We found that implementation of TM gave nurses an increased ability to act although there are still minor, but essential barriers to full integration. The patients expressed an increased feeling of security after having had positive experiences with TM. In addition, the patients reported that they had different preferences and needs regarding how much information they would like on what is communicated on the TM platform and how involved they wanted to be. Furthermore, the results indicate that although TM provides the community nurses with a tool to be more proactive in preventive care, the nurses found it challenging to facilitate behavioral changes in relation to such care. This is a complex issue as some of the patients report that they experience receiving limited information on strategies to prevent-re-ulceration.
The first theme describes an “enhancing professional self-efficacy for wound care”, which also implies that the knowledge and guidance provided to the community nurses are facilitating their actions. This is in line with previous research that has shown that TM increased health care professionals’ skills and knowledge on wound assessment [11, 12, 22, 23]. Increased knowledge, and consequently an enhanced ability to act, are important elements when evaluating the use of TM. Through these factors, the nurses may experience improved confidence and a feeling of security. This can in turn empower them to act and give high quality care.
These results are also reflected in the patients’ feedback, as they reported having developed more security through their experiences with TM. Furthermore, different factors such as self-esteem, positive emotions, and organizational and personal commitment have been found to mediate job satisfaction [24]. Considering this, it would be interesting to investigate how TM may affect or mediate job satisfaction, as it provides the nurses with an increased ability to act. This is important, not merely because of the positive aspect of job satisfaction in itself, but also because job satisfaction is a determinant of turnover intention. For instance, Perry et al. [25] found that turnover intention (i.e., employees’ intent to find a new job with another employer) is more present among employees that are less satisfied with their jobs. Hence, the results from the present study may have other important implications beyond the scope of this paper.
The results indicate that there are areas with room for further improvement. Although the nurses in the present study reported that they felt more secure and that TM provided them with an increased ability to act, they also recognized that TM has the potential to function even better. The nurses described different challenges with the technology that could be improved. These issues include difficulties with the basic services as the telecommunication system. Moreover, it also relates to more comprehensive issues. One such issue relates to a feeling that the application is not fully integrated in work life. Another relates to the experience of TM as a time-consuming process and consequently increasing workload, contrary to the intention of the use of TM.
The nurses expressed that the service managers should provide them with more time and resources to really get familiar with TM and thus be able to fully integrate it in practice. These results are in line with a scoping review that pointed out that the technology itself is a hindrance due to a shortage of resources and time, training, and finances [26]. This is also reflected in previous results from an earlier stage in this project showing that documentation is seen as overly time-consuming [12]. Moreover, adequate equipment and time is essential to benefit from this new technology [13]. In order to address these challenges, the responsibilities of health service managers in primary care need to be addressed more. These responsibilities also need to be specified to facilitate the adoption of new technologies and work to integrate them in practice. Consequently, the use of TM technology can be a relevant alternative and supplement to usual care [1].
The main difference between the current study and the qualitative study conducted in the first wave of the TM project [12] is that the current study provides knowledge regarding the experiences of both health care professionals and patients. Furthermore, Kolltveit et al. [12] found that introducing TM in primary and specialist health care implied a change in wound assessment knowledge and skills. The authors further emphasized that the health care professionals developed a better and increased understanding of what they saw when they evaluated the ulcers and performed wound care. The results from the present study indicate a change in relation to the nurses’ everyday work life, as the online web ulcer platform made it possible to seek help regarding the ulcer treatment from more experienced healthcare professionals.
The results further highlight that the differences in patient preferences and needs are central to consider in the implementation of TM. Some of the patients express that they would like to be more involved, while others express that they do not want further information or involvement. The latter group would therefore like the nurses to take full control over their situation. Two central concepts in the health science literature are person-centered-care or patient-centered care, respectively [27]. Both concepts imply that patients should be more involved as partners in their care and treatment. Thus, they highlight that the patient should be the most central stakeholder in the decision-making process [28]. A recent systematic review investigating the use of person-centered care in chronic wound care found improved outcomes regarding pressure ulcer prevention, patient satisfaction, patients’ knowledge and quality of life [29]. Considering the findings from Gethin et al. [29] and the results from the present study, we argue that patients’ needs, beliefs, strengths and personality should be carefully considered in the implementation process. This is also highlighted and pointed out by Foong et al. [2], who argued that patients’ preferences, attitudes and circumstances are important factors for successful adoption of digital technology in diabetic foot ulcer treatment.
The results showed that nurses found it challenging to facilitate behavioral changes in relation to preventive care. This is also somewhat reflected in the answers from patients, as they express that the nurses have limited focus on different strategies to prevent re-ulceration. However, the difficulty of overcoming patient inertia for facilitating change in behavior may not be directly linked to TM use. Instead, it may reflect that the nurses are not truly integrating technology into the process of care. This would require more careful planning and resourcing of the technology implementation process. Meanwhile, the nurses report working with preventive care – communicating central and easy-to-use advice – but experiencing that the patients do not make use of this information. To understand the discrepancies in how these experiences from nurses and patients are intertwined goes beyond the scope of the present study. However, it points out central aspects for future studies to examine. Moreover, we found that different patients had different needs and preferences – an aspect that could also be further improved through patient-centered care. For instance, Li et al. [30] found that an individualized, educational 12-week program (including one-on-one training during bedside visits, brochures, telephone follow-ups and home visits) significantly improved foot self-care behavior. However, there was no change regarding the incidence of the foot problems. Considering this study and the results from the present study, we argue that future implementation of TM should consider even more systematic and individual-level work with preventive care strategies. TM provides nurses with a tool to be more proactive in preventive care, but it seems difficult to overcome these challenges by only implementing TM without a complimentary behavioral strategy.
Treatment of foot ulcers among people with and without diabetes challenges the health care system in terms of resource distribution and management strategy [31]. By extension it has been important to investigate the effectiveness of TM, as it may represent an approach that can meet these challenges. The quantitative results that the current study derives from was reported in Smith-Strøm et al. [1] and Iversen et al. [3]. Smith-Strøm et al. [1] found that TM follow-up to patients was noninferior for ulcer healing time when compared with standard outpatient care. Furthermore, when comparing risk from death and amputation was considered, no significant differences in healing time was found. In secondary analyses of data from this study, Iversen et al. [3] aimed to compare changes in self-reported health, well-being and quality of life. The findings showed no significant differences between the intervention and control group in changes in scores for the patients’ reported outcomes. The current study found some room for further development in how we integrate TM in regular practice and need for better technological equipment. However, we do not know how patients experiences standard care and potential challenges that arise in such care compared to those in the TM setting. The current study does still provide essential insight that enriches our understanding of TM as an appropriate and effective method for wound care management and treatment.
Study limitations
The insights from this study provide knowledge on how nurses and patients experience the implementation of TM in primary care. A potential limitation is that the answers from patients might have been influenced by the interactions and established relationships with the nurses. This may have led them to give more positive answers to show gratitude for the treatment and their involvement. In addition, the nurses may have cultivated a specific culture within the clusters that may have affected their answers. This could lead to responses not necessarily representing their own actual views and experiences. The interviews were conducted over the telephone, which may have led to loss of nonverbal data that could have provided contextual information that could in turn have informed the analyses. As this is a technology-based intervention, one can argue that it would have been beneficial if the interview guide included specific questions regarding technical issues with and barriers to operating the TM technology. This might have provided us with clearer and more detailed information regarding the possible barriers when using this method. In addition it would have been beneficial if this further implementation study also included interviews with the healthcare professionals working at the hospital as this may have provided us with knowledge regarding their experience with the TM intervention. Both of these issues would be a fruitful topic for further research on similar TM approaches.
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