Technology in aged care: a qualitative survey of academic, research, and technology industry professionals

Aims and Objectives The study’s aim was two-fold: (1) to explore the experiences and perceptions of industry, academic, and research professionals concerning technologies used within aged care; and (2) to identify needs-led priorities for the future development and application of technologies within aged care. Background Global population ageing requires a recalibration of aged care policies, systems, and services to promote and support healthy ageing. It is expected that technology will play an important role in this regard. This study qualitatively assessed the landscape of technology use in aged care from the perspective of industry, academic, and research professionals. Design A purposefully designed cross-sectional survey collecting experiences, perspectives, and barriers about technology through open responses. Methods Using convenience sampling, thirty-five participants completed an online survey between April and October 2020. A descriptive qualitative content analysis approach was used to analyse the written responses. Reporting of findings followed the EQUATOR’s Standards for Reporting Qualitative Research checklist. Results Four themes were identified that characterised the use of technologies within aged care: (1) User Perceptions and Attitudes: wariness and reluctance to technology; (2) Systemic Issues within Aged Care: Under-resourced with opportunities for innovation; (3) Technology-Related Barriers: Equity, costs, privacy, integration, and interoperability and (4) Research Priorities: Co-design and integration of technology. Conclusions The existing technology does not meet the needs of older people, aged care personnel and the system in general, which prevents its successful implementation and uptake.


Introduction
Populations worldwide are experiencing rapid and unprecedented growth in the number of older adults (United Nations Department of Economic and Social Affairs Population Division, 2019) and the number of people aged 65 years or older is estimated to double to 1.5 billion by 2050 (United Nations Department of Economic and Social Affairs Population Division, 2019).Known as population ageing, this shift in the demographic landscape requires a global recalibration of aged care policies, systems, and services to ensure the needs of older adults are met and that their health and well-being are supported for healthy ageing (World Health Organization, 2018).
Healthy ageing is defined as 'the ongoing process of developing and maintaining functional ability that enables wellbeing in older age' (World Health Organization, 2015).This definition positions functional ability, rather than the absence of disease, as a crucial part of healthy ageing, highlighting the dual influences of intrinsic capacity (i.e.mental and physical capabilities) and environments and opportunities (i.e.home, community, society) on how adults experience ageing worldwide.The United Nations has declared 2021-2030 the Decade of Healthy Ageing and set out actionable priority areas that aim to: (a) tackle ageism; (b) ensure that communities and their environments are age-friendly; (c) deliver integrated, person-based primary health and social care; (d) and provide older adults with access to long-term care when they need it (World Health Organization, 2020a).New and existing technologies are anticipated to play an important role in helping societies worldwide enact these aims (World Health Organization, 2020b).
The opportunities for doing so have been exemplified during the COVID-19 pandemic (Chen, 2020).Indeed, with public health measures implemented globally, including lockdowns, social distancing, isolation, and quarantine (Ghebreyesus, 2020), technologies have been pivotal in supporting older adults to maintain social connection and ensure continued access to healthcare needs (Chen, 2020).
Different types of technologies are currently used in various ways within aged care (Pilotto et al., 2018) and can be broadly classified based on their focus on information and communication (e.g.videoconferencing, electronic health records); support and assistance (e.g.smart home technologies, sensors and wearables, telehealth); and human-computer interaction (e.g.social robots, humanoid robots).As with the pace of technology development in general, technology dedicated to older people is accelerating rapidly, with new innovative technologies constantly being developed and tested.However, their translation into realworld practice, the uptake and adoption into aged care services, remain slow and fragmented (Peine & Neven, 2019;Pilotto et al., 2018).Although this evidence-to-practice gap is attributed to numerous underlying factors, a lack of multidisciplinary collaboration between stakeholders from diverse areas of interestranging from nursing to computer sciencesand insufficient understanding of end-users needs and preferences, are thought to be amongst the most influential (Peine & Neven, 2019;Pilotto et al., 2018;Pruchno, 2019).Until these issues are addressed, the dichotomy between technology development and real-world use will likely persist, and technology's potential utility within aged care services will be hindered.
Seeking to increase the efficiency, effectiveness, and quality of care of older adults across aged care services, we focused on identifying appropriate technologies and real-world solutions from various perspectives.The study's aim was two-fold: (1) to explore the experiences and perceptions of the technology industry, academic, and research professionals about technologies used within aged care; and (2) to identify needs-led priorities for the future development and application of technologies within aged care.

Design
We undertook a broad cross-sectional survey of technology in aged care from the perspective of the relevant industry, academic, and research professionals that predominantly included openended questions.The survey was designed to prioritise qualitative data to enable us to go beyond the constraints of pre-determined, closed-response questions to generate rich, in-depth data that captured the subjective experiences and perceptions of a broad group of participants, as described in their own words (Braun et al., 2021).
Guided by the theoretical frameworks of naturalistic inquiry and the constructivist paradigm (Guba & Lincoln, 1989), we interpreted the raw data provided by participants using a descriptive qualitative content analysis approach (Hsieh & Shannon, 2005).This method was suitable because of its known advantage in systematically and objectively analysing a large and varied amount of qualitative data to understand the phenomena of interest and its appropriateness for the nature of the data collected in a written survey (Elo & Kyngäs, 2008)

Sample
Any adult (aged 18 years or older) who self-identified as an aged care and/or technology industry professional, academic, or researcher, lived anywhere in the world, and was able to read and write in English was eligible to take part.Convenience sampling was used.This involved participants voluntarily responding to promotional activities via professional aged care, technology, academic, and/or researcher networks (e.g.direct emails, newsletters); print, online, and social media (e.g.Twitter); and word-of-mouth.

Data collection
The survey could be completed online (hosted by LimeSurvey, GmbH, Germany) or on paper (with pre-paid return).At the beginning of the survey, participants were informed that it was anonymous and voluntary and that responding constituted their formal informed consent.Participants were advised that the survey primarily comprised questions requiring a free-text written response and that they should aim to spend no longer than 30-minutes completing the survey.Participants could stop the survey at any time, skip questions that they did not want to answer, and write as much or as little as they wanted for the open-response questions.
The survey was piloted with eleven industry professionals and/or academics/researchers leading to minor changes to improve the survey's readability, including bolded font to highlight the key parts of a question and the inclusion of additional signposting throughout the survey (e.g.'This section asks four questions about technology you use to support … ').These pilot data are included within the final dataset given no changes were made to any of the questions regarding their content.The survey was available for participants to complete between April and October 2020.

The survey
We designed the open-response qualitative survey (Table 1 contains the overview of survey questions) for this study based on a review of the literature defining healthy and successful ageing (Urtamo et al., 2019;World Health Organization, 2015) and in consultation with the expertise of the Australian Aged Care Technology Collaborative (AACTC; including scientists, researchers, and sector leaders from aged care, technology, allied health disciplines and consumer representatives).Open-ended questions aimed to obtain a non-directive answer to provoke participants' creative thinking and therefore contribute to substantive findings (Chevance et al., 2020;Decorte et al., 2019).Participants were not provided with additional prompts for the openended questions.

Data analysis
A total of 72 participants accessed the survey.After checking for eligibility against the inclusion criteria, we excluded 37 participants from the final dataset as they either did not meet all inclusion criteria (did not represent the selected industry), completed demographic questions only, and/or did not provide at least one written response to an open-ended question.
The dataset was imported into IBM SPSS Statistics for Windows version 27.0 (IBM Corp, NY) to analyse the quantitative closed-response demographic questions and into NVivo (QSR International Pty Ltd) to analyse the qualitative open-response questions.The qualitative content analysis, both directed and conventional (Hsieh & Shannon, 2005), was used to interpret participants' written responses according to the study's aims.DS began the analysis by organising the data within each question by undertaking line-by-line coding and applying data-driven labels to groups of words, phrases, or sentences to capture their meaning at the manifest and latent levels.During this analysis, DS regularly discussed and reviewed the developing codebook with WM and KL.When all data were fully coded, DS, KL, and JM then collaborated to compare, contrast, and consolidate the codes -first within each question and then within the dataset as a whole (Braun et al., 2021) and generated themes and subthemes that represented the main issues across the complete dataset by grouping similar codes together.To uphold analytical rigour, the described process was iterative and continuously discussed and reviewed with WM and KL until agreement was reached for four final themes.
We identified four themes from the qualitative survey data that focused on technology within aged care: (1) user perceptions; (2) systemic issues within aged care; (3) technology-related barriers; and (4) research priorities.The most illustrative, de-identified quotations were chosen to present the findings, representing participants' voices from various countries.
Theme 1: user perceptions and attitudes: wariness and reluctance to technology When considering technologies within aged care, the perceptions and attitudes of older adults and healthcare professionals were identified as key priorities.
Mainly, participants reflected that many older adults are generally reluctant to use technology and prefer in-person contact to technology during their care provision.In addition, as noted by one participant, some older adults are wary of technologies, fearing that it will replace face-toface care altogether: 'Some [older adults] see it as a threat to their accessing their preferred mode of social interaction/support (some people very frightened that they will be entirely cared for by computers and robots)' (#29, researcher, Australia).
Alongside this, participants also highlighted that many health professionals are reluctant to use technology within aged care and that this represents 'not a technology problem but a mindset [problem]' (#17, technology professional, Japan).This reluctance was thought to stem from the predominantly biomedical focus of health professionals, such that attention to an individual's basic physical needs takes precedence over other aspects of their health.For example: Treating physical symptoms remains the core for many GPs or physicians, even though mental, physical and social health aspects are connected' (#43, researcher, Sweden); and 'The staff generally are only interested in providing basic care.They are not interested in setting up readers or making appointments for Zoom meetings.(#72, researcher, Australia) Notably, long-term aged care providers were specifically criticised by some participants for not integrating and using technologies with their older adult residents to their fullest potential.One participant stated that providers lacked both 'initiative to innovate [and] passion to improve' (#28, researcher, Australia).
Theme 2: systemic issues within aged care: under-resourced with opportunities for innovation Participants described several issues within the aged care system that had implications for the use of technologies.Chiefly, participants wrote about aged care systems that were under-resourced and characterised by staff shortages and high workloads.On the one hand, these issues were thought to be hindering the integration and adoption of technologies within aged care, with one participant describing that 'care staff do not have the time to learn to use the technology [and] combined with lack of care staff, burnout and staff retention [this] is creating a major sustainability problem' (#17, technology professional, Japan).Participants also reflected that technology could help alleviate some of these issues by supporting staff and streamlining various aspects of their work.this ranged from reducing administrative burden to supporting the provision of physical and psychosocial care: 'Voice recognition and natural language processing technologies could help in reducing admin work and save time.Artificial intelligence offers great promise to support the clinical decision of nurse practitioners when specialists are not available' (#7, researcher, Australia); 'A devise [could] assist incontinence to remind scheduled toileting regime or assist them [older adult] to use the toilet, to maintain privacy and dignity' (#78, technology professional, Australia); and 'Technology can help with connection with family and friends, set up social groups and even exercise programs that older adults care use with minimal staff involvement' (#72, researcher, Australia).
Organisational support was essential across aged care, and it was suggested that settings might benefit from having staff with appropriate knowledge and expertise as technology leads.For example, 'Aged care services need technology champions who can learn and support staff to engage with and see the benefits of novel technologies.Higher levels organisation support is also key' (#14, researcher, Australia).
Theme 3: technology-related barriers: equity, costs, privacy, integration, and interoperability Within the written comments about technologies and aged care, participants identified various barriers related to the technology specifically.In general, participants considered technologies too expensive, and this prevents equitable and widespread uptake and use of technologies within aged care: 'Currently, it seems that these technologies are available to the privileged aged population who can afford the technology.It needs to be cost effective and widely available' (#57, technology professional, Australia).Limited interoperability between technologies across different technology platforms and aged care systems was thought to exacerbate this issue and make using technologies collectively difficult and unaffordable for the sector.For example, One of the biggest difficulties is lack of interoperability.This can be costly to the individual and services.Also, this can add to the number of platforms and/or apps that an individual or service is required to engage with in order to use technologies.(#11,researcher,UK) They outlined privacy and security as issues for older adults and health professionals using technologies within aged care.There was concern that data, either shared online or collected through multiple devices/platforms, were not always secure and, therefore, could be misused or stolen as one person stated: Data collected by sensors is mostly locked and sometimes not securedepends whether it's uploaded to the cloud and what protection mechanisms are there in place … Individuals need to trust who is viewing the data and to be assured it is not invading their privacy.(#27, researcher, UK) Participants reported the importance of providing education and training for all technology users in aged care and raising awareness about what is available.However, participants indicated that this process could be challenging for older adults and their carers and needs to be 'extensive and ongoing' (#72, researcher, Australia).

Contemporary Nurse
Theme 4: research priorities: co-design and integration of technology Participants highlighted several priority areas for future research on technology in aged care, including the acceptance of technology; education, training, and awareness; efficacy and effectiveness; co-design; and an integrated aged care administration system.Many participants described the need to understand better older adults' and health professionals' acceptance of technology within aged care, noting that, despite being an important influence on the adoption of technologies in real-world settings, there was scant research about this issue currently.One participant outlined, 'Assessing the acceptability of technologies is essential for its wider adoption [but] still not well investigated' (#7, researcher, Australia).
Several participants outlined that future research should focus on greater testing of technologies for use within aged care to provide greater evidence of both efficacy and effectiveness.They expressed concern about technology moving to commercialisation without sufficient and rigorous testing: 'technology is commercialised but then without scientific evidence to show it actually improves physical health' (#43, researcher, Sweden).Further, it was also noted that there was no clear framework to assess implementation and effectiveness within settings outside of controlled trials: 'Lack of accepted standards to evaluate effectiveness of technology in care settings -e.g.contribution to care plans are another challenge for aged care technologies' (#17, industry professional, Japan).
Another important priority was a participatory, co-design process.In qualifying this view, participants indicated that users' needs did not always feed into the design of technologies, thereby hindering their accessibility and utility.Therefore, they highlighted the value of including the full spectrum of end-users in the design process: 'Technology developers too frequently develop new systems in isolation, expecting people and services to adopt these.Tech development should be user-led and informed as much as possible' (#14, researcher, Australia); and 'Ensuring that technology development includes end-usersolder adults, family members, staffensures that product development addressed functionality and outcomes of relevance' (#48, researcher, US).
Participants also suggested the need for research to develop a more streamlined and integrated aged care administration system.As one participant wrote, 'there is an opportunity for technology to join up data sources' (#11, researcher, UK) and enable data about an individual to be shared easily between different settings and providers, and across various platforms.A selection of comments from three participants highlights the essence of this suggestion: 'A coordinated, centralised system that is secure … and specific to older adult healthcare needs.It should pull together all relevant information and update this in a timely way' (#14, researcher, Australia); 'smarter integration of platforms to allow for seamless transfer of information between care sectorsresidential to acute and back, for example' (#72, researcher, Australia); and 'technology that connects different healthcare providers that are all involved in the care of one person' (#47, researcher, US).

Discussion
Our study reports that the current use of technology within aged care is challenging.Several issues hinder technology translation into real-world practice at the level of the user, the aged care system, and the technology itself.Participants noted systemic limitations that include the lack of organisational support concerning technology uptake, as well as costs and funding structures that prevent co-designed and user-friendly technologies from being implemented into practice within aged care.
Our results also highlight problems relating to the capability and capacity of the aged care workforce, with survey respondent's reporting attitudes and reluctance toward technology implementation and uptake.This can be partially related to the system being understaffed and under-resourced.Any new change in the work routine and system related to the implementation of new technology can raise barriers and challenges when staff are unprepared and untrained in technology use with residents (Loh et al., 2009).Older people themselves might also be reluctant, or receive insufficient support in technology use, which was reflected in another study (Moyle et al., 2022).However, as the next generation of aged care users will more likely include people regularly using technologies, the need and preference for including them within the system might be rising (Wakui et al., 2021).Our findings align with previous research that reported limited staff and organisational support, client challenges, and selecting appropriate devices as the barriers to implementing technologies within aged care settings (Waycott et al., 2022).
Despite the anticipation that technologies are expected to play an important role to enact the UN's Decade of Healthy Ageing aims (World Health Organization, 2020b), the existing technology does not meet the needs of older people in the aged care system.Our respondents did not mention a general increase in technology uptake due to the health advice restrictions and social distancing measures imposed during the COVID-19 pandemic.This could be related to the researchers and technology developers already being frequent users of technology (Leal Filho, Wall et al., 2021) or a lack of specific questions exploring this topic within our survey.Nevertheless, the reported greater uptake of technology among older people generally during the COVID-19 pandemic (mainly as a means of communication and social connectivity) (Chen, 2020;Chirico et al., 2022;Strutt et al., 2022) was due to public health measures, including lockdowns, social distancing, and isolation, rather than addressing the barriers faced by older people.The COVID-19 pandemic also highlighted some of the existing limitations, such as lack of facility-wide Wi-Fi access (Moyle et al., 2020), or an insufficient number of staff members assisting older people (Chirico et al., 2022;Lion et al., 2022) leaving them unable to confidently use technology, being socially disconnected, and limiting their access to health and social care when needed (Peine & Neven, 2019;Pilotto et al., 2018;Pruchno, 2019).
The study findings also broaden the scope of the research priorities for future activities and strengthen the recommendations arising from the complementary surveys we conducted among older people, their family carers and aged care industry representatives (Moyle et al., 2022).These include the importance of co-design and the development of administrative systems for aged care providers, embracing working with personnel to create technologies to decrease staff workloads, and testing and evaluating technologies to implement them in the work environment (Pruchno, 2019).This is a further indication that the principles of the person-centred psychosocial approach promoting residents' preferences, needs, and expectations should be at the centre of the design and implementation of technologies (Waycott et al., 2022).This would lead not only to the successful long-term implementation of technologies but more importantly, to the improved quality of care across aged care systems (Clemensen et al., 2017).Such changes should be supported by (inter)national regulations and support interoperability of technologies used within aged care systems globally.

Limitations
Although the survey generated a dataset that was considered comparable to the depth and complexity of data usually generated through qualitative interviews and focus groups, as well as deemed to sufficiently address the study's aims, the size of our sample (n = 35) was within the lower boundaries typically achieved within qualitative surveys (Braun et al., 2021).Despite representing international views, our study also did not specifically explore the aspects of cross-cultural communication.The presented study did not capture the views of the aged care personnel, older adults and their informal caregivers.However, those views were explored and presented in another paper published by our group (Moyle et al., 2022).
The response rate may have been impacted by the length of the survey and its repetitious structure, as well as coinciding with the COVID-19 pandemic and the subsequent sequelae of social, health, and economic disruption worldwide (Leal Filho, Azul et al., 2021;Nicola et al., 2020).Further, although the survey was international in scope and included participants from eight countries, most participants were from Australia and the UK.

Conclusions
The findings highlight some important systemic aspects which require further research in this area.First, enablers and barriers across aged care personnel to (1) facilitate technology to older adults, and (2) their views about implementing technological solutions in their organisations should also be explored.Second, there is a need to look at the organisation of the aged care system, which prevents the successful implementation of technological solutions.Third, in addition to aged care system users, the technology facilitators (i.e.aged care personnel) should be involved in the co-design process to enable the future implementation of technologies into practice.This could increase the understanding of end-users' needs and preferences (Peine & Neven, 2019;Pilotto et al., 2018;Pruchno, 2019) and the successful implementation of technologies into practice.
The study's results suggest that existing technologies do not meet the needs of older people, aged care personnel, and the system in general, which prevents successful implementation and uptake.Involving aged care personnel together with older adults and their family members in technology co-design, especially when creating and planning for their real-world use, could help improve use and uptake of technologies within aged care environments.Future recommendations and policy changes should consider funding, system organisation, and training for personnel as integral parts of technology design and implementation.

Table 1 .
Overview of survey questions.
a. What technology do you use, or are aware of, available to aged care services that help support the [domain] needs of adults aged 65 years or older? 3. Mental Health b.Overall, how satisfied are you with the technology currently available to aged care services to help support the [domain] needs of adults aged 65 years or older? a 4. Social Wellbeing c.What problems are there, if any, with the technology currently available to aged care services to support the [domain] needs of adults b.What kinds of technology or innovation do you think could help improve the clinical/administration of aged care services, including primary, acute, and aged care? 9. Comments a.Any other comments about technology within aged care services a Closed-response question.
Notes: All variables are reported as n (%).Frequencies and proportions may not add up to n = 35 or 100% due to missing data or rounding.