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RESEARCH ARTICLE Open Access

Exploring resistance to implementation of welfare technology in municipal healthcare services – a longitudinal case study Etty R. Nilsen1*, Janne Dugstad2, Hilde Eide2, Monika Knudsen Gullslett2 and Tom Eide2

Abstract

Background: Industrialized and welfare societies are faced with vast challenges in the field of healthcare in the years to come. New technological opportunities and implementation of welfare technology through co-creation are considered part of the solution to this challenge. Resistance to new technology and resistance to change is, however, assumed to rise from employees, care receivers and next of kin. The purpose of this article is to identify and describe forms of resistance that emerged in five municipalities during a technology implementation project as part of the care for older people.

Methods: This is a longitudinal, single-embedded case study with elements of action research, following an implementation of welfare technology in the municipal healthcare services. Participants included staff from the municipalities, a network of technology developers and a group of researchers. Data from interviews, focus groups and participatory observation were analysed.

Results: Resistance to co-creation and implementation was found in all groups of stakeholders, mirroring the complexity of the municipal context. Four main forms of resistance were identified: 1) organizational resistance, 2) cultural resistance, 3) technological resistance and 4) ethical resistance, each including several subforms. The resistance emerges from a variety of perceived threats, partly parallel to, partly across the four main forms of resistance, such as a) threats to stability and predictability (fear of change), b) threats to role and group identity (fear of losing power or control) and c) threats to basic healthcare values (fear of losing moral or professional integrity).

Conclusion: The study refines the categorization of resistance to the implementation of welfare technology in healthcare settings. It identifies resistance categories, how resistance changes over time and suggests that resistance may play a productive role when the implementation is organized as a co-creation process. This indicates that the importance of organizational translation between professional cultures should not be underestimated, and supports research indicating that focus on co-initiation in the initial phase of implementation projects may help prevent different forms of resistance in complex co-creation processes.

Keywords: Ethical resistance, Welfare technology, Innovation, Co-creation, Municipal healthcare

* Correspondence: [email protected] 1The Science Centre Health and Technology, School of Business, University College of Southeast Norway, Postboks 235, N-3603 Kongsberg, Norway Full list of author information is available at the end of the article

© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Nilsen et al. BMC Health Services Research (2016) 16:657 DOI 10.1186/s12913-016-1913-5

Background 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 chal- lenges. Implementation of digital night surveillance tech- nologies 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 vul- nerable 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 imple- mentation in municipal nursing homes and home care services.

Implementation of innovation Innovation has been defined as “the intentional introduc- tion 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 tech- nologies 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, implemen- tation and continuation [13]. The implementation stage is according to Rogers “that which occurs when an individ- ual 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 technol- ogy proficiency. In the implementation phase of, for ex- ample, 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 disci- plines [25]. According to a recent review of research on resistance to healthcare information technologies, resist- ance 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 constel- lations may change as a result of technology implementa- tion [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 imple- mentation 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' un- willingness to implement decisions made by the manage- ment [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 imple- mentation 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 re- sistance [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].

Nilsen et al. BMC Health Services Research (2016) 16:657 Page 2 of 14

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 re- sistance behaviour is categorized by Coetsee [36] as ap- athy, 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 technolo- gies (HIT) that “more information is needed regarding organizational change, incentives, liability issues, end-users’ HIT competences and skills, structure and work process is- sues 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 technol- ogy. 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 set- ting 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 infor-

mation technology (IT) in hospital settings, Lapointe and Rivard [33] identified five basic components of resistance: Resistance behaviours (from passive uncooperative to ag- gressive), 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 be- haviours). They propose a dynamic explanation for resist- ance 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 net- work 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 technol-

ogy development in a co-creation process [21, 40] within a triple-helix inspired network [41], consisting of (1) a net- work 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 de- velop and implement the best possible solution to the challenges of night surveillance, in order to enhance se- curity 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 profes- sional manager or “orchestrator” [42]. The technology to be implemented included sensors

on doors and in electronic security blankets (on mat- tresses) used during the night. A web-based portal facili- tated communication via traditional PCs as well as mobile devices, such as tablet computers and smartphones. Most of the municipal services already had some welfare tech- nology 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 cat- egories and from different producers could function to- gether 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 ex- ploring 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 insti- tutions, 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.

Nilsen et al. BMC Health Services Research (2016) 16:657 Page 3 of 14

The home care services and the nursing homes in- cluded 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 wan- der around, which has been described as one of the most challenging behaviours to manage [44]. Night surveil- lance 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 pa- tient 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 ser- vice users. Then entered into a contract with a network orchestrator, a network of technological SMEs and a sci- ence 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.

Methods Aim and study design The aim of this study was to explore resistance to imple- mentation of welfare technology in five municipalities in

Norway. The design was explorative and draws on a lon- gitudinal single-embedded case study [45] with elements of action research. The study was carried out during 2013 and 2014. A case study is suitable for an explorative, in-depth

study of contemporary events in its real-life context [45]. The case was a project, organized with sub-projects in each of the municipalities, with a local project manager on site. The research took a multi-stakeholder perspective as both the technology developers in the business net- work, who also install the technology and train the health- care providers, and the healthcare providers, on various levels of the homecare services and nursing homes, were included in the study. The healthcare providers are the ac- tual users of the technology and are defined as the users in our study. The study does not include data from the end-users. Three main action research elements were applied: 1)

researcher participation in the project design and planning activities, 2) researcher participation in (and by occasion also facilitation of) knowledge sharing and reflection processes during workshops and meetings, including presentation of preliminary research findings, and 3) using focus group interviews not only to collect data but also to stimulate critical reflection on the co-creation and imple- mentation process [46, 47]. Table 1 gives an overview of the longitudinal design,

the timeline, the technology, the users and the data col- lection methods.

Table 1 Design and data collection methods – an overview

Stake-holders Technology Research activities

Q3 2013 Q4 2013 Q1 2014 Q2 2014

Municipality 1 Sensor technology Alarm system Web-based portal Installations: 8

EP WS PO FG

WS PO II

WS PO

WS PO

Municipality 2 Sensor technology Alarm system Web-based portal Installations: 11

EP WS PO FG

WS PO II

WS II PO

WS PO

Municipality 3 Sensor technology Alarm system Web-based portal Installations: 9

EP WS PO FG

WS PO II

WS PO

WS PO

Municipality 4 Sensor technology Alarm system Web-based portal Installations: 4

EP WS PO

WS PO

WS PO

Municipality 5 Sensor technology Alarm system Web-based portal Installations: 2

EP WS PO

WS PO

WS PO

Suppliers FG WS

WS FG WS

WS

Participants in each workshop 24 33 17 32

Abbreviations: EP Entered the project, II Individual interviews; FG Focus group interviews; PO: Participatory observation; WS Workshops

Nilsen et al. BMC Health Services Research (2016) 16:657 Page 4 of 14

Data collected The main sources of qualitative data were semi-structured interviews, both individual and focus group interviews, and observations in workshops and meetings. Altogether, data were collected through nine individual interviews, three focus group interviews and observations on site and in four workshops. In all, about 50 individuals (including the five researchers) took part in the workshops and meet- ings. The researchers facilitated some of the workshops in order to stimulate co-creation and the production of process data. Twenty-one individuals were interviewed, both healthcare providers (from all five municipalities) and technology developers. All interviewed informants participated in two or more of the workshops. Some of the participants in the focus groups were also interviewed in-depth individually. All participants consented to partici- pation in the research study. The selection of informants from the municipalities

for the individual interviews was aided by the project managers. The inclusion criteria were employees work- ing as either project manager, middle manager or night healthcare provider. Eight women and one man were interviewed in the period from September 2013 to November 2014. Four technology developers, all male, participated in a focus group interview in January 2014. The focus group method was in line with the methodology used in the project itself, which used the workshops as an arena for orchestrated interaction, collective reflection, knowledge sharing and innovation of services [42], thereby the interviews were an arena for co-creation in themselves [48]. The in-depth interviews followed a semi-structured interview guide (Additional file 1) [49, 50] and were car- ried out as conversations. An interview guide was used as a checklist at the end of the interview to ensure that all planned topics were included. The first two focus group interviews with healthcare providers from three of the mu- nicipalities were performed as part of a workshop ar- ranged early in the implementation phase, and were conducted by four of the researchers. The third focus group interview was conducted by two of the researchers with central representatives from the network of technol- ogy companies. The focus group interviews were con- ducted face-to-face and lasted for about 90 min each. Both the in-depth interviews and the focus group interview were digitally recorded and transcribed verbatim.

Data analysis Data from the interviews and observations were analysed and interpreted as inspired by Kvale’s description of the bricolage approach to data analysis [49]. Analysing data based on bricolage involves the use of various tech- niques and concepts during the process. We also used researcher triangulation [51], which meant that the whole research team with members from various fields such as

organization and innovation studies, sociology, psych- ology, nursing, healthcare research and ethics, took part in the analysis and interpretation process. The main reason for choosing a researcher triangulation approach was the need for different perspectives to understand the complexity of the innovation and co-creation process, involving five different municipalities, including differ- ent professional roles, service designs, IT systems, and local decision-making procedures. As a first step, following the description of analysis by

Kvale and Brinkmann [49], the transcribed texts from the interviews were systematically read through in a naïve manner. A reflexive, open-minded and inductive reading was pursued, as well as grasping the intuitive meaning of the text as a whole and to interpret the participants’ ex- perience and descriptions of the implementation of wel- fare technology. The themes in the analysis arose in an iterative process between reading and interpreting by sev- eral researchers, in order to find meaningful units and then themes according to the research question [49, 52]. Threats to validity were met by cooperating within the

research team in all phases of the research project, which ensured an open discussion as well as deep knowledge of the context. The reliability of the study was strengthened through researcher triangulation and continuous contact with the network. Threats to reliability have further been met by describing the research approach in detail.

Results At the outset, there were few signs of resistance among the participants. As the process moved on, various forms of resistant behaviour emerged, from scepticism of the usefulness and the functionality and safety of the tech- nology, to both passive and more active uncooperative attitudes towards the change of initial conditions, such as established routines, practices and technological infra- structure. The perceived threats were often communicated indirectly, and not always easy to identify, but in many cases, they were associated with technological instability, feelings of uncertainty and concerns for the quality of care. Resistance was found in different groups of participants and on different levels of the municipal organization. Four categories of resistance with several subcategories were identified, as laid out in Table 2. In the following, the findings will be presented in more

detail and exemplified, starting with organizational issues.

Organizational resistance Resistance to change in established routines The surveillance technology was primarily introduced on the night shift, and only the night shift personnel were trained to use it. Usually, the employees worked ei- ther only night shifts or only day/evening shifts, and there was only brief contact between the shifts. The use of the

Nilsen et al. BMC Health Services Research (2016) 16:657 Page 5 of 14

technology appeared to demand a closer cooperation be- tween the shifts. For instance, there was a need for the evening shift to prepare the technology while the patients were still awake. A night shift worker said: “We need to have good cooperation with them, so that the mattresses are placed correctly in the evening and that they are switched on the way they are supposed to.” Another night shift worker put it this way:

The day shift must make sure that things work, do things well, so that I can do a good job. I cannot ask the patients to wake up and get out of bed so that I can check that everything is OK in bed. That would be stupid.

The needs for adjusted routines and better communi- cation and cooperation between day/evening and night shifts were soon recognized. However, both project man- agers and healthcare personnel experienced a lack of interest and support from the responsible middle man- agers and unit leaders or ward nurses. As one of the pro- ject managers answered when asked whether the unit leader had taken an active role in the project: “No, she has barely participated and does not take the role. And she feels it is fine that I have that role”. This lack of managerial interest and omission to make

the necessary adjustments to established routines (which was beyond the authority of the project leaders) may be interpreted as a passive form of organizational resistance to change, which interfered with, and to some degree obstructed, the process of co-creation and implementation.

Resistance to necessary competence building The day shift did not receive any training in how to pre- pare and use the technology, and would hear about the project only through information in staff meetings. The need for training of the day shift personnel was soon

recognized by the project leaders and the other partici- pants, but the responsible unit leaders did not arrange for such. The lack of interest from the management in competence building across shifts resulted in a poor un- derstanding of the project and the technology on the part of the day shift. One of the personnel working night shift declared:

I feel that they do not understand any of this. It is a «night-shift-thing». (…) and I do not think they follow up, because it is never talked about. So I hoped we could have a more thorough conversation about this, not just two minutes in the staff meeting.

Systemic resistance to communication across groups and professions In addition to the lack of communication and cooperation between shifts, a more general issue emerged concerning communication, knowledge transfer and organizational learning. Communication channels across organizational levels, units and groups of professions within the complex municipal system were scarce. Those involved in the implementation of the surveillance technology lacked sufficient information about, for example, potential risks. Accordingly, this was an issue in workshops and inter-municipal meetings. However, not everybody in- volved could attend the workshops, and some groups – such as the cleaning staff – were not thought of as having a role in the implementation process. An example of an unforeseen risk, which proved to be a problem, was that cleaning personnel – not being sufficiently informed – on occasions moved electronic plugs and equipment in order to clean behind desks and in the corners. Breaking the electrical circuit might have the effect that sensors or communication devices shut down, and the error had to be detected before the system could be made functional again. The lack of communication channels across groups, levels and professions may represent an organizational re- sistance that made it difficult to prepare for unexpected errors that might obstruct or interfere with a successful implementation and use. During the workshops, it became clear that the procedures and written instructions had to include more groups than initially thought of.

Management resistance to participatory processes Little by little it became clear that neither the steering group nor the responsible municipal leaders or their central IT support departments had taken sufficient measures to ensure that the necessary infrastructure was in place to serve the participating homecare units and nursing homes. It appeared that the municipalities’ IT support departments had not been included in the initial phase of the project. This was in spite of the …

RESEARCH ARTICLE

Applications of artificial neural networks in

health care organizational decision-making: A

scoping review

Nida ShahidID 1,2*, Tim Rappon1, Whitney Berta1

1 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada, 2 Toronto

Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto,

Canada

* [email protected]

Abstract

Health care organizations are leveraging machine-learning techniques, such as artificial

neural networks (ANN), to improve delivery of care at a reduced cost. Applications of ANN

to diagnosis are well-known; however, ANN are increasingly used to inform health care

management decisions. We provide a seminal review of the applications of ANN to health

care organizational decision-making. We screened 3,397 articles from six databases with

coverage of Health Administration, Computer Science and Business Administration. We

extracted study characteristics, aim, methodology and context (including level of analysis)

from 80 articles meeting inclusion criteria. Articles were published from 1

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