How Digital Systems Are Used in Swedish Home Care Nursing Practice: A Qualitative Interview Study to Identify Challenges and Opportunities : CIN: Computers, Informatics, Nursing

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How Digital Systems Are Used in Swedish Home Care Nursing Practice

A Qualitative Interview Study to Identify Challenges and Opportunities

Persson, Johanna PhD; Larsson, Roger MSc; Erlingsdottir, Gudbjörg PhD; Rydenfält, Christofer PhD

Author Information
CIN: Computers, Informatics, Nursing ():10.1097/CIN.0000000000001006, January 17, 2023. | DOI: 10.1097/CIN.0000000000001006
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Abstract

A growing older population with a high degree of comorbidity and polypharmacy produces an increased need for long-term care.1–3 Two effects are that more healthcare is provided in peoples' homes and that digital solutions are perceived as a necessary means to manage such healthcare.4,5 For RNs in home care, this implies that their work becomes more digitalized.6 As the digital transformation progresses, it is important to evaluate how modern technology is being used and how it affects healthcare practice.

The digitalization of home care involves the introduction of welfare technology that empowers elderly people to live in their own homes as long as possible.7 This technology supports the autonomy and security of the patient and includes, for example, surveillance cameras that can detect falls, toilets that assists users throughout their toilet routines, or robots that automate medication management.4,8,9 Digitalization also involves the introduction of new types of systems for home care nursing personnel, such as digital keys and electronic health records (EHRs). In combination with portable devices, such as smartphones and tablets, this allows nurses to access digital systems in the field and to perform more administrative tasks on the move or at the point of care.6,10

From a working environment perspective, digitalization is a support but can also lead to unintended consequences, such as the introduction of new work tasks or altered communication patterns.11,12 When, for example, a nurse is given more administrative tasks as a side effect of working in a new digital system, negative emotions may emerge.13 Such effects on the working environment are, however, seldom evaluated, preventing opportunities for learning and improvement.11,14,15 It is hence important to evaluate the users' experiences of the technology in practice, to identify challenges and opportunities for improvement. One way of doing this is to approach the digitalization from a design perspective. Design thinking is one way of practicing design, built on three major principles: user-centeredness, ideation, and iterative prototyping.16,17User-centered means obtaining a thorough understanding of the users and the context of use to ensure that relevant challenges and opportunities are defined. The two other principles involve generating ideas for solutions and then prototyping and testing them. All of this is done in an iterative manner, which means that solutions, ideas, and challenges initially identified need to be redefined based on new knowledge that emerges from the process.14,18 One aspect of this is that the knowledge used to identify the initial problems must be updated to ensure that new solutions are not based on old or mistaken assumptions about reality. Because digitalization transforms practice rather quickly, it is necessary to recurringly revise the image of how work is done and generate a new and up-to-date description that can be used in subsequent iterations. This design mindset has gained popularity in complex healthcare settings,19 where design methods seek to work toward solutions for ill-defined problems.16,20,21 Home care is such a complex setting, with multiple sick patients interacting with several healthcare organizations and geographical locations. The home care nurse has a coordinating role, and digitalization can play a significant role in supporting the nurse in this work.

The aim of this article is to provide an up-to-date description of how digital technology is used (or not used) in the daily practice of Swedish home care nurses and from this description present challenges and opportunities for the next iteration of home care nursing digitalization.

METHODS

Study Setting

Healthcare in Sweden is decentralized, and the main responsibility lies with regional councils, whereas the organizational and financial responsibility for elderly care rests on local municipalities.22 Municipal care in Sweden includes care of older people living in their own homes and in special living arrangements such as nursing homes. This study focuses on care in the patients' own homes, provided by RNs. Nurses in this setting perform care remotely from their office facilities and remotely from their fellow colleagues.

Study Design

This study is focused on the primary steps of a design thinking process that aims to move the digitalization of home care nursing forward. These primary steps involve research on the users and the context of use in order to update current knowledge on how digitalization affects the working conditions for home care nurses in practice. Semistructured interviews were performed and analyzed. The findings were used to describe how digital technology is used in home care practice and to identify challenges and opportunities related to key aspects of the digitalization of home care nursing.

Data Collection

Semistructured interviews were performed between January and May 2020, in four home care nursing organizations in southern Sweden (before the COVID-19 pandemic broke out in this region). The four organizations represented both urban and rural areas and municipalities of different sizes. Twenty-four interviews were performed with 26 respondents: 24 home care nurses (two of these interviews were done in pair), one nurse practitioner, and one home care nursing strategist (Table 1). The respondents were selected and asked to participate with the help of each organization's unit manager. The interviews took on average 50 minutes (ranging from 24 to 80 minutes) and were recorded and transcribed. The study was performed according to ethical standard guidelines and was approved by the Swedish Ethical Review Authority (DNR 2019-04653).

Table 1 - Overview of Interview Participants
Municipality Time Interval Participants Comments
A January 2020 Eight interviews with nine people Seven single interviews and one double interview (nurses); seven RNs and one home care nursing strategista
B February 2020 Eight interviews with eight people Only single interviews. All with RNs
C April 2020 Two interviews with two people Only single interviews; one RN and one nurse practitionerb
D March-May 2020 Six interviews with seven people Five single interviews and one double interview. All with RNs
Summary January-May 2020 24 interviews performed with 24 nurses, one home care nursing strategist,a and one nurse practitionerb
a Responsible for strategic development of home care nursing in the municipality.
b Holds an expanded role in supervising home care nursing in the municipality.

Data Analysis

An inductive qualitative coding approach was applied to find dominant or significant patterns in the data.23,24 In this process, coding can be seen as a mechanical labeling where extracts from the data are interpreted in the theoretical or empirical contexts in which the study is set.25 It is worth noting that coding and analysis are not separate processes but coevolve and influence each other. The process for this specific study started with the main author conducting a first cycle of data coding. Together with authors C.R. and R.L., who knew the raw data well, the coding was discussed and revised twice during the process. There were no major disagreements, but minor changes were made to revise how certain data extracts where coded. The codes were analyzed for patterns that could be clustered into themes or useful for describing the home care nurses' work setting. All authors discussed and agreed upon the final data analysis. Figure 1 illustrates the process for data analysis.

F1
FIGURE 1:
Overview of data analysis process.

RESULTS

The results of the analysis of the interviews are presented in the following two sections. The first provides an up-to-date description of home care nurses' digital working environment and what characterizes their use of digital technology. The second section presents four themes identified in the analysis and the associated challenges and opportunities related to the use of technology in home care nursing.

An Up-to-Date Description of the Home Care Nurses' Digital Working Environment

The home care nurse acts in a context that reaches into and overlaps several other healthcare settings and services. This includes, at a minimum, interactions with the homemaker services, rehabilitation, primary care clinics, nursing homes, hospital departments, emergency care teams, and pharmacies. It also includes close communication with the patients themselves and at times with their families. In addition to directly caring for patients, a large part of their daily work involves communicating and exchanging information. This is done both synchronously, using telephone and face-to-face meetings, and asynchronously, using a fax machine, written notes, printed documents, e-mail, text messages, or other digital systems.

A typical day for a home care nurse starts in the office where the day's activities are planned and prepared. Then they leave the office to perform all scheduled home visits to patients before lunch. Several visits are performed in a row without returning to the office. Thus, all necessary equipment for all the visits must be prepared and brought along. The home care nurses mainly work on their own in the field unless there are special reasons for collaborating around a patient. Thus, the actual care work is largely performed in isolation. Afternoons are dedicated to administrative tasks at the office. The main task is to document the day's patient visits in the EHR. Other tasks include ordering materials, following up on medication-related issues, and contacting other care organizations or the patients' families. Occasionally, the afternoon is interrupted by a critical situation that must be dealt with straight away, which requires unscheduled patient visits.

The nurses are dependent on hardware and software in their work. Medical devices, such as thermometers, blood pressure cuffs, and saturation monitors are part of the nurse's equipment to measure patients' vital parameters. Technical developments have improved and expanded the use of such devices, with the effect that their “toolbox” is growing larger. In practice, this means that the nurse needs to decide from day to day which equipment to bring, depending on the planned tasks and any unforeseen events that may require additional equipment. The interviews revealed that the nurses sometimes did not trust the accuracy of the equipment because of their experience of measurement errors. This is exemplified by one nurse who expressed frustration over using pulse oximeters:

…first it shows 75 in saturation and then all of a sudden, it's 95, and then it's 82. So, you end up standing there for a number of minutes before you [determine that]… OK, now it's probably stable.

A lack of trust in their instruments can cause uncertainty, time spent on checking again to be sure that they have obtained the correct measurements, and unnecessary calls for emergency care.

Besides medical devices, the nurses' technical aids include a smartphone for calling, sending and receiving messages, and accessing various apps. The apps may be dedicated to the nursing portion of the work, for example, access to the national pharmaceutical register. There are also apps for other tasks such as unlocking doors, navigating, and car parking payment. Nurses sometimes had access to portable laptops or tablets that they could bring along into the field if they wanted to, although many chose not to.

Approximately 30 different digital systems, including computer software, mobile apps, or specific Web services, were mentioned in the interviews. Some systems were used in all the participating municipalities, such as a national software for sharing patient data, a software for overviewing pharmaceutical prescriptions, and a system for coordinating individual patient plans and hospital discharges. Other systems were local and could differ for each municipality, such as the EHR, digital key apps, and software for digital signing of patient-related tasks. The software system mainly used for administrative work is the EHR where all patient activities are documented. Hence, this is the digital environment where nurses spend the largest part of their administrative time. Another common administrative task is to order various materials such as wound dressing, nutrition, and enuresis support.

Four Themes Related to the Use of Technology—Challenges and Opportunities

Four overarching themes were identified related to the use of technology: accessing information in the field, documenting in the field, communicating with others, and increased complexity due to digitalization. The themes are described in the following subsection along with the challenges and opportunities identified in relation to them.

Accessing Information in the Field

This theme concerns how nurses access, or want to access, information in the field. Although approximately half of the respondents expressed that they had access to a laptop, they seldom brought it along when leaving the office. Even though one of the main reasons for contacting someone during patient visits was to access patient information, this information could be from various care organizations, such as the primary care clinic, the homemaker services, or a fellow nursing colleague. Another reason to contact a colleague was to ask for help or advice in a specific situation or to see if the colleague had material the nurse had forgotten to bring. One respondent elaborated on why a computer was not brought and how information needs were handled:

…you have access to a computer that you can bring along. But it's not something I usually do. I think it's a bit cumbersome to carry it on my rounds. If there is something special, it can usually wait until you return to the office, and you can get the information then. Otherwise, you can call the primary care clinic that has the medical records and they can read them to me…

Only two of the respondents had incorporated the use of laptops into their daily routine, whereas a few others brought a computer along to access information in the field when there is no colleague at the office that you can call:

So, we have a specific team that has computers they can take along, but it is mostly on the weekends that I have made use of it [the opportunity to bring a computer].

Others had simply not thought about the possibility of bringing a laptop. For them, it was something they used in the office:

Well, I haven't even thought about it [bringing the office laptop], but it can be a good idea, actually, to do that. You can have a little time over and use it to document.

It is clear that mobile access to information was not standardized, and the need for additional information was mainly handled by using one's cellphone to call a colleague or other care organizations. Table 2 summarizes the challenges and opportunities related to the theme Accessing information in the field.

Table 2 - Challenges and Opportunities Related to the Theme Accessing Information in the Field
Theme: Accessing information in the field
Challenges
 Carrying and starting a laptop may be cumbersome along with feeling insecure due to unstable Internet connection.
 It is not a requirement to bring a laptop for accessing information in the field. Each nurse is free to develop their own routine. This means that there needs to be a demand from the individual nurse's side in order to adopt new technology.
Opportunities for development
 Systems that are more easily accessed in the field. This could be in the form of either hardware that is easy to bring and quick to access or software that complements the lack of a colleague and can be a support in a care situation.
 Routines for how to work with new digital systems, be they physical devices or software, and to integrate them into one's work routine.

Documenting in the Field

The second theme is closely linked to the first because it concerns activities in the field and relates to documentation and administration. The standard procedure for nurses in the field was to keep track of the patients' information and the tasks to perform, using a list printed on a piece of paper. Either the nurses wrote short notes on this paper in the field, or they merely kept the information they needed to document in their heads, without taking any notes at all:

You have your piece of paper with a list of what you need to do during the day, where I usually write “Bring blah, blah, blah.”

Yes, of course. If you have 10 visits, you may have to jot down some notes.

And should you lose it [the piece of paper], that wouldn't be very good. Well, there's a lot of confidential information in it.

A few respondents expressed in the interviews a desire to bring a laptop or tablet to do patient documentation, order material, or carry out other administrative tasks at the point of care:

[A laptop] is what we would certainly like to have, or a tablet, so that we can write directly when we are out with the patient. We can't do that now. We can't fill in the medical records. We can't find medicine lists.

The notes that the nurses take during the day are, as already pointed out, mainly scribbled on paper and are a combination of patient information that needs to be documented in each patient's medical record and information neither related to a specific patient nor relevant to put in the medical record. Table 3 summarizes the challenges and opportunities for the theme Documenting in the field.

Table 3 - Challenges and Opportunities Related to the Theme Documenting in the Field
Theme: Documenting in the field
Challenges
 The information that is gathered by a nurse during the day is not only patient information that needs to be documented in the EHR. This means that even if the EHR could be accessed in the field, there is still a need to follow up on other kinds of information at the office in the afternoon.
 There is a risk that pieces of information are lost or that the confidentiality of the patient is violated by having information visible on a piece of paper.
Opportunities for development
 Systems that support the nurses in managing their routines for preparing and keeping track of the information gathered throughout the day, no matter if it is information that must go into the EHR, information that must be shared with others, or other temporary notes.
 •When developing and procuring software for documentation in the field, one should make sure it does not interfere with patient interaction. Rather, it could be an opportunity for more thoroughly involving the patient and relatives in the care process.

Communicating With Others

Communication with others constitutes a large part of the home care nurses' work. This is done by phone, fax machine, email, or other software with messaging functionality and can have high or low synchronicity. The following quotes exemplify communication with other care organizations and the patients' relatives:

I like to contact my colleagues to make assessments when I am uncertain and want to know a little more. …And I can also call the home care aides if there's something I wonder about. I do not know the patients as well, so I can find out if they are having a good day or a bad one. …I mostly call the primary care clinic when I want to get in touch with a doctor.

Then we have the relatives who call us a lot. Although I have to say that all communication with relatives, all information you can get is good.

When contacting primary care clinics, the nurse typically had to call the clinic, talk to a nurse that passed on the question to the doctor, or had to send a fax with information or a question to the doctor:

Then, according to the routine, I talk to the primary care clinic's nurse first. If the doctor who is responsible for the patient has telephone time just then, I can speak to him or her directly, but that is seldom the case.

Sometimes, the doctor called back during the day or notified the nurse in another way (sending a fax, for example) about actions to be taken. Sometimes, the feedback from the doctor was more indirect, such as when the nurse noticed that changes had been made to the patient's medicine list as a probable reaction to the nurse's request. Sometimes, the nurse did not get any response at all, and either continued to try to contact the primary care clinic or just hoped that the relevant actions had been taken. One example was when the nurse faxed the primary care clinic:

Almost all dialogue still takes place via fax. And I can say that it does not work so well because they answer those faxes quite sporadically. Sometimes I realize that no, they haven't answered in a month. Now there is a crisis.

Thus, communication is a central activity for the home care nurse and can result in work inefficiency when the communication structures are unclear, because time and energy need to be put into following up on loose ends. Table 4 summarizes the challenges and opportunities for the theme Communicating with others.

Table 4 - Challenges and Opportunities Related to the Theme Communicating With Others
Theme: Communicating with others
Challenges
 There are many channels and many different routines for communication between different parts of the organization. The home care nurse must often adapt to others' way of organizing their communication.
 Communication often has low synchronicity, which can result in the nurse spending much time following up on loose ends in the communication loop.
Opportunities for development
 Provide better communication support so that a two-way communication is ensured. This must not necessarily mean synchronous communication, but it should ensure that none of the parties involved are left without knowing if the other side has received and acted on the message.
 Standardize the ways of communicating, or make better use of the existing communication channels as opposed to introducing new ones, in order to reduce complexity.

Increased Complexity Due to Digitalization

The overall impression among the nurses was that digital technology is a natural part of their daily work and not something they usually reflect upon. One aspect was identified, though, that can result in increased complexity: When certain tasks were digitalized, similar tasks were not, which resulted in a significant increase in existing routines. An example was the task of ordering that includes care material, nutrition, and medicine. There was a plethora of systems used to order different items, where each item type had its own ordering routine. These routines could involve the use of faxes, phone calls, emails, or different software systems. One respondent described this in the following way:

So, it's a little hard to keep track of where to order. Some, for example, nutritional drinks and stuff like that, we fax it down to a kitchen here that orders it for us. So, we make use of different systems all the time.

Another aspect adding complexity was that a task that was digitalized was not completely transferred into the digital domain, which meant that a parallel routine was still needed to solve part of the task. One example was the management of the carpool. One respondent described how the digitalization of part of the process made it more complex because it changed from just using a physical piece of paper to using both a digital system and physical paper:

But then [after the implementation of a digital driving record] it turns out that it only registers that the car is in use. It doesn't register that I am the one who is driving it. So, if something should happen, we must have loose pieces of paper in here and write down who has taken the car. …And doing it this way did not make it any better, in my opinion…. For us, it [digitalization] usually makes no difference.

So even if approximately 80% of a task is digitalized, the remaining nondigitalized 20% can be cumbersome enough to lower the motivation for use or the feeling of making work more efficient. There were also comments on the usability of the systems, where the nurses experienced that the systems required many clicks, that it was unclear how to use them, or that they did not match the way a task is performed. The following quotes illustrate this (the second quote is from an interview with a pair of nurses):

And then it's also so strange [in a given digital system]. Because if the patient takes his medication himself, there is no way of entering it into the system. Then it sets off an alarm. And it takes lots of time to go through all these alarms.

Respondent 2: “Now we've counted it to… when entering information [in the EHR], it takes…, was it 19 or 22 clicks?”

Respondent 1 answers: “22 strokes.”

Respondent 2: “Yes, to get into the medical record.”

Respondent 1: “And then when we go to the next patient, we have to start all over.”

The digital systems are necessary for work and are considered to contain relevant functionality. However, they are not as supportive as they could be. Table 5 summarizes challenges and opportunities for the theme Increased complexity due to digitalization.

Table 5 - Challenges and Opportunities Related to the Theme Increased Complexity Due to Digitalization
Theme: Increased complexity due to digitalization
Challenges
 When different digital systems or routines are used for similar tasks, the overall work situation can become more complex.
 The introduction of digital systems that solve isolated tasks may lead to fragmentation of work and a decrease in the degree of standardization of how tasks are done.
 When tasks are not completely digitalized, this can increase work complexity and be inefficient.
 Basic usability issues can affect the work environment negatively.
Opportunities for development
 Methods to more easily evaluate the digital work environment and the digital systems.
 Improve the process of procurement to ensure that the requirements for high usability and good user experience are taken into consideration.

DISCUSSION

Digitalization transforms healthcare practice. For digitalization to be meaningful, the introduction of new digital systems must be useful in relation to the tasks and the context of use. Management needs to understand the complexities associated with the changes in work practice that digitalization implies. Examples of strategies requested in the process of digitalization are an active involvement of employees and careful evaluation of the effects in practice.26–28 To identify paths forward for digitalization of home care nursing, one needs to apply a perspective that takes everyday practice into consideration, including the users' own perspectives on usage of digital technologies. This study aimed to provide an up-to-date description of how digital technology is used in the daily practice of home care nurses and to identify challenges and opportunities for the digitalization of home care nursing that are firmly rooted in the context of use. The results can be applied when taking the next step in the digitalization of home care nursing.

To summarize, digitalization has not transformed the organization of daily practice in home care nursing. The nurses perform planned patient visits during the morning and spend the afternoon doing documentation and following up on various activities. However, the variety of medical devices and information and communication technology used in practice has gradually increased. This makes home care nursing a complex sociotechnical system where new digital systems must be integrated with existing routines and technology.19,29 The themes that were identified, and their relating challenges and opportunities, are here discussed in three sections where the first two, accessing information and documenting in the field, are combined because of their close relationship.

Accessing Information and Documenting in the Field

Access to portable devices such as laptops did not result in changes in how work was organized for the interviewed nurses. They seldom brought a laptop to the patient visit, even if they had access to it, and their afternoons were dedicated to administrative tasks using a computer back at the office. Apparently, it was not always considered sufficiently meaningful to have access to their digital systems in the field. The determining factors could be whether the technology fit the task, or if there was an explicit demand for using laptops. This corresponds with classic theories, such as the technology acceptance model that emphasizes the role of perceived usefulness in relation to the adoption of technology.30 When mobile technology was perceived as being useful or required in relation to the task—such as when working with new patients or on weekends when there were no colleagues to call—it was used.

The results indicate that there were practical thresholds that inhibited the use of digital technology, for example, unstable Internet access, too long startup time, too much other equipment to carry, or cumbersome user interfaces. These thresholds or barriers are somewhat different from those identified in earlier studies when digitalization was not as common. They included, for example, economical aspects, confidentiality rules, and evidence of the benefit of using a digital system.31,32

We saw opportunities for better management of information and documentation in the field. One example concerns the physical notes that nurses use today. This piece of paper serves as an easily accessible reminder and a quick way for jotting down notes that are later handled in the office. However, it is not secure to work this way in the sense that patient information can easily be lost or be visible to unauthorized people. If a digital solution is to overcome such drawbacks, it must be designed so that it is as easy to use as a piece of paper and so that it matches the nurses' mental models of managing such information. One aspect could be that the nurses may indeed want to have paper notes as private working documents and not as something that goes into the EHR or is shared with others. Thus, it would be interesting to investigate how digital technology is perceived to affect employees' privacy, including work-related information not meant for sharing.33

Communication

Communication emerged as a major activity in daily work and as a source of inefficiency and disturbance when interrupted. The communication challenges include interrupted communication and a lack of response, unclear communication routines, and the multitude of media channels over which communication is commenced. It is apparent that home care nurses have large communication needs, both within and across organizational boundaries. This study has not delved deeply enough into the communication flows to understand how communication works in detail and the ways information flows around the home care nurse. The results indicate a need for a better understanding of the communication processes, the media channels that are used, and especially how interruptions and communication with low synchronicity affect the nurses' work.

Complexity and Digitalization

The results provide examples of challenges in the interface between humans, technology, and organizations. Although these issues are not unknown, the maturity of the systems seemed to be low, with functionality that is not completely developed to match the given task and with basic usability problems.34,35 This has previously been identified as a main inhibitor for the adoption of digital systems in home care, as well as a source of error.6,36 An irony here is that when the functionality does not completely support the task, parts or all of the old routine are often kept to handle the task. Thus, the task complexity can actually increase rather than decrease. This can be compared with the ironies associated with automation, saying that automation can actually involve new types of demands for the users.37

Previous research indicates that gaining an understanding of the consequences of new digital systems for daily work is necessary, both on the individual (micro) and organizational (meso) levels; this, however, is frequently overlooked.15,38 In other words, the introduction of new digital systems is often regarded as technology implementation, while in reality, it is also an organizational change. For digital transformation to be efficient and beneficial, it should be viewed as an ongoing process, where development and improvements must be based on up-to-date and relevant testimonies from healthcare practitioners.14,39

Limitations

Home care nursing practice is multifaceted and involves many stakeholders. This study approached the digitalization of home care nursing from the nurses' perspective and left out other perspectives, such as those of primary care clinics and home care services. The study is furthermore limited to analyzing the digitalization in a few home care nursing organizations in Sweden. We believe that such a limit in scope is motivated to gain the depth needed to accurately understand the effects of the digital transformation of healthcare on the meso and micro levels, in this case, the home care nurses' organizational and individual levels, respectively. We acknowledge that digitalization cannot be successfully approached with a “one-size-fits-all” mindset, meaning that the same solution will work for all professions and all situations. Thus, it is essential that one has an in-depth understanding of the digitalization in the specific contexts to be able to identify the challenges and opportunities related to such digitalization.

CONCLUSION

Digitalization is an established part of current home care nursing practice in Sweden. Based on the description of today's practice, which has been outlined in this article, challenges and opportunities have been identified in three areas: (1) nurses' ability to access information and conduct documentation in the field. Here we would especially like to emphasize the process of integrating new digital systems with existing routines and systems; (2) the multitude of communication processes, including different channels and different levels of synchronicity, which home care nurses must manage in the daily work; and (3) an increasingly complex digital working environment, where digitalization appears to make work routines more complex at times. Systematic and regular evaluations can identify where improvements can be most efficient. This can, for example, involve identifying and solving specific usability issues or formulating requirements for upcoming procurement processes. We recommend that these areas guide forthcoming design stages in home care nursing digitalization.

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Keywords:

Community healthcare; Design thinking; Digitalization; Home care nursing; Working environment

Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc.