114 Chapter 4 might motivate and remind them about their role. We became aware that key users often consider these activities as additional tasks, instead of part of their job. For the other strategy, education, either key users or the manufacturer (often the clinical advisor) provided on-the-job-training sessions. While most nurses indicated that they had participated in an on-the-job-training session (2020 72%; 2023 61%), given the dose and fidelity of TIMBER’s use, participating in these sessions had a limited contribution to knowledge acquisition and incentive to use TIMBER’s functions. In the process evaluation we did not evaluate the quality and content of the educational sessions, which could have impacted these results. However, it is likely that nurses did not feel the need to fully engage with the on-the-job-training sessions, as the prevailing mindset appeared to be ‘it is just a bed’. Additionally, it is possible the practical application of these functions was too complex to convey effectively in a single on-the-job-training session. We agree with Nilsen and Bernhardsson [18] in emphasizing the importance of considering context holistically, as successful implementation often relies on the interplay of multiple contextual factors. Addressing determinants or contextual factors in isolation risks overlooking how seemingly minor determinants can combine to create powerful effects, or how strong determinants might interact to generate limited impact [18]. For example, failing to address contextual factors, such as selecting the appropriate location for key user training, could lead to misjudgments about the effectiveness of deploying key-users. It is important to consider practical constraints, such as the fact that nurses are unlikely to walk 20 minutes from their wards to attend an educational session. A qualitative study by Groeneveld et al. revealed that a number of nurses, particularly those who were approaching retirement, tended not to be interested in learning how to work with technological innovations [19]. Nurses expected that younger nurses would be better skilled in working with technology [19]. Our study, however, did not provide evidence for such expectations. All nurses had high expectations of the beds from the outset, but often underestimated what knowledge was needed to use the technology. Most of them seemed to expect the smart bed to be an intuitive form of technology that required no additional skills or knowledge. The innovation of smart functions in medical beds is still evolving. Recent advancements include predicting daytime behavior in children with autism spectrum disorder [20], detecting insomnia [21], heartrate monitoring [22], and estimating skin temperature [23]. Based on the barriers identified in this study, we highlight the importance of co-designing innovations with nurses, as they are the primary healthcare providers working with these technologies daily. We recommend using implementation
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