97 Barriers and Facilitators Associated with the Implementation of Technical Improvements in Medical Beds 4 This process evaluation study aims to examine the extent and quality of the use of the new smart functions in these medical beds – referred to as Technical Improvements in Medical Beds (TIMBER). Specifically, we investigate the mechanisms through which TIMBER was intended to function, the responses of patients and nurses, and the contextual factors that facilitate or hinder the use of these smart functions. Additionally, our evaluation considers factors such as the compatibility with the existing technological infrastructure, the impact of the socio-political context, and the skills, beliefs, and practices of key stakeholders. Background In March 2019, smart hospital beds were introduced in our university medical center. These beds were selected through an extensive tendering process that involved various stakeholders, including nurse managers, nurses, wound care nurses, quality and safety advisors, and infection prevention experts. Compared to the previous medical beds, these smart beds offered additional technical features, such as an integrated weighing scale, bed-exit alarm, full seating functionality, and a head-angle alarm. These enhancements were designed to support various clinical needs, including easier malnutrition screening, improved management of edema and hypervolemia, reduced risk of in-hospital falls, and prevention of pneumonia. The causal assumptions underlying each smart function are detailed in Table 1. The complexity of TIMBER stems from several factors. First, the beds offer numerous functions, requiring either participation in educational sessions, specific skills, or reference to a detailed 98-page user manual to operate the functions correctly. For instance, the fall-detection feature relies on an initialization of the weight function once per patient to ensure reliability. With up to 2300 nurses, along with other caregivers such as nursing assistants, facility care staff, and physical therapists, ensuring consistent education and adoption is a demanding task. This large number of professionals who will use TIMBER presents a significant challenge. Second, not every function is relevant for every patient. For example, a nurse might determine that there is no need to activate certain features, such as the head-of-bed-angle alarm, which may result in limited interest in getting to know this function or quickly forgetting about its existence. The implementation plan for integrating TIMBER was developed by an employee of the manufacturer. To the best of our knowledge, no specific implementation framework, model, or theory was used to guide the plan. The strategies employed primarily focused on education and facilitation. Education followed the train-the-trainer principle, a common method in nursing practice [12]. At least one key user per ward was trained,
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