
84]. Trust expresses relative security and includes the possibility for negative consequences; therefore, both trust and risk are incorporated in the decision-making [
85].
The care providers’ perception of the technology having risks for residents impeded the implementation [
86]. The reports of risky situations during implementation of IATs [
87] emphasise how the care service managers and staff are experienced risk assessors who continuously mitigated risk with promotion of the independence of persons with dementia and reduction of the care burden. To a large degree, however, the care providers and their managers did not have the competence to assess risks created by the digital monitoring technology [
88], which inhibited balancing of implementation decisions [
18] so that the technology did not impose threats to patient safety. In the early phase of implementation, their low technological competence combined with poor strategies for problem solving was a striking phenomenon, which was expressed through an inability to discriminate causes of technological malfunctions. The vendors established control measures that the nursing homes adapted as the implementation proceeded. Competence building and frequent reflections fostered a collective awareness of safety issues [
89] and supported the development of a safety culture [
90] over time.
The inherent slowness of radical change
A four-year implementation of any technology might seem excessive, and time and resources could probably have been saved if the planning and preparations had been more thorough. However, as the implementation represented radical innovation, a sequence of time-consuming strategies, such as competence building and establishing new routines through continuous co-creation, dialogue and translation, had to take place to enable the care providers to integrate the new monitoring service in their clinical practice and realise the benefits and co-create value with their residents. From a value perspective, the benefits are weighed towards the costs. Despite the barriers, individual and organisational interactions, resource integration and learning within and between the actors in the consortium steadily supported the endurance of the inherent slowness of radical change. The care providers became experienced innovators [
27] through these efforts. Towards the end of the implementation, they took calculated risks and experimented with the technology in contrast to previous reports from implementation of monitoring technology in residential care [e.g. 16].
Implications for practice
The key findings of this study can be summarised into three points representing the main facilitators of digital transformation and recommendations when planning innovation and implementation processes: a) involving key actors from the very start; b) organising for dialogue and co-creation throughout the implementation period; and c) planning for competence building and iterative improvement of technologies and clinical practices.
Further research
According to this study, both the meso and micro levels of the existing healthcare ecosystems [
91] will need to change to accommodate digital transformation by integrating IT competency and possibly also IT support into the healthcare organisation and service provision to benefit the value co-creation within the ecosystem and with service users. Future research into how this can be done is recommended. A quantitative study evaluating the benefits of the digital transformation, in terms of both cost savings and outcome measures related to the effectiveness of the system, is also recommended.
Strengths and limitations
This study covers the full duration of an implementation process involving a relatively high number of participants and technical installations. The interdisciplinary research team represents a research strength with their high levels of competence within economic and organisational studies, leadership and ethics, innovation management and healthcare professional practices in psychology and nursing. The study limitations are related to the vast material, which implies that all actors affected by the implementation were not directly involved in the data collection. The residents and their families were merely passive actors in the co-creation activities of the study and the research data involving them were primarily provided by other actors. Further, more descriptive, quantitative information related to the uptake of the technology would be useful. Because this is a case study, transferability may be difficult in other situations, although the rich descriptions of the settings and participants may enable readers to determine transferability [
92].
Contributions
This study contributes to the implementation literature by identification of factors facilitating implementation of IATs in residential care services, which can be defined as radical innovation. The longitudinal nature of the study and the close research interaction with thick descriptions of the co-creation activities and facilitating factors that developed across groups and levels of actors over time [
93] contribute to the literature on co-creation of healthcare services as well as of value in those settings. The digital transformation of healthcare services differs from other public sector organisations because of the complex governance and relationship to risk [
94]. The study contributes to the literature on risks and safety issues, which have been poorly explored in relation to assisted living technology in the care for persons with dementia [
95].
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