All participants reported that using digital medicine dispensers influenced their relationships with patients in terms of personal interaction and healthcare delivery. Since no major differences regarding reported experiences among health professionals and municipalities appeared, we present our results without differentiating groups of participants. From the interviews, three analytical categories associated with changes in caregiver-patient relationships related to using digital medicine dispensers in home health services emerged: 1) National and local pressure to make services more efficient; 2) Shifts towards empowering patients; and 3) Surveillance mechanisms in the technology.
National and local pressure to make services more efficient
Participants reported that pressure from national and local authorities to maximise efficiency was a chief driver for implementing digital medicine dispensers in home healthcare services. For home healthcare professionals, pressure to free up time and resources had influenced their relationships with patients. They had already faced time constraints in delivering adequate care, and recognised that traditional face-to-face care would become unsustainable. Short visits for medication assistance were unduly expensive since travel time was the same regardless of the visit’s purpose. The home healthcare professionals expressed that leaving medication to digital medicine dispensers afforded them more time to deliver quality care to patients with greater needs: ‘We can manage our time better. Instead of coming and going all of the time, it is better if we sit down and spend some time with the user.’ (Nurse).
To encourage patients to trust the technology, home healthcare professionals also expressed the importance of their confidence that the technology’s benefits outweighed its potential disadvantages. For some professionals, such confidence was necessary to successfully implement the technology. Some home healthcare professionals reported troubled relationships with patients who feared reduced services upon consenting to use the medicine dispenser. In introducing the technology to patients, the professionals had to consider such worries:
My impression is that many older users keep wondering what the municipality will save money on this time. They often say ‘I want to have what I’ve been promised. What are you going to deny me today?’. So [it is important to make clear] that we work to achieve the same goal and to tell them that I’m not here to deny them a lot of things and withdraw the healthcare that you should have. (Occupational therapist)
However, participants also reported that pressure to be more efficient benefitted patients as well. In general, assistive technology could allow older patients to grow old in their homes, thereby delaying their institutionalisation and supporting their autonomy, which the home health professionals identified as an important message to communicate to patients in order to maintain trust in their relationships. Offering a medicine dispenser instead of time-consuming traditional medication procedures could also mean higher-quality care and safety in medication therapy: ‘Cost savings becomes a side effect. In my view, it [the medicine dispenser] improves the quality of services and makes them safer’ (Nurse).
Shifts towards empowering patients
Participants reported that another major driver of implementing digital technology in home healthcare services was its contribution to empowering the technology’s users (i.e. patients). Whereas traditional healthcare can be paternalistic and create passive, dependent patients, the new technology can support patient autonomy, at least in parts of care, as home healthcare professionals expressed, in particular adding that the traditional healthcare model, with its frequent home visits could strain some patients. As part of that model, medication assistance often consists of brief, hurried, and often delayed visits from nurses that patients have to stay at home to receive, as one nurse explained: ‘They [patients] need to wait for home healthcare services every time, which is exhausting and also ties them down.
Home healthcare professionals reported that both younger and older home healthcare service users wished to be independent. For many participants, the context for their positive experiences with digital medicine dispensers was the introduction of a national healthcare model called ‘Everyday Rehabilitation’, the healthcare philosophy of which prioritises helping patients to cope with chronic disease and supporting active living. Home healthcare professionals hoped that assistive technology could be part of their efforts to achieve that goal for the sake of patients as individuals. As an occupational therapist explained:
Everyday rehabilitation becomes increasingly important to integrate welfare technology into the daily lives of users. I always like to stress that. As an occupational therapist, my experience with assistive tools is that it’s irrelevant how many gadgets are available. What counts is that the assistive technology makes users more active. If it makes users more passive instead, then we have failed.
However, a reported disadvantage of the technology was that care focused on empowerment and self-care has not been suitable for all, especially not frail and dependent older patients. Participants agreed that many patients continue to need so-called ‘traditional care’, involving professional’s presence in order to ensure that adequate healthcare is provided. Regarding such users, participants expressed that patient-caregiver relationships would suffer if care were administrated by way of remote technology. Healthcare professionals remained wary about which users should be equipped with digital medicine dispensers, and, in particular, when during the course of care such interventions were appropriate:
I think it comes down to when we start using dispensers for our users. It’s important that they’re not too ill at that point. In one case we responded too late. She [the user] couldn’t handle using it [the dispenser] and unplugged it. In that case we should have intervened earlier, before her dementia had progressed too far (Nurse assistant).
Of course, no participant characterised medication assistance technology as the sole point of contact with patients, but instead conceived the technology as a means to enhance care. Many participants reported that successfully implementing digital medicine dispensers into care required good patient-caregiver relationships, which themselves required building trusting relationships by ways of face-to-face interaction and by assessing individual care needs before the introducing of technology. In any case, information about the technology had to be modified to suit each individual patient and his or her situation.
Lastly, whereas advocating independence was convincing for some patients, advocating safety was more convincing for others. Although participants stated that taking the time to educate patients was important, they added that healthcare professionals also need to ensure that delegating healthcare tasks to technology devices would result in safe, improved care. Professional experiences had taught them that healthcare professionals’ insecurity with new technology would negatively affect their relationships with patients, who would develop the same sort of insecurity. As a nurse working for a technology supplier summarised: ‘Insufficient knowledge makes people “rush” things. Health professionals aren’t trained, and users don’t get sufficient instructions and become anxious.’
Surveillance mechanisms in the technology
Participants reported that when healthcare professionals think that technology can improve quality and safety in care, they express a positive attitude towards the technology. They added that safety and quality can benefit from control mechanisms that compensate for fewer face-to-face services, including alarms that notify the home healthcare service. Surveillance mechanisms in medicine dispensers can also provide knowledge about the medication habits of patients who declined to receive visits at home from home healthcare services:
We [the home healthcare service providers] have a woman with diabetes who’s been badly regulated. We think it’s partially because she forgets to take her medication, since we’ve found three or four doses left when we replaced her pill dispenser. She hasn’t requested more follow-up visits from home healthcare services, and we replace her pill container only once a week. We’ve discussed the situation with her several times, but nothing happened. [With the new digital dispenser], I now hope to see a long-term improvement in her blood sugar level (Nurse).
However, participants also expressed that surveillance sometimes monitors not only medication practices, but also aspects of users’ lifestyles. Even if home healthcare professionals had programmed digital dispensers in cooperation with users, aspects of users’ habits became apparent because surveillance allowed insights into their lifestyles at home, as a nurse recalled to a particular patient:
I had a patient. We [She and I] agreed that the dispenser could be left open from 8 to 9 in the morning. Great, I thought, it’s programmed accordingly. But then the alarm went off, several days in a row. I soon realised that she doesn’t wake up early, yet wished to give the impression that she does, because she thinks it’s embarrassing to not be an early riser. We [the healthcare professionals] can see what sort of lives patens lead, and their true habits become disclosed.
Participants explained that they often discuss with each other the ethical challenges of their relationships with patients when delivering digital health services. The most common challenge related to the dichotomy of warm hands and cold technology - warm hands being synonymous with compassionate care delivered individually and cold technology being associated with technical surveillance and control of patients’ lives. Although reducing care to rote technical tasks concerned participants, possibilities for control and surveillance were not conceived as problematic, but advantageous for relationships with patients since such means can better inform healthcare professionals and help them to accommodate patients’ needs. A nurse reflected upon ethical dilemmas that she usually discusses with peers:
We’re good at highlighting ethical problems with technology. We rarely discuss more hidden problems, but instead conclude that whenever we determine what’s ethically right we’re on the right track.
Some participants reported that the technology improved their relationship with patients, particularly by allowing them to care for patients without having to focus on medication. For some patients, digital medicine dispensers made administration of medication more predictable than other arrangements had and participants expressed that if patients perceived the benefit of using technology to receive higher quality of care, then patients were likely to be more comfortable with the surveillance that accompanied using the technology. In one instance, the ideal of delivering so-called ‘warm care’ was challenged by a story about a patient who had reportedly said ‘There’s nothing wrong with the focus on warm hands, but for me, it’s more important to get my medicine at the right time’. To encourage less willing patients to accept the technology, participants reported giving them information about the benefits of using the devices. However, it remained unclear whether patients were made aware of possibilities for monitoring their lifestyles. As participants indicated, as long as healthcare professionals felt that patients could be helped even by means of additional surveillance possibilities, then implementing technology was not portrayed as a problem:
We thought they would be able to manage better and take their own medicine even if they were allowed to use the medicine dispenser. Because in that way, we would be able to control whether they took their medicines (Assistant nurse).
Among other unexpected consequences of using the technology participants reported, was that even if patients managed to become independent in administrating their medication by using the digital medicine dispenser, a new form of dependence for patients and their next-of-kin emerged when technical problems occurred and they required assistance from healthcare professionals. Although participants claimed that such threats to autonomy sparked distrust in new services and technologies among patients, they also perceived that problems with the technology typically stemmed from user error. As one nurse explained:
You should remember that this is technology and that it’s not infallible. You should avoid for instance using GPS technology or a medicine dispenser alert system as an excuse for doing nothing as long as it doesn’t sound an alarm, because one day it will suddenly fail. Its battery could go dead without anyone noticing, or something else could go wrong. In that sense, technology can never replace human contact. An alarm won’t go off every time a user has a fall injury or fails to take his or her medicine.
Altogether, implementing technology such as digital medicine dispensers introduced new, unforeseen opportunities and challenges for the relationship between home healthcare professionals and their patients.