This is the first study to explore facilitators and barriers during the full-scale implementation of WNCSs in residential care facilities using the MIDI questionnaire. The care providers’ evaluation of the implementation identified far more facilitators than barriers. The most pronounced facilitators were identified by virtually all the care providers. The first were the expected outcomes of the WNCSs, the importance and probability of achieving shorter response time to calls and increased safety for residents and families. The second was the subjective norm, the perceived behavioural expectations, imposed on the care providers by the manager. The two greatest barriers were the care providers’ status of knowledge at the start of implementation and the difficulty to learn the WNCS. Overall, the item scores indicated that the WNCSs were well received and that the implementation strategies and processes were satisfactory. This was supported by the facilitating effects of the care providers having gained some experience with the systems, that they considered the WNCSs to be in line with their professional responsibilities, and that almost all of their colleagues used the systems as intended.
The expected and perceived facilitating effects of the WNCS outcomes related to enhanced safety, were in line with previous implementations of less advanced call systems in residential care (53). Importantly, the WNCSs were perceived as safe, not just expected to be safe. This indicated that the ethical implications of the WNCS’ design and functions corresponded well with moral values of the care providers, as found by Detweiler and Hindriks (14) and Ienca, Wangmo, Jotterand, Kressig, and Elger (54). Strong leadership combined with shared mental models among nursing staff have previously been found to be associated with prompt response to calls in hospital settings (4, 55), as well as in a geriatric evaluation facility (56). Cappelen, Harris, Storm and Aase (57) found engaged nursing managers to be role models for promoting improvements to patient safety in Norwegian nursing homes. The role taken by unit managers in combination with the safety propositions of the WNCSs found in our study, indicates that patient safety probably will be safeguarded through the use of the new system.
The managers’ level of engagement and active involvement in the implementation of WNCSs appears to be higher in this study than in previous studies of health information technology implementation in residential care facilities, which reported a lack of involvement as well as lack of systematic planning and decision-making from managers (29, 31, 32, 35). The care providers’ evaluation of the managers’ efforts supported the effect of an implementation strategy adopted by all care facilities; that the unit managers had learned to use the WNCS and taken an essential role for driving the implementation (58). The importance of their role as implementation champions is also supported by Shea and Belden (59) who found the champions to impact the implementation process, the usage behaviour and the overall success of the specific technology. Moreover, a transformational leadership style, formulating a vision for the future and building nursing staff capacities, have been found to result in higher levels of success in implementing change initiatives in residential care facilities (60). However, the determinants and moderators of middle managers’ role have not been explained (39). Our study did not aim to investigate managers’ motivation, but the choice of implementation strategies as well as the results of the survey indicate that the managers were motivated. However, it is not conclusive as to whether the full-scale scope of the implementation involving all residents and nursing staff, a general increased interest in digital transformation, or perceived regulatory requirements as reported by Bezboruah, Paulson, and Smith (29), motivated the managers to be a driving force in the implementation process.
Rapid competence building
The two most prominent barriers occurred at the outset of the implementation and were related to competence. This was not surprising, as there are discrepancies between care providers’ health technology proficiency as compared to the expectancies of the Norwegian government (61). Competence was evaluated with respect to knowledge, skills, learning strategies and implementation strategies. Even though the WNCSs were perceived as difficult to learn and the prior level of knowledge was somewhat low, the care providers rated themselves and their colleagues as competent users of the WNCS within the first year of implementation. The ability to acquire and maintain clinical competency is the result of both personal factors as well as contributing factors in the work environment (62). Within the window of time from the outset of the implementation until the survey was undertaken, the care providers had gained experience from using the WNCS devices. Most of them had acquired skills and increased their knowledge about the WNCSs through structured training-sessions, which is a recommended implementation strategy (35, 53, 63). They could easily understand instructions given by their manager and communicate about the WNCS and the implementation. Once training had been provided, there seemed to be less need for further instructions than previously reported from similar settings (29, 31). Bearing in mind that a cross-sectional study can not establish causality (64), implementation strategies involving training and support most likely contributed to these outcomes and the rapid change in competence. Learning during implementations in residential care has been found to be a process of making connections between new knowledge and skills, and existing knowledge and practices (37). In our study, the care providers’ smart phone application skills in fact facilitated the implementation. This was partly due to the learning strategies they applied, such as self-training and gaining experience from using the system over time. Personal knowledge and skills from using smart phones in their private lives probably further contributed to the rapid and successful uptake of smart phones and applications (65), since 95% of the Norwegian population (aged 9-79) have access to a smart phone (66).
Full-scale implementation with tiny innovative steps
Although the mobile transceivers worn by the residents and the smartphones operated by the care providers represented new technology in the residential care settings, the tasks and routines implied by the WNCSs were much in line with the workflows known from previous call systems. The strategic decision initially to implement well known call system functionalities in full-scale and await the more complex functionalities was likely significant for the facilitating effects of the expected outcomes, ethical implications and competence building. Knowledge of and adherence to routines is fundamental to maintain patient safety (67), and the WNCSs were perceived not only to maintain, but to enhance patient safety. Such a connection between actions and outcomes has been found to further stimulate the learning process (37). Thus, the organizational readiness seemed aligned with the challenges imposed during the implementation along the four dimensions proposed by Holt, Helfrich (68): appropriateness, managerial support, self-efficacy and personal valence. In our study, the WNCS was perceived as appropriate for the RCF by the care providers; they found the managers to be supportive; they became confident about their self-efficacy; and, they found the WNCS personally beneficial. In contrast, technology implementations that simultaneously challenge care providers’ knowledge, values and workflows have been found to rely on resource intensive service innovations, compromising patient safety and predicting time consuming competence building and implementation processes (30, 31). According to Bezboruah, Paulson, and Smith (29) most nursing homes do not realize the full potential benefits that implemented health IT systems offer. It remains unknown if the RCFs will utilize all the WNCS features procured.
Implications for practice
This study has presented implementation strategies and WNCS functionalities, which seem to contribute to successful implementation, although not without complications. The importance of motivating managers was underscored, as was the impact of managers as role models with the ability to prepare the care unit for the implementation. The barriers identified in this study stress the urgency of providing equipment and material resources in due time, and offer training in the practical handling of the technology at the outset of the implementation. Nearly two out of five participants found it difficult to understand instructions provided by the vendors, which calls for specific attention to communication and information exchange between professions and groups involved in innovative implementations. This is in line with previous reports of differences in language and culture between technologists and care providers (32).
For alarms to be effective, they must be part of a much more comprehensive care plan for each resident (9). Some of the new digital functionalities offered by the WNCSs potentially expand and enrich the quality of care by allowing the care provider to remain focused on the residents, but may also have negative implications (1, 32, 69). The more complex technologies that presumably disrupt established workflows and challenge existing patterns of interdependence among individuals or groups, will be more demanding to implement (70) and potentially pose new threats to patient safety. The ECRI institute (71) recently introduced missed alarms resulting from inappropriately configured secondary notification devices and systems on their Top 10 Health Technology Hazards, and further research on patient safety issues is needed as more of the novel WNCS-functionalities are introduced into clinical practice.
The care providers’ perceptions of the technology enhancing safety is likely to contribute to the residents’ feeling of increased safety (72). This study did not include residents, and research on residents and families’ perspectives related to WNCSs should be undertaken.
Strengths and limitations
This study contributes to the knowledge of full-scale implementation of WNCS. The research is however limited to the first phase of the full-scale implementation, as the RCFs implemented WNCS-functionalities that primarily supported established workflows and planned to implement new and more advanced functionalities over time.
The questionnaire applied took the perspective of the care provider, meaning that the perspectives of the administration and management, the support agencies, the vendors, as well as residents and families are not reported.
A large proportion (19.4%) of the respondents were WNCS super users, who had received more extensive training, which represents a bias.
The response rate to the questionnaire was low, which may have given a bias of the measures of outcome. Hence, we have not made comparisons between professional groups or the RCFs regarding the MIDI scores, but have reported from the entire group of participants. We do not know whether the characteristics of non-responders would differ from responders.
The current study was conducted within the first year of WNCS implementation. We were not able to investigate whether the time from the outset of implementation to the administration of the survey (e.g. 0-3 months, 4-6 months, 7-9 months, or 10-12 months) affected the results. Further, we were not able to contrast how the two conceptualisations of WNCS implementation, as an upgrade or as digital transformative processes, affected the implementations.