Abstract
We investigated why hospice nurses were slow to adopt videophones to care for their patients. We used the unified theory of acceptance and use of technology (UTAUT) model and the organizational readiness for change (ORC) assessment via interviews and focus groups with hospice staff. Twenty-five hospice employees participated. Eighteen (72%) were in clinical positions and seven were in non-clinical positions (28%). Thirty-nine percent of respondents reported no videophone training, despite the fact that every employee had received training. Only four staff members actually used a videophone with patients. The respondents overwhelmingly stated that they had the organizational resources necessary to use the videophone and that it was easy to operate. Despite initial enthusiasm, leaders in the hospice agency did not endorse the videophones for work, nor offer incentives for using the videophones or providing them to patients. It is important to note that videophone technology is not meant to replace face-to-face visits, but to supplement them and to provide an additional tool for the nurses.
Introduction
Hospice nurses provide high quality care to their patients, but their work is both physically and emotionally taxing. 1–3 Hospice organizations encounter difficulties in providing care to rural and remote patients due to staffing shortages, high personnel turnover and the travel distances required. 4,5 Telehealth may be useful for hospice providers, especially those who provide home health services. 6
The use of telehealth in a hospice setting is referred to as telehospice. Telehospice can provide benefits for both patients and hospice workers, including increased quality of care, improved access to care, reduced costs and decreased travel time. 6 The first documented use of telehospice occurred in the late 1990s, when health professionals employed telephones, televisions and video cameras for communicating with patients in other locations. 7 Subsequently, various technologies have been utilized in hospice settings, such as the Internet, computers and videophones. 8,9
Several telehospice projects have employed videophones. 10–12 Videophones operate like conventional telephones, through ordinary analogue telephone lines (i.e. PSTN), but also include a video screen. Videophones allow patients and providers to see and hear one another, and allow minor patient assessments to be conducted while the two parties remain in separate places. 6 Several positive aspects of using videophones for telehospice have been identified. For example, they have been shown to increase patient satisfaction, increase feelings of safety and reduce anxiety. 10,11 However, negative aspects of telehospice have also been reported, such as technical difficulties, confusion about when to refer patients and underutilization of the technology. 12,13
Staff communication, perceptions and management have been identified as areas from which these difficulties originate. 13,14 Despite attempts to overcome these barriers, the adoption of telehospice has been slow. This contrasts with the rapid adoption of other home telehealth applications, such as home monitoring. We have examined the underutilization of a telehospice programme in Michigan. The research questions were:
Methods
A mixed-method study design was used to investigate hospice providers' perceptions of videophones and actual videophone use. All hospice employees participated in the project, including clinical (i.e. nurses, on-call nurses), social work (specialized social workers and bereavement counsellors), administrative and supervisory staff. The total number of staff was 25. Data were collected between July and October 2007.
First, structured survey instruments informed by the UTAUT and the ORC were employed. The UTAUT instrument was only administered to the staff members who had used a videophone or had been trained to use one (n = 14). The ORC was administered to all staff members (n = 25). The participants were asked to rank their agreement with statements on a five point Likert scale (1 = strong disagreement to 5 = strong agreement). The survey also included three open-ended items, allowing staff to report their experiences.
Once surveys were completed, two follow-up focus groups were conducted with a total of ten participants in order to clarify discrepant findings. For example, the quantitative items on the questionnaires clearly indicated that the hospice staff were open to new technologies and to change. However, the videophones had not been utilized as expected.
Results
Both quantitative and qualitative findings from the UTAUT and ORC instruments revealed matters affecting technology adoption in the hospice.
At the beginning of the project, the hospice management, specifically the administrative director and the clinical manager, were very enthusiastic about using videophones and helped us to obtain research grant funding. The survey data confirmed that hospice managers initially expressed support for the project. For example, the survey results demonstrated high levels of agreement with the following statements: ‘people who are important to me think that I should use the videophone’ (mean 3.8, range 1–5), ‘the senior management of this department has been helpful in the use of the video phone’ (mean 4.0, range 2–5) and ‘the organization has supported the use of the videophone’ (mean 4.3, range 3–5).
However, as the project progressed, the hospice leaders' interest diminished. They did not encourage participation and refused to respond to many requests regarding the project. For example, in a follow-up focus group, a nurse noted, ‘We were presented it for use. I wouldn't say we were encouraged.’ Indeed, participant responses indicated that the staff were rarely told to use the videophones. One nurse stated, ‘We weren't told to use the phone specifically, but were made aware that they were available.’ Another said that during the duration of the project, the supervisor mentioned using the phone in about ten instances. Telehealth was considered supplemental care and it was not mandated as part of a nurses' daily work. Some staff members thus realized that leadership was a missing component. When asked what could be improved a case manager said, ‘Education and encouragement. There is a lot of talk, but at some point you just need to take the bull by the horns and just do it.’
Available resources were also found to be a factor in underutilization. For the purposes of the present study resources were defined as training, on-site workshops and access to information technology (IT) staff and support. The survey responses indicated that participants felt that they had the necessary resources. For example, they indicated strong agreement with the following statements: ‘A specific person (or group) is available for assistance with system (i.e. the videophone) difficulties’ (mean 4.1, range 1–5), ‘staff training and continuing education are priorities in our department’ (mean 4.3, range 2–5), and ‘our department holds regular in-service training’ (mean 4.5, range 2-5). The nurses and other staff noted that they had everything required to do their jobs, were adequately trained on how to use the videophones and had a technical team who could assist them.
In general, the surveys indicated that the providers had the resources necessary for telehospice work. However, these resources were not operationalized or activated in ways to address the needs of the telehospice services. For example, staff attending the focus groups revealed that the IT staff could not help them solve problems and they were not given adequate time with the videophones. One nurse said, ‘I couldn't get a dial tone last time I used it. I called the technical staff. But, they can't usually fix it when something goes wrong.’ Another nurse stated that ‘we need to have time to use it’ while another said ‘we never had a chance to get comfortable with it.’ In addition, some staff did not seem to realize that resources were available to them. When asked about how things could be improved, one nurse commented ‘Get more training and don't be afraid.’
Ease of use refers to the functionality of technology as it relates to the user, its intuitiveness and the degree of complexity perceived by the user. 17 In other words, this theme addresses the users' perceptions of how easy a technology appears to be. 18–20 The concept of ease of use seems intuitive, as there has been a plethora of adoption and diffusion literature on this topic which demonstrates that if the technology is too difficult to use, people will not employ it. The survey indicated that the majority of hospice staff who were either trained or had used the videophone strongly agreed that the equipment was easy to use (mean 4.4, range 3–5). They also strongly agreed that it was easy for them to learn how to use it (mean 4.4, range 3–5).
However, it was clear that it was not enough to have a ‘simple’ piece of equipment at one's disposal. Other factors affecting the successful completion of a telehospice visit included the provider's perceived ease of use for themselves, the provider's perceived convenience for their hospice clients and the provider's desire to use the system. A handful of participants expressed general frustration with the system. However, commitment emerged as a more significant issue. During a training session, hospice nurses stated that they kept the videophone turned off because they did not want to answer it. Ease of use for elderly patients was also a concern for the hospice staff. One nurse noted, ‘I took it to an elderly couple. It was a bother ringing all the time. They didn't know which phone was ringing. They were hard of hearing.’ In addition, the providers took it upon themselves to select who might be a good candidate for telehospice, rather than following the agreed protocol to offer it to all patients meeting the eligibility requirements. The nurses explained that, ‘We get to know our patients really well, so we don't ask everybody.’
During a focus group, a new staff member stated that he was not aware of the telehospice work. The majority of the nurses were able to explain how to use the videophone to this individual, thus demonstrating that they were aware of how it worked and were comfortable in describing it to others. They told the new member, ‘It [the videophone] can help give you an idea of their pain level and breathing rate. You can do some assessment with it. I thought the picture was good. I could see there could be a lot of benefit.’ The providers were quite capable of explaining how the technology worked. Yet ease of use and a clear understanding of the potential of telehospice did not appear to overcome an unwillingness or lack of enthusiasm for the service.
Lack of rewards or appropriate incentives to use the technology also affected non-adoption. For example, the survey results indicated that the nurses were not afraid to use the videophone. The majority of staff members disagreed or strongly disagreed that they were anxious (mean 1.6, range 1–4), intimidated (mean 1.7, range 1–4) and apprehensive (mean 2.1, range 1–4) of the videophones. Survey data also indicated that the respondents felt they could complete tasks using the videophones with no outside help (mean 4.1, range 3–5). In addition, the survey revealed that respondents could accomplish tasks they set their minds to (mean 4.4, range 3–5), could adapt quickly to change (mean 4.3, range 3–5) and could improve their skills (mean 4.5, range 3–5). Each item indicates that the staff had a readiness and ability to adopt the videophones into care; however, actual usage did not occur. Hospice staff had little sense of any reward or penalty that would have motivated them to use the videophones for patient care. For example, respondents disagreed (mean 1.7, range 1–3) with the idea that using the videophones would increase their chances of being awarded a pay rise.
These findings suggest that rewards for videophone usage or punitive action for non-usage are matters that warrant further investigation. The use of rewards for utilizing new technologies has been examined in organizations during the implementation of technological applications. Personal rewards, pay-rises and recognition have been found to be important in maintaining telehealth programmes. 21,22 The compensation for using telemedicine technologies must rival other incentives, such as travel reimbursement, which is viewed by nurses as a supplemental income. 22
Discussion
The results of the present study support propositions from the UTAUT and ORC that organizational factors are crucial in the successful adoption of telehospice. Participants recognized the need for strong leadership, adequate resources, technology that is easy to use, and a clearly communicated rewards/incentive structure. Yet the qualitative data showed that the hospice organization had done little more than pay lip service to linking these organizational needs with the telehospice programme.
Vast underutilization of videophones for telehospice clearly occurred in the hospice organization. The videophones were used less than ten times for communication with patients during the two years that the videophones were located at the hospice facility, even though survey results suggested that the organization was a prime candidate for the adoption of new technology. This underutilization may be attributed to hospice culture, which has previously called technology ‘impersonal, objective, reproducible and generalizable’. 23 The main goal of palliative care is to comfort patients and their families, so the insertion of devices that may replace in-person contact does not necessarily align with the organization's mission. For example, physical touch is normally thought to be fundamental to hospice care. 24–26 Hence, it important to note that videophone technology is not meant to replace face-to-face visits, but to supplement them and to provide an additional tool for the nurses. Future research should address this potential barrier to the use of telehealth in hospice work.