Development of the theoretical framework
The study aims at investigating the acceptability of the innovative technology INTERCheckWEB, in case of drugs interaction decisions. This study proposed a theoretical framework that includes the Technology Acceptance Model – TAM2 core constructs, useful for predicting the individual's acceptance of ITs, including social and cognitive instrumental factors [24-25].
TAM 2 model was considered because of both its successful use in the healthcare setting, and its parsimony and strong explanatory power [26-28].
Since no evidence on actual use for the innovative technology are registered, in the clinical routine activities, the only intention to use variable was assessed.
Coherently with these premises, the study addressed the following research question: “Which are the key factors determining the intention to use INTERCheckWEB, for clinicians in the clinical practice?”
The deep investigation about the above research question requires the analysis of different independent variables, and their relationship with the acceptability of the innovative technology, measured by the clinicians’ intention to use, thus considering the factors suggested by TAM2: perceived usefulness, perceived ease of use, image and output quality.
Based on these arguments, the following hypotheses were, accordingly, developed.
Perceived usefulness could be defined as "the degree to which a person believes that using a particular system would enhance his or her job performance” .
The perceived usefulness of INTERCheckWEB is related to the clinician’s effort to improve daily activities, and to the proper use of the tool itself, intended as the simplicity of the operation, aiming at the best quality and safety, for the patient [24, 25, 29]. It emerged a direct and positive relationship between the clinicians’ belief of a good use-performance trade-off and a higher perceived usefulness: the greater the instrument perceived usefulness, the greater the clinician's willingness to accept the introduction of INTERCheckWEB in the daily activities.
- HP1: Perceived usefulness has a positive impact on INTERCheckWEB intention to use.
Perceived ease of use
Perceived ease of use could be defined as “the level a person believes that using a specific innovative technology would be free of effort” . The perceived ease of use influences the innovation adoption. The ease of use is also influenced by the complexity and compatibility of the innovative system, compared with the current situation [23, 24].
In particular, the greater the simplicity of INTERCheckWEB, the greater the perceived ease of use, the greater the willingness of the clinician to accept this instrument.
- HP2: Perceived ease of use has a positive impact on INTERCheckWEB intention to use.
Image could be defined as “the degree to which the use of an innovation is perceived to enhance a person’s status in a social system” . If an innovative technology is strongly recommended by the healthcare organization and the clinician does not embrace this innovation, its image would be negatively compromised. On the other hand, the acceptance of technology and the perceived ease of use of the system would modify the behavior of the clinician, having a positive impact on his image [25, 29]. In this view, the image of the clinician will be improved as much as the use of INTERCheckWEB is welcome by third parties.
- HP3: Image has a positive impact on INTERCheckWEB intention to use.
Quality output focuses on the fact that, the information, could be clearer and more detailed, encouraging the clinician to accept its introduction. The strength of the tool is to provide the clinicians with high-quality information, identifying the best way to manage the individuals and organizational aspects of the process. Flexibility is the aspect that best summarizes the tool characteristics, and it is expected to strongly encourage the clinicians to adopt this technology . The greater the flexibility of INTERCheckWEB, meant as the ability of the system to provide information for each investigated element, the greater the quality of the requested output, therefore, the propensity of the clinician to use this instrument.
- HP4: Quality output has a positive impact on INTERCheckWEB intention to use.
Despite the direct relationships between the above-mentioned independent variables and INTERCheckWEB intention to use, the proposed framework also includes two moderator variables (voluntary use and experience).
Voluntary use is related to people perceptions. In an environment workplace, the employees’ resort to tools because they are influenced by the circumstances . The matter, hereby investigated, is the clinicians’ willingness to break down the traditional barriers that may impede the innovation acceptance . Thus, the clinician is more likely to use INTERCheckWEB if the willingness to overcome traditional barriers is higher.
- HP5: Voluntary use positively moderates the relationship between perceived usefulness and INTERCheckWEB intention to use.
Perceived usefulness and intention to use innovative ITs could be higher with increasing experience over time. Furthermore, as individuals gained direct experience with a system, they relied less on social information in defining perceived usefulness. However, they continued to judge a system’s usefulness, based on potential status benefits, resulting from its use .
Based on the above, the following hypotheses were developed.
- HP6: Experience positively moderates the relationship between perceived usefulness and INTERCheckWEB intention to use.
- HP7: Experience positively moderates the relationship between image and INTERCheckWEB intention to use.
A synthesis of the research framework is proposed in the following Figure 1.
For a more comprehensive framework, a set of control variables was investigated: i) clinician age; ii) clinician working experience; iii) IT attitude (in terms of clinician’s attitude to use ITs), and iv) IT skills, in terms of clinicians’ capability to use digital instruments.
A study design composed of the following three phases was conducted.
1. Adaptation of the existing scales for a specific healthcare sector questionnaire.
The questionnaire aimed at gathering clinicians’ perceptions with regard to their intention to use the innovative software Intercheckweb, based on specific factors proved to affect this variable. In this view, the questionnaire derived from TAM 2 model, considered all the scales previously published and validated by literature evidence [24-25]. All the scales useful to test the hypotheses concerning the users’ acceptability to be supported by personal computers and software, have been selected because of their validation in previous literature, in the healthcare services delivery setting [24-25].
The above questionnaire, based on validated English scales, was translated in the Italian language, in order to avoid comprehension concerns (please see Supplementary File 1).
Before administering the questionnaire, a draft was reviewed by five experts, to verify the coherence and the comprehensibility of the document, especially in the adaptation of some sentences, from other sectors, to the healthcare one.
An Exploratory Factor Analysis (EFA) was carried out, to establish if changes introduced in the adaptation process for healthcare sector had affected the structure of the scales. All the items presenting a factor loading higher than 0.3 were included in the definition variables, because of the maximisation of each construct variance, along one dimension. Furthermore, to assure the reliability of the constructs, the assessment of Cronbach’s alpha was implemented. A value greater than 0.7 was assumed, to test items and create the new variables, useful to verify the study hypotheses .
2. Data collection in Italian hospitals wards
The sample of the study was composed by head physicians and hospital clinical managers of second level (N=70) referring to the Internal Medicine wards, of four Italian medium size hospitals.
In June 2019, all the professionals involved in the study completed the questionnaire previously defined, through an interview conducted by a trained interviewer. Besides the personal information related to each respondent (professional role, age, seniority and working experience), the questionnaire was composed by a qualitative section in which a 7-item Likert scale was implemented. In particular, the interview process aimed at getting the clinicians’ insight concerning their intention to use INTERCheckWEB and the independent/moderator/control variables previously described that are perceived usefulness, perceived ease of use, image, quality output, voluntary use, as well as IT skills and attitude, as previously described.
3. Data analysis
Data derived from the questionnaire were first analysed considering descriptive statistics, frequencies and distributions. Preliminary analyses were performed to ensure no violation of the assumptions of normality, linearity and homoscedasticity.
Furthermore, inferential analyses were conducted.
- Relationships between the variables were investigated, to test the existence of correlations among them. In particular, the “person product-moment” correlation coefficient was assessed, to test the existence of small (from 0.10 to 0.29), medium (from 0.3 to 0.49), or large (from 0.5 to 1) correlations among variables .
- A final investigation of the relationship among the variables, using a hierarchical sequential linear regression model (with enter methodology), was implemented to test the hypotheses, useful in order to establish the impacts of independent variables, and moderators respectively. In particular, the Adjusted R2 was examined, in order to control the explanatory power of each model . This approach allows testing the hypotheses, through incremental models, in order to establish the specific impact of each single input variable, on the dependent variable. The option “exclude case pairwise” was implemented, because was the preferable methodology, for a small sample and avoiding any kind of data exclusion. Three different models were developed, thus defining the influence of the different variables (control, independent and moderator variables), on the dependent variable.
- Model 1: Model composed of only the control variables (clinicians’ age, clinicians’ working experience, clinicians’ IT skills, clinicians’ IT attitude).
- Model 2: Model composed of Model 1, with the inclusion of the independent variables (perceived usefulness, perceived ease of use, image and output quality).
- Model 3: Model composed of Model 1 and Model 2, with the inclusion of the moderator variables (moderator effect of voluntary use and experience).
All the statistical analyses were performed using the Statistical Package for Social Science (IBM SPSS Statistics Viewer - Version 25).