Approaches to welfare technology in municipal eldercare

Abstract

Welfare technologies have been proposed in Scandinavian countries as way to ensure accessible and efficient care to those who need it. Significant investments have been made to develop and deploy these technologies. This study used a multiple case study design to explore how welfare technologies are implemented in Swedish eldercare practices. The multiple case study generated detailed knowledge and insights from a broad perspective on the employment of welfare technologies within various municipalities. The study revealed three approaches for integrating welfare technologies into municipal eldercare services: as an end-product, as a project, and as a strategy. Findings indicate that municipal welfare technology practices are diverse and multifaceted, yet implementing such practices is a complex process. This study proposes a focus shift, from technological solutions to organizational context, eldercare personnel, and care receivers.

Keywords:

• Implementation methods
• municipal eldercare
• welfare technology

Introduction

The growing older population, increasing healthcare costs, and lack of care workers have implications on current healthcare practices around the world (Gurwitz & Pearson, 2019; Hsu & Yamada, 2019; Song, Song, Timakum, Ryu, & Lee, 2018). Accordingly, our current welfare systems are unmaintainable, and it is necessary to adapt, learn, and develop health- and eldercare that meet the needs of patients and providers (Proksch, Busch-Casler, Haberstroh, & Pinkwart, 2019). To meet these needs, welfare technologies are critical for eldercare organizations (Kruse & Beane, 2018; Rodrigues et al., 2018; Zhang, Schmidt, White, & Lenz, 2018). Understanding the use of welfare technologies is interesting not only for medical and social scientists but also for policymakers interested in using these technologies to drive efficiency and decrease care costs (Keasberry, Scott, Sullivan, Staib, & Ashby, 2018). Nevertheless, welfare technologies are only as effective as their implementation (Ertner, 2019). Some researchers perceive the implementation of welfare technologies as a rationalist, instrumental tool—a simple, linear, coherent, and stable process of implementing best practice or adopting different techniques or welfare technologies (Cozza, Crevani, Hallin, & Schaeffer, 2019). However, studies show that implementation is a complex process, involving a wide range of actors who translate the means and goals differently into practices (Ertner, 2019; Kamp & Hansen, 2019; Rydenfält, Persson, Erlingsdottir, & Johansson, 2019).

In Scandinavian countries, investing in welfare technology is widely believed to be one of the most important strategies for meeting the challenges of an aging population and the shortage of frontline care workers (Kamp, Obstfelder, & Andersson, 2019; Wickström, Regner, & Micko, 2017). Substantial national and international investments are being made to develop these technologies (Kamp et al., 2019). Sweden, as a particular example among Scandinavian countries, is of interest when studying the implementation methods of welfare technology since it ranks high on quality of healthcare and healthcare measures (Anell, Glenngard, & Merkur, 2012; Tchouaket, Lamarche, Goulet, & Contandriopoulos, 2012). Although several alternatives and variations of welfare technologies are available, limited research has been undertaken to examine welfare technology practices in Swedish municipal eldercare organizations (Zander, Johansson-Pajala, & Gustafsson, 2019). This paper contributes to the emerging field of digital health in eldercare by addressing the following research questions:

How do municipalities approach welfare technology implementation?

What are the major characteristics of these implementation practices?

Although welfare technologies are discussed collectively as if they are all essentially the same, there are vast differences between these technologies, ranging from single-user security alarms to multi-user mobile systems and everything in between. However, the purpose of this study is not to investigate the different kinds of technologies but instead to analyze the different practices of implementing welfare technologies in Swedish municipal eldercare.

This paper is organized as follows: First, it provides an overview of current research on welfare technology implementation and its challenges; it then introduces the research setting, data collection, and analyses. The following section presents the study results on the different approaches to implementing welfare technologies in municipal eldercare and outlines the shortcomings of each. Lastly, the paper offers an alternative approach to implementing welfare technologies in municipal eldercare.

Background

A rapidly growing literature now documents the relationship between healthcare and the utilization of welfare technologies (Cozza, 2018; Frennert & Östlund, 2018; Kolkowska, Nöu, Sjölinder, & Scandurra, 2017; Rydenfält et al., 2019). The preventive health potential of welfare technologies is of particular interest. Trencher and Karvonen (2019) have explored how residents’ wellbeing and health can be incorporated into the infrastructures of smart cities. They argue that municipalities play a crucial role as digital educators to help residents utilize smart health technologies and to reinforce preventive longevously public health services. In Sweden, according to a recent survey, municipalities envisage more automation and remote monitoring services in eldercare (Rydenfält et al., 2019). In this context, it is of immense importance to recognize the end-user, which in elder care is older people, relatives, and care professionals. Kong and Woods (2018) have identified a discrepancy in how older people envisage welfare technologies compared to the implementers. Along with other researchers (Katz, 1996; Neven, 2010; Östlund, Olander, Jonsson, & Frennert, 2015), Kong and Woods (2018) argue that older people are often portrayed as a problem in need of a technical fix. In doing so, developers and implementers fail to focus on individual and interpersonal aspects, instead treating older people as a heterogenic group (Kong, Fang, & Lou, 2017).

Welfare technology introduces new landscapes of care by challenging preexisting care cultures and practices (Mol, Moser, & Pols, 2015). How these changes take place depends on the implementation. Within healthcare and social services, implementation of welfare technology requires action and commitment across professional, organizational, sectoral, and cultural boundaries (Ertner, 2019; Kamp et al., 2019). In Sweden and other Scandinavian countries, eldercare is a fundamental component of the welfare system (Szebehely, Stranz, & Strandell, 2017). Eldercare, for which all Swedish citizens of age are eligible, is tax-funded (Szebehely & Trydegård, 2012). The Scandinavian welfare model supports citizens in need of help and autonomy from the family network (Sipilä, 1997). In 2016, the Swedish government approved a new vision for healthcare and social services, titled Vision for eHealth 2025 (Wickström et al., 2017). The goal outlined in this vision is for Sweden to be a world leader in utilizing eHealth and digital transformation to promote equity in healthcare and social services by 2025. Essential to the realization of this vision is the implementation of welfare technology, which refers to digital transformation and a systematic approach beyond single assistive technologies (Heine & Winther Wehner, 2012). Welfare technology is defined as the knowledge and use of technology to maintain or increase the feeling of safety, activity, participation, and independence for a person (any age) who has or is at increased risk of developing a disability (Hagen, 2011; Kolkowska et al., 2017; Modig, 2012). While the definition focuses on technology to improve the life of a person with or at risk of developing a disability, the concept of welfare technology is broad and includes a variety of technologies provided by Swedish society through municipalities or county councils/regions as aids (Sjöberg, Olsson, & Larsen, 2014). Although the definition of welfare technology does not include social and organizational aspects, organizational structures and care practices affect how welfare technology is appropriated, adapted, and used (Mol, Moser, & Pols, 2010; Nilsen, Dugstad, Eide, Gullslett, & Eide, 2016; Pols, 2017; Sánchez-Criado, López, Roberts, & Domènech, 2014).

Implementation strategies are affected by three dimensions: regulative, normative, and cultural-cognitive (Kibler, Salmivaara, Stenholm, & Terjesen, 2018; Laurell, 2018; Li, Terjesen, & Umans, 2020). The regulative dimension refers to laws and regulations. The normative dimension refers to the collective values and norms on what should be done (e.g., best practices) (Bruton, Ahlstrom, & Li, 2010; May et al., 2011). The cultural-cognitive dimension refers to the individual’s perception on what should be done (Welter, Xheneti, & Smallbone, 2018). As the implementation of welfare technology takes place across different administrative layers as well as in different organizational, technological, and cultural contexts (Kamp & Hansen, 2019; Nilsen et al., 2016), the regulative dimension is shared, whereas the normative and cultural-cognitive dimensions may differ. Thus, local actors and conditions affect how the implementation transforms preexisting care practices. To deal with the dynamic and relational nature of the implementation of welfare technologies, this study examines the implementation methods applied across Swedish municipalities. This would demonstrate how welfare technologies are implemented in practice and provide novel insights into how the implementation process may optimize the utilization of welfare technologies in municipal eldercare.

Method

Research setting

The fieldwork presented in this paper took place in multiple Swedish municipalities. Swedish eldercare services are governed on national, regional, and local levels (Meagher & Szebehely, 2013). State subsidies, legislation, and policy declarations are regulated on a national level, while most health- and medical care is regulated on a regional level. On the local level, 290 municipalities are responsible for providing eldercare. The local authorities determine local objectives and services, tax rates, guidelines, and budgets. Local authorities have a high level of autonomy but must follow the Social Service Act which states that municipal eldercare must ensure a reasonable standard of living for people aged 65 years or older. In the past, the logic of the municipal steering model was that local authorities were responsible for both a needs assessment and care provision (Blomberg, 2008). Nowadays, the steering model is adjusted to market principles—in which managers are responsible for assessing the specific needs of eligible individuals, determining which care services they are entitled to, outlining a care plan based on their needs, and monitoring and evaluating the care provided in light of the individual’s changing needs. The care providers may be either local authorities or private providers (e.g., for-profit companies or nonprofit organizations) (Szebehely & Trydegård, 2012). After the initial needs assessment is carried out by local authorities, the individual of age, in need of care, can choose care provider (public or private provider); they pay the same fee to the local authority, independently, regardless of whether a private or public provider is chosen. The fee is based on the services needed and the income of the individual receiving the care. A maximum ceiling for the fee was introduced in 2012, which is approximately 200 euros per month (Palme, 2017).

Research design

Eldercare practices are complex social situations involving many different stakeholders and technologies. A case study perspective gives fruitful insights to explore which types of approaches are used in municipalities, when implementing welfare technology (Flyvbjerg, 2006; Yin, 2009). Research through case study design is an iterative qualitative research approach that uses real-world context to inform the research. The data was collected from interviews, observations, and document analysis. Using different kind of data collection methods provide different kind of perspective and understandings. The data collection followed the method of observe, think, test, and revise (Baskarada, 2014). Baskarada (2014) describe this method as follows

during and after observations [and interviews], the researchers think about the meanings of information collected in terms of what it may imply. This thinking leads to ideas about new types of information required in order to confirm existing interpretations or rule out alternative explanations. During the test phase the researchers collect additional information which, when examined, may lead to revisions of initial interpretations. Such revisions may in turn lead to another test phase. This process can be stopped when a plausible explanation has been developed, there are no outlier or unexplained data, no further interpretations are possible, or it is obvious that any additional data will not lead to new information/insights. (Baskarada, 2014, p. 17)

Interviews were conducted with local politicians, case managers, IT strategists, managers, nurse assistants, nurses, and physiotherapists (Table 1). The researcher conducted and recorded all interviews, each of which lasted from 60 to 120 min. Participants in each municipality were selected using purposive sampling aimed at gathering input from representatives of multiple occupations involved in municipal eldercare. The purpose of this sampling strategy was to get a broad view of welfare technology implementation methods and their challenges from professionals with first-hand knowledge who were able and willing to participate and who best represented the culture of municipal eldercare. Participants were recruited and interviewed continuously until data saturation was reached. The interviews were guided by pre-determined questions, with conversations evolving as part of back and forth exchanges prompted by the pre-determined questions. The questions concerned what welfare technology was used in the municipal eldercare organization, how the technology was introduced to care staff and patients, and what experiences and qualities of the technology implementation the interviewees found important.

Table 1. Interviewed and observed professionals involved in providing eldercare services.

	Number
Municipalities	10
Interviews	Local politicians (5)
	Case managers (9)
	IT strategists (6)
	Managers (7)
	Frontline nurse assistants (8)
	Nurses (4)
	Occupational therapists (5)
Observations	Frontline nurse assistants (5)
Meetings	Management meetings (4)
	Staff and Management (5)
Names, locations, and municipalities withheld to secure anonymity.

Empirical material was also collected through observations of frontline nurse assistants during their working day. The researcher shadowed the nurse assistants without participating in the everyday care activities, although regular interactions took place in order for the researcher to clarify certain situations and tasks. The observations were documented through notes (DeWalt & DeWalt, 2010). The researcher also sat in on management meetings, including those held with and without frontline care staff, when welfare technology was on the meeting agenda. Local documents—such as policies and guidelines, minutes from meetings, evaluations, and implementation plans —were used as additional empirical material. The material was used to help in identifying major characteristics of approaches operating during the implementation processes.

The empirical data was collected over a period of 18 months (January 2018–July 2019). Ten municipalities were selected based on differences in size, geographical location, and political government to create a representative sample of welfare technology implementation in Swedish municipal eldercare.

Analysis

The empirical data was analyzed using qualitative coding (Auerbach & Silverstein, 2003). NVivo was used to manage the data. During the analysis phase, all empirical data was converged, following the guidelines for analysis of multiple case studies (Yin, 2009). The multiple case study was conducted as part of a larger research project. Thus, in the multiple case study presented in this paper, the unit of analysis was welfare technology implementation methods. Local documents were also analyzed thematically. This allowed comparisons between cases as well as comparisons between implementation practices and written routines and guidelines. All data were produced in a specific societal and organizational context, which is considered in the analysis. This research was reviewed and approved by the Swedish Regional Review Board.

Results

This section presents different types of approaches to implementing welfare technology in municipal eldercare. The empirical analysis identified three approaches: welfare technology as an end product, welfare technology as a project, and welfare technology as a strategy (Table 2). These variations are related to welfare technology practices in municipal eldercare, not to individuals. The empirical analysis revealed that these three types of welfare technology practices are recurrently and relatively consistently reproduced (Shove, Pantzar, & Watson, 2012) in a diverse set of municipalities. Each of the three approaches represents enactments from several municipalities and individuals.

Table 2. Welfare technology implementation approaches in municipal eldercare.

	“Understandings” of change	Engagements and procedures	Limitations
As an end-product	The assumption is that accessibility to technology will transform the eldercare organization by instant diffusion of welfare technologies	Investments are made in several welfare technologies	No plans for education, training, evaluation, and implementation Only sufficient to disrupt the status quo if made obligatory to only subscribe welfare technology instead of traditional services
As a project	The assumption is that lessons learned from the project will drizzle through the eldercare organization and lead to changes in care practices	Project groups are formed to manage the project	Lack of long-term plans Often dependent on “key driving person” Difficulties in sustaining after conclusion of project Only involves segments of the organization Imbalance between those involved in the project and those who are not
As a strategy	The assumption is that there needs to be an overall welfare technology strategy to lead change	Policies and routines are developt Concerns the whole organization Large scale	Top-level decision Slow process

As an end-product

Some municipalities had procured welfare technology such as digital medical reminders, GPS trackers connected to the social security system, or nighttime surveillance cameras. During the initial needs assessment, case managers could suggest any of those welfare technologies if they thought that the technology corresponded to the care receiver’s needs. In most municipalities studied, the care receiver could choose more traditional assistance, such as physical visits, a social security alarm without GPS, or a person who delivered medication. Many of the interviewed case managers noted that they lacked the necessary knowledge on the welfare technologies procured to determine what was best for the client and, therefore, preferred to suggest traditional care. One of the case managers stated,

We have recently procured GPS trackers that are connected to the social security alarm. It seems like a good idea that the care receivers can receive help when they are out and about. However, I am not sure how the help is actually provided and how the GPS tracker works. Therefore, I do not suggest it as a solution. So far, none of the care receivers have asked for GPS trackers. (Female Case Manager)

As this interview excerpt illustrates, welfare technology had been procured, but case managers have not received adequate information about the technology to feel secure suggesting it to the care receivers. The care receivers themselves do not request the technology, either. Consequently, the welfare technology by itself was not sufficient to disrupt the status quo.

However, a few of the municipalities studied required case managers to suggest camera surveillance at night during the initial needs assessment. In addition, the case managers had to prescribe night cameras if the individual needed surveillance at night. These municipal eldercare organizations had an agreement with their care providers to install cameras and conduct digital surveillance at night. In these instances, it appears organizational changes were made to integrate the technology into care practices. As one case manager said,

A couple of years ago, we decided that we would provide camera surveillance if the care receiver only needed surveillance and did not have any other needs during the night. All the case managers received information and training about the technology. We met the care providers, who taught us how they put up the cameras and what the digital surveillance entails. I feel that camera surveillance at night is good both for the care receivers, since they won’t be woken up at night, and for the care providers, since it is more efficient than having to physically travel to all care receivers at night. (Male Case Manager)

What characterizes the end-product based approach?

Using welfare technology in municipal eldercare as an end product or as a substitute for traditional care is one approach identified in this study. Procuring technology and making it part of the services provided may be interpreted as a deterministic perspective. As such, the dispersal of technology may be interpreted as a driving force for changing care practices. However, according to the findings, this manner of applying welfare technology brought out both friction and potential. As the extracts above show, technology by itself does not drive change. The first extract reveals tensions from the case manager who did not understand the technology and was not required to prescribe it. Case managers who relayed these experiences preferred to maintain traditional services, whereas prescriptions for the technologies were more prevalent in the municipalities where welfare technology recommendations were obligatory. In those municipalities, organizational transformation had occurred, and therefore, the case managers prescribed the technology to their care receivers. Here, welfare technology (i.e., night surveillance cameras) became part of the needs assessment as a result of an organizational decision; through a normalization process, welfare technology became part of a care routine and has been maintained within the organizational context.

As a project

Another approach to implementing municipal welfare technology in practice revealed in this study is through projects. Oftentimes, the municipalities had applied for funding from government programs to support digitalization and the use of welfare technology in municipal eldercare. This funding was used to support municipal projects that deploy and test various eldercare technologies, such as bed sensors, virtual reality for cognitive stimulation, smart door locks for keyless access, and digital medical reminders. Project teams comprised members representing different functions within the care organization. A project manager, often belonging to the provider unit, was responsible for running the project, and a segment of the care organization (such as a ward, nursing home, or homecare area) was chosen to test the technology. Through project work, the team members gained knowledge and experience integrating technology into care work, and the organization segments selected to test the technologies learnt how to use the technology. Research results suggest that the participants were simultaneously positive about and critical of various aspects of the government initiative for welfare technology projects. While most acknowledged the value of the government investing in welfare technology projects, they also expressed concern regarding the structural ability of the eldercare organization to incorporate welfare technologies into care practices. Further, while the participants acknowledged the benefits of the implemented welfare technology projects, they also highlighted the lack of continuity in using the technology after the project ended. Another noted disadvantage was that deployment of the welfare technology projects tested in select segments of the organization seldomly spread to other parts of the organization. This resulted in an imbalance of welfare technology knowledge and experience among staff in the municipal eldercare organization. Therefore, the knowledge and experience gain for the whole organization was limited, and organizational transformation did not occur. As one of the interviewed study participants said,

Initially you hear a lot about the project. You learn about what kind of technology is going to be deployed and tested. However, you never hear about the results of the testing or what was actually learnt. After a while, you hear about another project, and it is the same story again. Initially, a lot of information is shared, but after a while, the information spread fizzles out. In my opinion, our welfare technology projects never seem to result in any concrete organisational changes. It is always the same persons who are involved, while we others do not get involved or are not invited to learn about the results. It is just about doing projects to get visibility in the local press in order to be viewed by the public as progressive and up-to-date with technology. It is not actually about making changes. (Female Nurse Assistant)

This extract shows that the frontline nurse assistant felt left out and was not invited into the implementation of welfare technology projects. Her opinions mirrored those of several interviewees who were not directly involved in project work. However, their opinions were in stark contrast to the interviewed individuals who were involved in project work. One of the project managers said,

We have been really lucky and received funding both from the Swedish government and the European Union. By being involved in several welfare technology projects, we have learnt how to implement welfare technology and what works and what does not work. Furthermore, we have learnt what kind of governance is needed for embedding the technology. This knowledge and these experiences are something we can draw on for new projects and when we have the budget to initiate organisational transformation. (Male Project Manager)

In contrast to the frontline nurse assistant, the project manager perceived project work as important for gaining knowledge. However, he also acknowledged that there was no funding in the municipal eldercare budget to scale up the technology integration. This points toward the lack of resources and structures to use project work as a driver of organizational digital transformation. Thus, the local level gained knowledge but did not undergo structural changes of care practices.

What characterizes the project based approach?

The project based approach for implementing welfare technology involved limitations and advantages. The limitations identified through this study included lack of long-term plans and upscaling, difficulties in sustaining welfare technology in practice after project completion, dependence on key project members, and imbalance between those involved in the project and those who were not. The identified advantage was gained knowledge and understanding of welfare technology usage in municipal eldercare for those involved in the projects.

As a strategy

Some of the municipalities involved in the study approached welfare technology implementation by developing a strategy. The strategy work occurred at the management level and was often initiated by local politicians; they perceived it as change management and initiated recommendations to incorporate it into the operational care work. As a local politician expressed,

We have developed a strategy for digitization, welfare technology, and eHealth. Our municipality has the vision of becoming a leader in digital transformation of eldercare. Our basic idea is that digital care should be the same for everyone in the municipality. Regardless of the neighbourhood, you should get equal care. We, therefore, work with welfare technology to work smarter and take advantage of our resources. (Female Local Politician)

In this interview excerpt, implementing welfare technology through a strategy appears to be driven by the goals of efficient use of municipal resources and provision of equitable care for municipality citizens. These arguments echo the assumed benefits of digitalization and the use of welfare technology advocated by the Swedish government (Wickström et al., 2017).

Many of the municipal eldercare organizations in the study had initiated several welfare technology projects but realized that they needed an overall strategy to work more systematically with welfare technology. Accordingly, strategy as an approach to implementing welfare technology is arguably a progression from incorporating welfare technology as a project. One of the managers commented,

We need to think differently about care work. We have to examine the way we do care work and what we can do differently. We will also have to recruit people with new kinds of competencies. We need to simplify and remove the administration or get better at administering faster. Changes take time. Funding is good for starting a change, but the change must first be thought through so that it does not result in insulated islands. (Male Manager)

In the extract above, the manager highlights that organizational transformation requires well-thought-out strategies and ways of working. He acknowledged that new kinds of competencies may be needed to support digital transformation and the uptake of welfare technology in municipal eldercare. The need for different and new competencies in eldercare organizations was also highlighted by another manager

With welfare technologies there needs to be opportunities to fail, redo, and test again. We need employees who are innovative and adventurous. They should know how to provide care, but they should also have digital skills. They must be able to convey technical solutions to other employees and to the older users, and they must be able to translate the technical into an understandable language. They should be involved in translating the needs for care into technical solutions. I believe that younger employees want to work with technology and have higher expectations that technology will be used in healthcare and care. (Female Manager)

This extract exemplifies that implementing welfare technology through strategy is not about welfare technology or digitalization as a technical fix but about future employees and their ability to transform eldercare practices. This suggests that management does not believe it can digitally transform the practice of eldercare as it is; rather, change is only possible with new kinds of competencies among employees.

What characterizes the strategy-based approach?

The empirical results show that applying welfare technology through strategy development involves new polices and routines for the whole organization. In the municipalities studied, the welfare strategy was a top-level decision, developed by politicians and executive management with the help of IT strategists.

Discussion

Several researchers note (Andreassen, Kjekshus, & Tjora, 2015; Essén & Lindblad, 2013; Halford, Lotherington, Obstfelder, & Dyb, 2010) that despite large investments in welfare technology, it has proven to be difficult to integrate welfare technology into the everyday services of municipal eldercare. The multiple case study, on which this article is based, sought to identify how municipalities implement welfare technology, and the major characteristics of the different implementation practices. The study revealed three approaches for integrating welfare technologies into municipal eldercare services: as an end-product, as a project, and as a strategy.

Depending on the approach, the perception of implementing welfare technology varied. In the end-product based approach, large investments were made to procure and implement specific welfare technologies in order to digitize certain services offered by the municipal eldercare organization (for example nighttime camera surveillance instead of physical night visits). One major factor explaining the choice of the end-product based approach, is that traditionally municipality eldercare organizations have an experience of prescribing technology for people who are in need. In the past, walkers, grabbers and specialized beds have been prescribed by the municipality eldercare organization through a need’s assessment process. The end-product based approach is an extension of this approach. However, the differences between traditional technologies (e.g., walkers, grabbers or specialized furniture’s) and welfare technologies, are that while traditional technologies may be perceived as stand-alone products that are not dependent on network platforms, standards, etc., welfare technologies on the other hand are. Treating welfare technologies as stand-alone products introduces new problems, such as lack of interconnectability and compatibility with other technologies. Furthermore, the study revealed that many of the municipalities that use the end-product based approach lacked sufficient time and resource to educate and train care personnel and therefore were unable to make them feel comfortable and safe in their roles as welfare technology prescribers. For example, some of the case managers’ perception was that they had not been given enough information about- and training on the products that they were supposed to prescribe to care receivers. It has previously been shown that successful implementation of welfare technologies requires both time and resources (Atroshi, 2015; Øderud, Ausen, Aketun, & Thorgersen, 2017). As welfare technology changes care work and practices, new competences, training and education is needed. Lo, Waldahl, and Antonsen (2019) highlight that successful introduction and implementation of welfare technology originates mostly from appropriate organizational change and competence development (Lo et al., 2019). The findings of this study indicate that in the municipalities, where welfare technology prescriptions were obligatory, welfare technology (i.e., night surveillance cameras) became part of the needs assessment as a result of an organizational decision. This led to, through a normalization process, that welfare technology became part of a care routine and was maintained within the eldercare practice.

The major factor explaining the choice of the project-based approach, was external funding from the Swedish government. External funding enabled municipalities to become sites for designing, testing and learning about welfare technologies in order to respond to particular societal, political and economic issues. The advantage of this approach was that it enabled experimentation and exploration of welfare technologies. The project-based approach created a space to navigate, negotiate and reduce uncertainty about welfare technologies through real-world experiments, gaining knowledge and experience by ‘doing-by-learning’ and ‘learning-by-doing’. The project based approach affected the shaping of knowledge and understandings in regard to welfare technologies among the project participants, but seldomly contributed to overall organizational transformative changes in care practices, welfare technology usages and adoption, due to the lack of continuance- and full-scale implementation plans post project delivery. The level of knowledge gained from the project-based approach varied considerably among the project participants. The project leader, in most cases, was the driving force in the project and had great motivation as well as responsibility to see the project through, while the motivation of the project participants, people whose roles in the organization was seen as a means to automatically transfer knowledge into the organization i.e., carry knowledge and learning from project to daily roles, varied greatly due to involvement, responsibility and roles in the project and expectations to explore and experiment with welfare technologies. Welfare technologies that were aligned with existing care work beliefs and knowledge created more involvement among project members than those which were not. In this context, the normative cultural-cognitive dimension on the local level is of importance (Bruton et al., 2010; May et al., 2011; Welter et al., 2018).

A major factor explaining the choice of the strategy-based approach, was initiatives from local politicians. In these cases, the local politicians had the vision to digitize as many of the municipal eldercare services as possible in order to keep the municipality up-to-date and handle the increasing costs of eldercare. In this context, a technology-optimistic discourse was apparent. Welfare technologies were portrayed as having a great potential to solve eldercare-capacity challenges. This discourse is very much in line with the Swedish national discourse on welfare technology (Wickström et al., 2017). In contrast to the end-product based approach, the strategy-based approach has a holistic view of welfare technology and eldercare practices (e.g., using welfare technologies to support transformative organizational changes). However, the findings of this study indicate that the strategy-based approach was characterized by top-level decisions. One problem, as a result of top-level decisions, was resistance to adopt welfare technologies among the care personnel. This, for example, was found in the case managers’ talk about feeling short of time for learning, using and prescribing welfare technologies. Nilsen et al. (2016) argue that resistance to the deployment of welfare technology can come from fear of change, fear of losing power or control, and fear of losing moral and professional control. The relationship between technology and professional identity seems to be a persuasive cause for resistance (Nilsen et al., 2016). Therefore, negotiations on how to acquire, adapt, and shape technology in continuous work practices may alter resistance over time (Kamp & Hansen, 2019; Shove et al., 2012; Wenger, 1999). Indeed, end-user involvement in the decision-making process of procurement, deployment, and implementation of technology at a workplace may successfully counteract resistance (Greenbaum & Kyng, 1991; Hartswood, Procter, Rouncefield, & Sharpe, 2000; Murray et al., 2010).

At the end of this article, it appears fitting to highlight five interconnected key points when implementing welfare technology. First, implementation of welfare technology is a sociotechnical process, in which there has to be room for mutual learning and mutual transformation of both the structures of the care organization and the care workers’ way of working (Berg, 2001). As such, the approach chosen to implement welfare technology needs to be flexible and adaptable. Second, welfare technologies are not ready-made or plug-and-play (Mol et al., 2010; Pols, 2011; Sánchez-Criado et al., 2014) because both the technology and the organization in which the technology is situated simultaneously shape and reconstruct each other, depending on the meanings given to the welfare technology by the users. It depends on the context and the care practice. A “good practice” for implementing welfare technology is using the knowledge and experience that already exists in the organization (Berg, 2001). In other words, since the success of implementing the technology is so dependent on the context and established practices (and existing knowledge and beliefs of staff), it is only logical that those factors be used as the basis for determining how to implement the technologies. Third, focus should be placed on the purpose for using technology to provide quality care and not on technical aspects or a certain technology (Hofmann, 2013). Fourth, a shared strategy or vision drawn by politicians and management in conjunction with end users, that is agreed upon by the organization’s employees may be essential to promoting shared goals and aims of welfare technology deployment or to stipulating a future image of welfare technology deployment. However, putting welfare technology into practice in order to achieve the aims and goals ought to be accomplished through an iterative implementation process that is open to bricolage, improvization, and mutual negotiations as the aims and goals will most likely evolve during the implementation process (Berg, 2001). Five, time and resources, and plans for maintenance are crucial success factors for welfare technology implementation.

Limitations

The findings are based on an exploratory multiple case study and are limited by the innate aspects of qualitative studies (Baxter & Jack, 2008). The findings cannot be generalized to other contexts or cultures. However, further quantitative studies can achieve wider generalization of the findings. It might also be of interest for future research to investigate the similarities and differences when implementing welfare technology in other public service sectors, such as education or social services.

Furthermore, the complexity and the richness of the empirical data have been categorized by the qualitative coding (Auerbach & Silverstein, 2003) and the aim of analytic generalization (Yin, 2009). Thus, the results represent patterns and wholes, not individuals or separate data sources.

Conclusion

The aim of the multiple case study presented was to explore the ways Swedish municipalities implement welfare technology and the characteristics of municipal welfare technology practices. The study revealed three approaches to welfare technology implementation in municipal eldercare were revealed. One was viewing welfare technology as an end product. As such, the welfare technology was procured and perceived as a simple tool for performing traditional care services digitally. However, procuring welfare technology was not sufficient to disrupt the status quo (prescribing traditional care services). On the other hand, when prescribing technology instead of traditional services was made obligatory, technology usage became embedded into care practices and reinforced organizational changes. Another common way welfare technology was incorporated was through projects. A project structure was established, and lessons about benefits and drawbacks of integrating technology into care practice were learnt by those involved in the projects. The team members also learnt about what kind governance, infrastructure, and training was needed for integrating technology in eldercare practices. However, the technologies were seldom taken up by the whole eldercare organization but instead evolved into isolated islands. Furthermore, the knowledge and experiences gained stayed within the circle of those involved in the projects. A third approach to welfare technology was through strategy. In most cases, the strategy was developed at a management level. Several of the municipalities that chose the strategy-based approach had previously undertaken welfare technology projects but had realized that they needed an overall strategy to systematically work with transforming the municipal eldercare practices. Based on these findings, this study proposes using the insights and knowledge that already exist in the organization. A way forward is to view the deployment of welfare technology as an iterative process aiming at increasing human welfare and providing equal access and just distribution of care through and by technology while also respecting privacy, dignity, and vulnerability of the patients and care personnel. In conclusion, this study provides an analysis on different methods for incorporating welfare technology into Swedish municipal eldercare. The difficulties involved in technological changes in eldercare organizations are related to societal structures and power relations in eldercare organizations. This indicates a need to continue to describe and analyze appropriate methods and processes of welfare technology implementation in municipal eldercare practices.

Acknowledgments

I would like to thank professor Britt Östlund, who has contributed by securing the funding for this research. I would also like to thank all my voluntary respondents and anonymous reviewers.

Disclosure statement

The author declares that this research has no commercial or financial affiliations that could be construed as a potential conflict of interest.

Additional information

Funding

This work was supported by the Swedish Research Council for Health, Working Life and Welfare [grant numbers 01755, 2017] and partially financed by the Knowledge Foundation through the Internet of Things and People research profile.

Notes on contributors

Susanne Frennert

Susanne Frennert works as senior lecturer/associate professor at the Faculty of Technology and Society at Malmö University. Susanne Frennert’s expertise lies in the field of Human Computer Interaction, Human Robot Interaction, cognitive science, human factors and participatory design—involving older people in the design process of social robots and healthcare technologies to better match their needs, wants, and desires.