In the analysis of the empirical material, we identified two overarching themes that were linked to our research question: 1) demands and solutions and 2) two sides of autonomy.
Theme 1: Demands and solutions
Demands and solutions are an overarching theme that encompasses several aspects. It consists of three subthemes.
Greater demands
All informants described an increased demand for municipal care services, driven by a growing number of elderly citizens with more severe health conditions. They noted that recipients of public services are in poorer health compared to previous years. One informant explained that current homecare services require more advanced care than before, as patients are referred to hospitals later and are discharged in a more vulnerable state. The overall picture presented by the informants is one of a significantly more challenging situation, with homecare services facing a sharp increase in responsibilities and tasks. This shift—from less vulnerable to more fragile patients, from lower to higher expectations, and from basic to advanced care—represents a profound transformation in municipal care services.
To some degree, family members take part in this transformation. One informant described her experiences with family members who, very soon after homecare is approved, expect that the care and the entire responsibility are passed on to the municipality. Several of the informants also found the patients much more demanding than before and that relatives and the patient herself are more aware of patients’ rights, have higher expectations, and are more likely to expect the health sector to meet patients’ social needs in addition to medical and caring needs. However, technology is not always the solution family members ask for. Some of the informants have experienced that relatives think that technology is at odds with good care, believing that healthcare personnel’s physical presence provides the best care:
“If we suggest technology, the response from relatives is often: No, they should rather have a visit. And you have to go and see [the patient], just go and check on them”. (Head of Unit A, municipality A).
According to the informant, relatives prefer physical presence. Relatives do not formulate the added value of visits compared to using technology in exact terms. However, they seem to want care that includes more than purely medical aspects. Alternatively, they do not trust the technology. Healthcare personnel, on the other hand, think that technology can work as an alternative to physical presence.
A need for action
Informants, including personnel who worked with clients, described that due to the lack of resources they “have to do something” to handle all the patients and to help everyone who needs care. Technology is a part of this “something”. One municipal manager expressed that healthcare workers think they “have no choice” and “no alternatives”, while other managers argued that they “cannot not” use welfare technology as it is unavoidable in the sense of being a safe and labour-efficient way of offering services. In addition, many informants described welfare technology as a good way of improving the quality of the services regardless of whether it saves costs:
“The gains are not necessarily limited to reduced costs, that is, saving money, it is also quality. When it comes to pill dispensers and medication, I think it is a quality for the patient to get medicine at the right time and feel that he/she can cope.” (High level Manager, municipality B).
“Other examples of quality improvements are when technologies can be used to avoid disturbances, for example by replacing nocturnal visits where there is a risk of waking the patient” (Advisor, municipality A).
A gain in the form of increased quality made managers positive about technology, but they found financial gains more difficult to specify and realise:
“And then you think that technology should solve and help us with scarce resources – to solve some tasks. But it is also difficult to realise that advantage and think you should save or cut employees. We don’t necessarily do that” (Deputy manager, municipality A)
The sense that technology is essential because of the demanding situation and its potential to improve the quality of services leads managers to appreciate technology even if the concrete gains are difficult to determine.
Formal implementation and practice
Most managers from the administrative level of the municipalities embraced welfare technology to a large degree and they did not question the use of technology in general. Technologies like pill dispensers and personal security alarms were seen as a highly needed and necessary part of the services, and unit managers described that they continually worked to implement technology in their units. All three municipalities explicitly promoted the use of welfare technology in their strategy plans and the benefits of welfare technology were broadly shared among the municipal managers. Informants from the healthcare units were informed of the welfare technology strategies of their municipalities and acknowledged that technology is an important part of providing homecare services.
However, technology suppliers expressed that welfare technology is not helpful for everyone and that limitations exist. One of them exemplified that pill dispensers may be wrong for patients with severe mental health problems. Other reservations about technology use also emerged. Informants with daily contact with patients carefully stressed that they approached each patient individually and applied technology only when useful and adequate to the patient’s condition and needs. They emphasised the need for close individual follow-ups and considerations of whether the patient is confident and feels safe with the technology. They were afraid of standardising care through technology, at the expense of individual needs. In addition, the need for technology can also quickly change due to changes in the patient’s condition, and technology decisions must therefore be evaluated continuously, according to the informants:
“It is re-considered and evaluated again and again. The patients who get pill dispensers – it is evaluated: Is it still justifiable and okay that they have this dispenser, or should we provide the care differently?” (Mid-level manager A, municipality C).
The undeniable benefits of welfare technology were also modified by the healthcare managers who highlighted the importance of individual adjustments:
“It’s all about the mapping, to map in advance – what’s right for you? Does the patient need social contact? Or can technology help?” (Deputy manager, municipality A).
Whether to use welfare technology for the specific patient is a shared decision between healthcare personnel, family members, the GP, and the patient herself. In specific cases, technologically skilled personnel are involved, but the patient always has the final word:
“But I think it is the user who should be in this – who is the one who decides for himself whether to use this or not. It is not the municipality who decides» (Mid-level manager A, municipality C).
According to the informants, patients are never forced to use welfare technology and can discontinue its use at any time. However, patients are informed about available alternatives, and healthcare personnel may sometimes attempt to persuade them of the technology’s benefits. They have observed that when patients are informed and feel confident in how the technology functions, they are more likely to adopt it.
Theme two: two sides of autonomy
The benefits of welfare technology were highlighted by the informants. However, as the previous section conveyed, informants were also ambiguous about the use of welfare technology.
Patient’s autonomy benefits the municipality
Autonomy was highlighted as an important theme and value, but the material shows that informants also expressed an ambivalence related to autonomy. The strategy for welfare technology of one of the municipalities (B) states that welfare technology should ensure that citizens will be able to stay at home as long as possible, and many agreed, as one of the healthcare workers commented:
“The goal is for as many people as possible to be able to take care of themselves at home for as long as possible. This is the overall goal for this municipality. We are getting much older than before, and the life expectancy is very high here (…) If we are going to provide for everyone, this is what we must do [to use welfare technology] to get enough people to work and provide the service we are going to do”. (Team leader A, municipality B)
The opportunity to take care of yourself through welfare technology, as stated by the team manager above, was emphasised in the interviews. This autonomy appears as crucial for the municipalities to fulfil expectations and requirements for the services. One manager outlined the benefits of patients self-administering their medication with the help of technology:
We see the benefit in terms of them [the patients] getting the medicine at the right time. We don’t necessarily have to be there when they take the medicine. We don’t always need to be there to give them the medicine, they can take it themselves. Then we can come later in the day with the supervision we are supposed to have. We manage our time a little better. Actually, we have very good experience with it. (Head of Unit A, municipality A)
The view that autonomous patients are good for the municipality, is shared by technology suppliers who point out that the use of technology can provide flexibility and the possibility to re-organise services in more efficient ways.
Autonomy is an essential value
Health professionals viewed autonomy as even more important for the patients themselves. They believed that welfare technology empowers elderly individuals by promoting greater independence, enabling them to manage their own lives, bodies, and time with more control.
“We have many examples of patients in home care who sat and looked at the clock and wondered when they were going to get their morning medicine, who can now report that after they have received pill dispensers they can come and go from their own home when it suits them. . . We enable them to be independent”. (Head of unit A, municipality B)
Other professionals strongly stressed that welfare technology allows patients to exercise greater freedom, allowing them to choose whether or not to receive visits from healthcare personnel, ultimately fostering a sense of independence. Among the suppliers, this freedom was explicitly emphasised, as they viewed visits as a constraint. One of the suppliers described this limitation in the following way:
“Today, there are very many people who are deprived of the opportunity to live a more independent life. They are almost imprisoned in their own home. Because they will have visits from the home care services 2–3 times per day, only to give one dose of medicine in their hand.” (Pill dispenser company A)
Visits can sometimes be disruptive, and healthcare personnel described that some patients prefer not to be checked, especially if they share a room with another person. Digital monitoring systems prevent disturbances during the night, and devices like pill dispensers, GPSs, and alarms reduce unwanted contact while maintaining safety. By reducing physical and social interaction, welfare technology also alleviated patients’ feeling of being a burden. Relatives were similarly affected by the increased use of such technologies. Many healthcare informants had experienced that devices like security alarms and pill dispensers eased the daily caregiving responsibilities and the anxieties of relatives. Families felt more reassured and relied more on the services provided, transferring more of the responsibility to the healthcare system. The technology suppliers explicitly highlighted autonomy as one of the most important aspects in designing and developing their welfare technology products. They wanted to offer a technology that enable patients to maintain independence despite the growing demand for home-based care. As two suppliers explained, autonomy was central to them because:
“It is deep in people, it seems, to be able to be independent, to fend for themselves and not be dependent on others.” (Pill dispenser company A).
“To handle one’s own medication is extremely important. Independence, coping, flexibility, not the least in everyday life, is of value for clients who depend on a service and who have to wait for a service provider to come.” (Robotics developer)
As the quotes illustrate, the informants use emphatic language to emphasise the significance of autonomy, clearly presenting it as a fundamental value.
Potential downsides of autonomy
While autonomy was applauded among all informants, healthcare personnel also reflected critically on the potential negative aspects of technology. One of the healthcare managers questioned whether the patients are becoming more independent and said:
“We must be aware of what we are doing”. (Head og Unit A, municipality A)
This manager pointed to the dilemma expressed by many other informants; that more autonomy for the patient requires closer follow-up to ensure that the patient’s condition is adequately monitored and to be able to detect and act on the deterioration of the patient’s condition. Increased independence for the patient was seen as a challenge as healthcare personnel ended up having less direct contact and had to largely rely on technology. Some of the healthcare personnel felt unsure in this situation. Furthermore, another tension with welfare technology that healthcare personnel expressed was whether more autonomy in healthcare services could safeguard a dignified life for the elderly.
“It is – I think it is – good care is linked to dignity in your life. That you feel that it is a dignified life at home. We are very keen to offer services that enable everyone to stay at home for as long as possible. But does it feel like a worthy life? Are you able to take care of yourself or not? I think it has to do with dignity”. (Head of Unit A, Municipality A)
As the informant questioned above, a dignified life was not seen as the same as an independent life. Many informants were concerned that the elderly were becoming lonelier with more technology and were unable to manage social aspects of their lives.
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