Background
There has been a global shift in the need for digital transformation focusing on health care policies, systems, and services. Promoting and supporting a digital health ecosystem is increasingly acknowledged as an efficient approach to accelerate management, coordination and effectiveness of care, with digital systems and technologies identified as pivotal drivers of this transformation [1, 2]. Digital transformation has already begun in the Australian healthcare system where the National Digital Health Strategy aims to create an inclusive, sustainable, and healthier future for Australians in the years 2023–2028 [3]. This strategy recognises that health information should accompany people across the settings of care and enable people and families to participate in care decisions with their health care team.
The aged care sector in Australia is facing significant scrutiny to improve care outcomes and communication between funders, providers, clients and families [3]. Through increased innovation and technology use, aged care has an opportunity to streamline clinical data management and administrative systems to better report and respond to the complex needs of older people. Technology is seen as the keystone in communication between health care professions, families and carers which can improve quality and safety in rehabilitation and palliative care in health and aged care [4]. Digital transformation has expanded within the aged care sector, in response to the recent pandemic, with rapid uptake of telehealth [5] and the expectation that aged care workers incorporate the use of technology such as electronic health/medical records; computerised support systems, applications (Apps), and tablets [6, 7]. As a result, aged care workers (including registered; enrolled; and assistant nurses) are now expected to utilise technology alongside providing complex clinical care to clients or residents [8].
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Introducing new technology can promote and improve health care, and improve productivity [3]. However in the aged care context, attention to the implementation strategy is needed to engage staff and simplify the process to address core needs [9]. Coupled with the increasing responsibility and regulatory requirements, introducing additional technology could potentially prove onerous for aged care workers and create challenges for effective implementation [6]. A recent survey of digital maturity in aged care showed that there is wide disparity in use of technology for care and administrative purposes, and noted the need for investment in staff upskilling, resources and support for long term strategies for the sector [10].
Palliative care is defined as an approach that aims to provide relief from suffering for a person living with a life-limiting illness and their family [11]. With over 36% of deaths occurring in Residential Aged Care (RAC) setting [12], palliative care is now recognised as an integral part of aged care in Australia [11]. While palliative care, and considerations for end-of-life caring are considered a core aspect of aged care practice, there has been limited attention given to how digital technologies could enhance palliative care within this evolving digital landscape of aged care. While there are studies exploring the application of technology in health care [7], there is very little evidence of nurses’ perspectives on the use and implementation of new technologies in the aged care setting [13‐15].
Aim
This study aimed to explore the perspectives and expectations of RAC nurses regarding the utilisation of technology to enhance care at the end-of-life.
Methods
Design
A qualitative descriptive research study design based on the secondary analysis of data collected as part of a larger study. Data collection was conducted using semi-structured interviews and focus group discussions [16]. Reflexive thematic analysis was adopted to ensure rigour and quality in analysis [17].
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Setting
The data for this study was extracted from a larger multi-method implementation evaluation qualitative study, namely The ELDAC (End-of-life Directions for Aged Care) Digital Dashboard Implementation (EDDI) study. The ELDAC EDDI study was designed to implement a dashboard for aged care staff to graphically view and track end-of-life processes and care activities for residents and was trialed across participating aged care sites. Data were collected through focus groups and semi-structured interviews with aged care staff in their workplaces both pre and post dashboard. For the purpose of this study, the pre-intervention interview and focus group data was used to describe the perspectives of the nurses and care workers in residential aged care to understand their experience with and perspectives of digital technologies in relation to palliative and end-of-life care.
Study population
Informed consent were obtained from 83 participants which included care/support staff, clinicians, and care-managers across 15 RAC sites from three different states - Queensland, Western Australia, and Tasmania.
Sampling and recruitment
In the larger (EDDI) study, aged care sites were recruited through IT companies (four) who provided services to them. They were asked to forward the dashboard information and service level invitation to participate in the study, via email. Meetings were scheduled with interested services via telephone or video conferencing to discuss involvement and the related expectations. Services who signed and returned a ‘Service level information and consent form’, and ‘Acceptance of T&Cs of funding’ were enrolled in the larger study.
Recruitment of focus group and interview participants was done by the distribution of study invitation posters and participant information and consent forms among clinical and care staff at each site after enrolment in the larger study was accepted by the service representatives. Voluntary response sampling was used as staff who were interested in participating in the focus group or interviews contacted the researchers to discuss their involvement.
The recruitment materials noted that the invitation was to take part in a focus group [or an interview] and the participation was voluntary.
Data collection and analysis
Due to COVID-19 related restrictions implemented across aged care services at the time, data were collected virtually via video conferencing software (Microsoft Teams or Zoom), or telephonically. Data for this study was collected as part of the larger study procedures. Data collection took place between September and November 2020 and was led by a research team composing of an experienced female health academic researcher with a background in palliative and end-of-life care, and information technology in aged care (JT); and a female research fellow with a nursing degree and experience in digital health, chronic and palliative care research (PV) – who conducted the interviews. Both team members fully collaborated on the study from conceptualisation to dissemination.
An interview guide was used to facilitate interviews and the focus groups (Table 1). The data collection approach was directed by the research question and considered to meet the analytical requirement of data saturation [18].
Table 1
Semi-structured question guide for interviews and focus groups conducted
Questions on baseline digital technology use patterns: |
|---|
1. What system do you use for management of resident/client’s clinical data? a. How does this system help you provide good quality end-of-life care? |
2. What other kinds of technologies do you use at your workplace? [explore each technology type and their function] a. How do these technologies impact on your care providing role? |
Questions on end-of-life care and digital technology: |
1. Do you think technology can be utilised to help care providers like yourselves provide good quality end-of life care? |
2. Can you think of an example of how digital technology helped you provide good quality end-of-life care? |
3. Do you think there are challenges to using digital technology in your workplace? If yes, how do you think they can be addressed? |
4. If we were not limited by funds and had all the IT skills we needed, what kind of digital technology would you like built to help you do palliative care and end-of-life care better? |
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The data collected (interviews and focus groups) were audio and/or video recorded (which lasted between 40 and 60 min) and transcribed verbatim by an external professional transcription service. The interviewer took notes and used reflexive journaling as a means for self-reflection and minimise researcher bias. According to Tobin and Begley (2004), ensuring that data is appropriately documented, including methods, decisions, and the final analysis, demonstrates dependability, and self-reflection of the research process for reflexivity [19].
Once the transcription was completed, the data was managed using NVivo 12 software [20] and analysed using reflexive thematic analysis [17]. The researchers used an inductive approach to identify codes so that the analysis was data driven [21, 22] and chose reflexive thematic analysis as it aided in critical self-reflection while engaging with the data. The codes were generated by capturing segments of raw data and organising them into meaningful groups which were then reconsidered and further coded to identify notable trends and patterns [23]. The second researcher then coded the data which was compared and discussed until an accord was reached for intercoder consistency, to ensure a true reflection of the data [24]. The study team regularly discussed and reflected on the themes and sub-themes that were generated for the purpose of improvement.
The standards for reporting qualitative research (SRQR) checklist was used to enhance the quality and transparency of this study [25].
Ethical considerations
This study received ethical approval from Flinders University Social and Behavioural Research Ethics Committee (8594). All interview participants were informed that participation was voluntary and could be withdrawn at any time. Participants were reimbursement with a $25 gift card, offered as acknowledgement of their time and contribution. All data collected was deidentified, securely stored and password protected on computers at Flinders University.
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Results
Site and participant characteristics
Data was collected across 14 RAC facilities from two states and one territory in Australia as one facility withdrew participation before the digital dashboard was implemented. A total of 64 participants were involved, majority of whom were female (86%), employed as RNs (56%) and were involved in providing direct care to residents. This was followed by nurses in clinical or managerial leadership roles (23.5%), enrolled/endorsed enrolled nurses (EN/EEN) (14%), and care workers/admin support (6.5%). The following four themes were generated from the data: (1) engagement with various digital systems and platforms; (2) ambivalence toward technology; (3) challenges and concerns in technology use; and (4) anticipated technology roles in end-of-life care.
In the following section, participants are reported using the key conventions as below: (Gender: F = Female, M = Male; Role: RN = Registered Nurse, EN = Enrolled Nurse, EEN = Endorsed Enrolled Nurse, CNS = Clinical Nurse Consultant, CSW = Care/support worker, CM = Clinical Manager).
Theme 1: Engagement with various digital systems and platforms
Participants reported using various kinds of digital technologies and programs in the residential aged care setting such as: medication management portals, incident reporting systems, rostering platforms, training portal and digital systems for clinical documentation. These systems and platforms are not consolidated which requires nurses to use multiple systems for various aspects of functioning, every day.
“We have iCare for all the [client care] information we compile on computers. We use MedMobile, for medications- through iPads and the MedMobile app. And then we’ve got TechOne for our incident reporting and payslips, and Kronos for docking in what time we finish.” [Female, EEN].
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The use of video-based telehealth was reported by some of the participants, however the need for support in setting up the telehealth session by an experience staff member was apparent.
“I get a phone call from [hospital-based team]. They send me an email or talk to me, and I liaise- to make sure that I get the links and get online. I actually have to put a note in my diary to go and do the session… to make sure that they [nurses or resident] don’t drop the iPad, they don’t disconnect themselves… to make sure that the device is always charged.” [Female, RN].
In supporting end-of-life and palliative care, participants noted limited integration of technology on this front, primarily confined to digital data capture of certain elements of end-of-life care in computer-based forms.
“We have an ‘end-of-life’ section [in the clinical data management system] that we fill out when the residents are admitted into the facility … it’s all about their likes and dislikes, their burial or cremation plan, what type of medication they would prefer etc. Then, there is a form that we use that the doctor signs to say, “offer this”, “don’t offer that”, “do this”. So, it is quite substantial [data keeping] system to use for palliative care.” [Male, RN].
Theme 2: ambivalence toward technology
Participants reported ambivalent attitudes towards technology, and its role in supporting care at the end-of-life.
Use of technology to document clinical and care data was reported as being an efficient approach that enabled timely access to crucial information relevant to care planning and delivery.
“When we are sitting at a desk, and we can go through everything through a computer because it’s on the desktop now. We don’t need to go to [paper] files and find out the details and then ring doctor or ring family, so everything on the one screen, so it’s a timesaving tool.” [Female, RN].
There was consensus that technology has a role in facilitating easy data access, thereby supporting the process of safer care delivery and appropriate clinical decision-making.
“I definitely think technology in end-of-life care is very important. Technology makes it easier because you have everything readily available at your fingertips. Whereas with paper-based, handwriting can be difficult to understand, papers can go missing, misplaced, put in the wrong spots. It [technology] makes it safer and easier to access the information you need to be able to provide the care in the way that the resident wants.” [Female, RN].
Participants highlighted the potential of technology to facilitate communication. This was seen as a value-add in the context of end of life caring where health deterioration and change can occur quite rapidly.
“I agree, technology is the way to go. Communication is vital, especially in a situation like palliative care where things can change within 24, 48 hours. So, even if we communicate well between resident and the carer and the caregiver [using technology], that would improve the level of care tremendously.” [Male, CSW].
However, there were apprehensions among participants regarding the integration of technology into end-of-life care, as some noted that technology could detract from the hands-on aspect of care, which is central to end-of-life caregiving.
“So, you take around a little tablet [device] when you are doing a person’s cares, but then you are becoming so task [oriented]– as a nurse we are very task-oriented, because we have so much paperwork. And to me, I just think that takes away from the personal, the hands-on care, especially when someone is dying.” [Female, EN].
Similarly, some participants also displayed reluctance toward technology and resistance towards its acceptance and use.
“I am kind of anti-technology, however, have I seen it improve a great many things? Yes, I have.” [Female, RN].“End-of-life care is all about the human on human. I really can’t think of any technology that, yeah, that would help.” [Female, RN].
Theme 3: challenges and concerns in technology use
While nurses were engaged with various technologies in the aged care setting, there were challenges in using technology.
Basic infrastructural issues such as lack of uninterrupted electricity supply, and availability of reliable telephone and internet access made it difficult for nurses to engage effectively with the technologies they had in place.
“Our phone service is very challenging. …it’s very hard to fix it, especially on a weekend, so we all just try to spend time to fix it.” [Female, RN].“Yeah, the only challenge is when the power goes out… So, XX is a small town 40 kms west of XX and they have power outages here. We’ve just had one from 9 o’clock this morning till 2pm this afternoon.’ [Male, RN].
These infrastructural challenges led to double handling of data. The same service noted the following approach in the instances of power outage:
“We go paper based if we have a power outage to write any progress notes and then they get uploaded into the system as well. So that’s definitely a challenge.” [Male, RN].
When it comes to digital data management, participants noted the common occurrence of double handling of data and expressed concerns about the issues it poses.
“Having all that [clinical data management system] is difficult because it relies on someone like me, to actually upload it. So it is that physicality of having someone stand there and upload them all and then go to the computer and bring them across from our email to put it into iCare. It is a time-consuming process.” [Female, RN].
Participants noted that having clinical and care data scattered across multiple mediums presents a challenge to seamless data access, particularly in the end-of-life care context.
“When it comes to end-of-life [documentation], it goes to a paper trail and that paper trail [file] is left in the resident’s room so that the staff go in and do their part… it becomes a paper trail once the doctor announces [the resident is] ‘end-of-life’. Which is a shame because it would be nice if they [clinical data management systems and paper documentation] could speak to each other.” [Female, EEN].
Older nurses could also find it a bit difficult to use technology.
“The younger ones just know their computers a lot better, they can go from one area [tab] to another… just sending a fax was a bit of an ordeal for us older ones” [Female, RN].
The need for ongoing support when it comes to use of technology was noted as crucial to facilitating technology use.
“One of the best things you could do for our situation is training in technology for the nurses to be able to access and to use all that programming [digital technology].” [Female, CSW].
Theme 4: anticipated technology roles in end-of-life care
Participants felt that technology has a role to play in the context of end of life caring in the RAC setting, and shared their viewpoints on how end of life care planning and processes could potentially be facilitated by innovative technologies.
Technology’s potential to aid symptom assessment and ongoing monitoring of residents was considered valuable for identification of decline and the implementation of early intervention measures.
“It would be great to have a device that evaluates cortisol levels to assess pain for residents who are unable to verbalise. If the device picks up cortisol levels, interprets that to pain level and then tell us what dose of analgesia we need to give the residents, that would be good.” [Female, RN].“A 24-hour monitor in the room, that alerts you at the smallest of a symptom.” [Female, RN].
The desire for automation and technology in high priority but error prone areas of care, such as medication administration and documentation, was also highlighted by some participants.
“Being able to have an opioid or analgesic tool that could guide practices… touch a button and go, “Oh okay, we hit 10 PRNs for this person, maybe it’s time, we have to talk to the doctor.” [Female, CNS].“When we use the syringe driver [continuous sub-cutaneous medication administration device] on our palliative care residents, we need check on the machine every few hours to look at how much medication and battery life is left. It would be great if we could build a syringe driver that could do all that measurement automatically and record it for us.” [Female, RN].
Participants recognised the value of technology-enhanced telehealth support, especially in relation to connection and collaboration with general practitioners, as an area where technology could provide added value.
“… if we need a doctor straight away, we get on the telephone and we have a smart TV or something where we can say “look, she has declined”. We give them [doctors] the notes and ask if they can prescribe or if we can give her morphine. So, we get an instant doctor.” [Female, CSW].
Participants desired a technology that could integrate their clinical assessment data and provide them with an overview or an indication when their resident starts to decline gradually as they approach their end of life.
“I think we can build like system that tells us if a resident is end-of-life or not. It takes record of their symptoms and when the symptoms progress, the system would tell us if the resident has progressed in their [decline] trajectory. That way we don’t have to go look at different forms to determine what is happening with the resident and we can just look at their progression in the system.” [Male, RN].“Like a fall is happening on a separate day, and incontinence episode is happening on a separate day. But because no one [technology] is putting them together, no one has picked up that this man has actually declined from the last time we did a funding review.” [Female, CM].
Once the gradual decline is identified, participants also recognised the value of having a palliative care dashboard, akin to a centralised platform, that consolidates all relevant elements of end-of-life care planning. This would support clinicians in delivering timely and appropriate care.
“… to have a dashboard that we can look at and have an overview- so you can see who is palliating in the building [service]. Because currently, we’re doing it in a multidisciplinary team meeting, but we’re scouring through layers of [paper notes]. …To be able to see in one place- where the resident is at, what families have been contacted, and what case review or conversations we have had. To have technology to say how the family are coping, and to be able to plan that care a little bit better, by alerting us into all the areas too.” [Female, CM].
Discussion
There has been a growing interest in examining the intersection of digital technology and nursing practice over the past decade. Although number of recent studies have investigated the role of technology in the realm of nursing education [26], nursing care [27], and virtual care [28]; to our knowledge this study is the first to delve into the attitudes and expectations of aged care nurses regarding technology’s application in end-of-life and palliative care contexts. This study found that, nurses in Australian RAC are open to engage with technologies for end-of-life provision, despite some ambivalence and challenges encountered in the process.
Nurses in RAC use various digital systems and platforms daily but have mixed feelings about integrating technology into end-of-life care, alluding to concerns about potentially diminishing the hands-on aspect of nursing care. This ambivalence echoes findings from recent studies where nurses acknowledged technology’s potential to improve care quality and streamline processes, but expressed concerns about technologies detracting from direct patient care, and limiting their critical thinking [29, 30]. Similar concerns were raised by Australian nurses in tertiary care setting, where reliance on basic clinical technologies was associated with reduced patient interaction [31]. As attitudes toward technology and perceptions of its usefulness significantly shape the adoption of digital health solutions [32], it is imperative to clearly articulate the benefits of technology in improving practice and patient outcomes to ensure meaningful adoption by nurses [33].
While there is room for improvement in nurses’ attitudes towards technology, it is evident that nurses face practical challenges when engaging with technology in the RAC. Issues such as poor interoperability and the use of multiple data management methods [paper as well as digital system] resulted in double- handling of data, ultimately increasing their workload. Similar challenge has been reported previously [34] with the logistical difficultly of having to collect clinical/care data on paper followed by entry into the digital system leading to increased workload for nurses. This challenge underscores the importance of technology being user-friendly and highlights the need for technology to seamlessly fit into existing systems. While there’s limited understanding of the digital data management challenges in Australian aged care settings, palliative care providers emphasise the importance of seamlessly integrating new technology into existing systems for improved usability [35]. With the increasing momentum for greater technology integration in aged care, it is crucial to design digital technologies that require minimal cognitive effort for effective use [15]. Furthermore, there is a need to engage aged care nurses in the design/development, user testing and implementation of technology to ensure a strong nursing contribution towards developing intuitive products, that enhance workflow in real-world care environments.
Ensuring technology is user-friendly for nurses requires providing adequate training and continuous support to facilitate their engagement. Echoing what has been noted in the broader literature [6, 36], nurses in this study highlighted the importance of training and support in using digital tools for end-of-life care. This coherence is mirrored in a recent study of Australian nurses and allied health professionals, which revealed low levels of digital literacy and capability among the workforce [37], and called for strategies to enhance their digital competency. Indeed, recognising the importance of digital skills in healthcare settings is crucial because poor skills among healthcare professionals can create negative use experience and attitude towards technologies [38], as well as risk patient safety and lead to errors in care [39]. Supporting nurses to adopt digital technologies can have widespread benefits [36]. When nurses feel confident using technology, they see it as more useful and easier to use, leading to increased acceptance and engagement [40]. Ongoing technical support is vital for this process [41]. As aged care becomes increasingly digital, it’s important to provide nurses with support to become familiar with digital tools, build their confidence, and ensure effective use for better care outcomes [42].
Reflecting the sentiments of nurses across different care settings [43, 44], nurses in this study also recognised the value of technology in supporting end-of-life and palliative care. Palliative care professionals in Australia are known to share similar perspectives, expressing openness to technology and its potential to enhance palliative care [13]. Nurses in this study emphasised the need for technology-enabled support in symptom assessment and continuous monitoring, recognising the crucial role of thorough symptom management in delivering high-quality end-of-life care [45]. While tasks relating to symptom management and daily care are crucial in end-of-life caregiving, direct care staff are known to find the heavy task-orientation of their role to be in direct conflict with the interpersonal aspect of caregiving [46‐48]. This highlights the need for technology that reduces task burdens and fosters interpersonal caregiving opportunities. Such innovations could help staff better understand residents’ unique needs and preferences, enabling more personalized and tailored care [49]. Nursing literature increasingly calls for technology that not only enhances care but also creates safer, more efficient, and effective practice environments [6, 50]. These technological solutions have the potential to minimize the strain of routine tasks, freeing up nurses to focus more on meaningful, interpersonal caregiving [51].
Similarly, nurses also recognised the potential for automation technology in error-prone areas like medication administration and documentation, which is consistent with existing literature [43]. While evidence shows that automated drug administration systems reduce errors in acute care setting [52], their use in managing controlled [Schedule 4 and Schedule 8] medications remain limited [53]. Since managing complex end-of-life pain and symptoms often requires the use of controlled medications, further research is needed to explore how technology can best assist in the process of controlled medication administration and management in aged care during the end-of-life period.
While acknowledging the value and potential of telehealth, nurses reported challenges in managing telehealth sessions. This finding aligns with a recent systematic review, which highlighted that nursing digital skills gaps are a barrier to telehealth implementation [28]. Telehealth presents a promising solution to improve timely care access, especially for those receiving care in the RAC where around-the-clock clinical/medical resources may be limited [54]. While telehealth is found to be feasible in RAC setting [54], as well as safe and effective in end of life and palliative care context [55‐57]; it still encounters challenges [58, 59]. To ensure the successful integration of telehealth into end-of-life care practices, adequate resources and support must be provided to nurses as virtual care models continue to evolve alongside traditional approaches.
Nurses articulated the need for a consolidated dashboard integrating clinical data to monitor residents’ decline, reflecting a widespread healthcare challenge. Despite collecting vast amounts of data, clinicians face challenges in finding consolidated information within digital systems, which could hinder their ability to make effective decisions and deliver care [60]. Encouragingly, there is growing evidence to suggest that integrated dashboards are not only useful and effective but also user-friendly [61], particularly in aged care settings [62]. While real-time dashboards have proven successful in acute care for early warning of patient decline [63, 64], interest in tailored solutions for aged care is growing. A current study in Australian aged care is evaluating a predictive analysis and decision support dashboard, primarily focusing on clinical indicators and falls [65]. There are opportunities to expand the role of such dashboards in supporting palliative and end-of-life care in aged care delivery.
Limitations
There are a few limitations to consider when interpreting this study’s findings. Firstly, because most of the study sites were in Queensland, it is important to exercise caution when generalising these results more broadly. Secondly, as, participation was via voluntary self-selection, the findings might not fully represent the views of those who chose not to participate. Thirdly, care workers had limited involvement and data input into this study, possibly affecting how well their perspectives were captured. Similarly, the views of care recipients and their families were not included, suggesting the need for caution in interpreting the findings and highlighting an area for future research. Fourthly, as secondary analysis was conducted, there may have been opportunities for nuances or specificities of the research question that may have been missed. Lastly, due to COVID-19 restrictions in 2020, we couldn’t collect data in person, which might have impacted how engaged the participants were during data collection procedures.
Conclusion
Nurses in RAC are increasingly open to using technology for end-of-life care, despite facing challenges. While they use digital systems daily, integrating technology into end-of-life care raises concerns about losing hands-on aspect of nursing. To ensure successful adoption, it is crucial to highlight how technology enhances care, reduces task burdens, and creates more opportunities for interpersonal nursing care. Additionally, providing nurses with ongoing support and training is essential. Nurses see the potential of technology in supporting palliative care and emphasise the need for user-friendly solutions. Consolidated dashboards combining clinical and care data offer further opportunities to enhance end-of-life care in aged care facilities. However, care providers must engage in data discussions and secure informed consent from recipients, ensuring they understand how their data is stored, accessed, and used.
Acknowledgements
The authors would like to thank all the participants of this study for their time and contribution.
Declarations
Ethics approval and consent to participate
This study received ethical approval from Flinders University Social and Behavioural Research Ethics Committee (8594). All interview participants were informed that participation was voluntary and could be withdrawn at any time. Informed consent to participate was obtained from all the participants in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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