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• To recognise the benefits of virtual care interventions in providing person-centred care to patients with dementia in hospital
• To understand the barriers to the implementation of virtual care interventions for hospitalised older people with dementia
• To learn about the experiences of hospitalised older people with dementia using an iPad
Background Being in an unfamiliar environment away from family can exacerbate emotional stress in hospitalised older people with dementia. Technology solutions can be used to address their mental and emotional health needs.
Aim To generate greater understanding of technology adoption and to test strategies supporting virtual care interventions in hospitalised older people with dementia, such as the use of an iPad to connect them with their family members.
Method Older people with dementia in two Canadian hospitals were observed and interviewed to explore their experiences of using an iPad. Focus groups were conducted with staff and interviews were undertaken with two frontline nurses and three research partners with lived experience of dementia in hospitalised older people. Data were thematically analysed in collaboration with 12 stakeholders. Strategies to overcome the barriers identified were tested as part of the study.
Findings There were three main barriers to implementing virtual care interventions: lack of familiarity with the technology; difficulties with operating the device; and privacy and connectivity issues. Strategies to overcome these barriers included providing personalised support, working with users to support adaptation, and ensuring privacy and optimal connectivity.
Conclusion Using an iPad has the potential to enable hospitalised older people with dementia to connect with their family members and take part in activities that support person-centred care. This is particularly important in times, such as the COVID-19 pandemic, when restrictions to hospital visits lead to social isolation.
Nursing Older People. doi: 10.7748/nop.2020.e1294
Peer reviewThis article has been subject to external double-blind peer review and has been checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Hung L (2020) Using virtual care interventions to provide person-centred care to hospitalised older people with dementia. Nursing Older People. doi: 10.7748/nop.2020.e1294
Published online: 11 November 2020
Older people, and people with a range of underlying conditions, including dementia, are at higher risk of developing severe illness from COVID-19 (Centers for Disease Control and Prevention 2020). While restricting hospital visits to prevent the spread of COVID-19 is necessary, hospitalised older people with dementia may not understand this policy (Hung and Mann 2020). For people with dementia, being in an unfamiliar environment with no family support can be overwhelming, and separation from family and friends can exacerbate emotional stress (Sommerlad et al 2019). Furthermore, family carers of hospitalised people with dementia frequently experience high levels of anxiety (Boltz et al 2015).
There is a significant demand for innovative, non-pharmacological interventions to address the mental and emotional health needs of the growing population of older people with cognitive impairment. Technology can be empowering for people with dementia, particularly in respect of their psychosocial needs (Kenigsberg et al 2019), and smartphones and tablets can be important resources for vulnerable older adults (Fang et al 2018).
In a review of the use of tablets with people with dementia in care settings (Hung et al 2020), benefits included increased engagement in care activities and decreased responsive behaviours, such as physical and verbal aggression, which arise through stress, anxiety or unmet need. One study investigating the use of Skype on iPads by older residents in care homes reported positive results, such as residents being able to talk with their families (Moyle et al 2018). Other research has identified benefits from the use of tablets, such as reminiscence through images and music and cognitive stimulation through apps and games (Evans et al 2017).
Virtual care is a broad term that goes beyond telemedicine and encompasses a range of interventions delivered through communication technology. Through video and audio connections, patients can interact remotely from any location with formal or informal carers. Families can speak with hospitalised relatives in real time or send pre-recorded video messages. Virtual care interventions include any therapeutic intervention using communication technology, such as cycling while watching a video on YouTube, playing a digital game or singing to online music.
Although there is a growing amount of research into the use of digital devices with older people (Hung et al 2020), little research has been conducted into the technology adoption experiences of users. Marston et al (2019) suggested that more research using qualitative interviews and focus groups is required to gain a better understanding of the technology experiences and needs of older people. The author of this article has previously conducted a feasibility study in Canada that explored the use of iPads to connect hospitalised patients with dementia and their families (Hung et al 2018). The study reported in this article was also conducted in Canada and sought to understand how this new practice could be adopted in settings such as acute medical units and mental health units.
This knowledge translation study aimed to generate greater understanding of technology adoption and to test strategies supporting virtual care interventions designed to provide person-centred care to hospitalised older people with dementia, such as the use of an iPad to connect patients with their families. The research question was: ‘What are the primary barriers and enabling strategies to implementing virtual care when seeking to support improved social connections between patients and their families?’
Understanding participants’ perspectives was essential to ensure that effective strategies could be developed to overcome the identified barriers. The study therefore used qualitative methods including focus groups, observation of care and interviews.
The study was conducted in one mental health unit and two medical units at two large urban hospitals in Vancouver, Canada: Vancouver General Hospital and Richmond Hospital. The 19-bed mental health unit provides assessment and treatment of neurocognitive disorders and mental health conditions in older adults; the average length of stay is 4-6 weeks, but patients with behavioural symptoms might stay for six months or longer. The two 20-bed medical units provide acute medical assessment and treatment to older adults; the average length of stay is eight days, but patients with complex conditions, such as complicated delirium, may stay for up to four weeks.
Virtual care interventions had been introduced at Vancouver General Hospital in 2018 and had become part of the daily care of patients with dementia. In the study, staff continued to explore innovative ways of delivering these interventions. At Richmond Hospital, virtual care interventions were introduced as part of the study and were quickly adopted and adapted by staff. The interventions used during the study were person-centred, tailored to each patient’s needs and wishes, and used as required. Two core interventions consisted of supporting patients to speak to their family members in a video call and in showing patients a pre-recorded video message from their family members.
The Woodward Foundation and Richmond Hospital Foundation, which are associated with the two hospitals where the study was conducted, provided funds to purchase the iPads used to deliver the virtual care interventions.
Effective infection prevention and control was ensured by staff following a standard protocol for cleaning the equipment, consisting of cleaning the iPads with disinfectant wipes twice after each individual patient use.
Study participants encompassed 10 patients, 10 family members and 40 members of staff. Purposive sampling was applied to the recruitment of patients to ensure the inclusion of diverse and under-represented populations. The researchers – the author of this article and members of her team – selected patients to reflect diversity in areas such as type of dementia; responsive behaviours, such as physical and verbal aggression, which arise through stress or anxiety; sociocultural background; gender; and age.
Inclusion criteria for patients to participate were as follows:
• Having a diagnosis of dementia.
• Being able to participate in a video call on an iPad.
• Having shown responsive behaviours during the period of recruitment to the study.
Table 1 shows the demographic characteristics of participating patients.
The participating family members were four daughters, four sons and two spouses. In terms of staff, the researchers applied a convenience sampling method, inviting all frontline staff working on the dates of the focus groups to participate. Table 2 shows the breakdown of staff participants by professional role. All participating staff were experienced and had been employed at their respective sites for a mean number of five years (range 2-30 years).
The study started in January 2019 and ended in February 2020. The research process was not linear but iterative. Data collection, data analysis and the testing of strategies were conducted concurrently. In this knowledge translation study, researchers did not only want to understand barriers and strategies, but also support the implementation, in real time, of practical strategies to overcome identified barriers. Barriers and strategies were discussed in the focus groups and participating nurses subsequently tested the strategies in practice, adjusting them to local needs.
Data were collected via three staff focus groups; two interviews with nurses; observation of, and interviews with, patients; and three interviews with stakeholders.
The three focus groups lasted 30-45 minutes and took place with a total of 38 staff. Open-ended questions were used, such as ‘What is your experience of using the iPad to deliver family videos for patient care?’, ‘What are the barriers to using the iPad to deliver family videos for patient care?’ and ‘What resources and support do you need to apply the iPad intervention in everyday practice?’
Interviews lasting 10-20 minutes were conducted with two frontline nurses immediately after they had supported patients to use the iPad. The nurses were asked: ‘What was your experience about using the iPad to support patient care?’, ‘What worked well and what did not? Why?’
Each participating patient was observed by the researchers between two and four times while they were using the iPad. Immediately after each observation, interviews were conducted with patients in a conversational style. A total of 22 interviews took place, each lasting approximately 10 minutes. Patients were asked, for example: ‘What did you like and dislike about using the iPad here in the hospital and why?’ and ‘What would help to improve your experience?’
Three stakeholders with lived experience of dementia in hospitalised older people were interviewed as ‘partners in research’: one patient partner, one family partner and one nurse leader working at one of the units. The three stakeholders played an advisory role in decision-making about the research process, including planning and dissemination. The interviews, which lasted between 15 and 20 minutes, included questions such as: ‘What is your perspective on using an iPad to deliver family videos for patient care?’, ‘What does the use of technology mean to you?’ and ‘Why is virtual care important for people with dementia in hospital?’
The focus group discussions were recorded, the observations of care and interviews were video-recorded, and all content was transcribed verbatim.
Thematic analysis (Braun and Clarke 2006) was used to identify important enabling strategies for implementing virtual care interventions. Monthly research meetings were held with 12 stakeholders who supported the researchers with data analysis. These 12 stakeholders comprised: three nurses, including the interviewed nurse leader; two patient partners, including the interviewed patient partner; three family partners, including the interviewed family partner; two doctors; one occupational therapist; and one member of recreation staff. They were recruited to join the research team because they brought different perspectives to the analysis and interpretation of the data.
Data analysis involved six phases:
• Phase 1: familiarisation with the data.
• Phase 2: generating initial codes.
• Phase 3: searching for themes.
• Phase 4: reviewing each theme.
• Phase 5: refining and naming the themes.
• Phase 6: producing results.
In phase 1, the stakeholders read the transcripts and watched the videos to gain a sense of the overall issues and concepts. In phases 2 and 3, the author developed codes, extracted data and grouped them into potential themes. In phases 4 and 5, the stakeholders checked the themes to ensure that they accurately reflected the coded extracts and data sets. The themes were then divided into:
• Barriers to the implementation of virtual care interventions for hospitalised older adults with dementia.
• Strategies that can be used to overcome these barriers.
In phase 6, the author worked with the stakeholders to produce tools for knowledge dissemination, including a manuscript for publication, posters for conference presentations, newsletters to health authorities and social media promotion.
The study was approved by the University of British Columbia research ethics board and the Vancouver Coastal Health Research Institute (VCHRI). Participation was voluntary. Patients and family members who had expressed an interest in participating after having received information about the study met one of the researchers, who explained the purpose and procedures of the study and answered any questions. Written consent was obtained from patients at the beginning of the study. If patients were unable to complete the written consent form, a family member could do it for them. Verbal assent was sought from patients before and during each observation of care to remind them of the purpose of the study and of their right to withdraw from it at any time (Hung et al 2017). Staff and family members also provided written informed consent.
During the first month of the study, the researchers found, when observing patients, that real-time video calls did not always work. First, some patients would forget – sometimes as soon as the call had ended – that they had just spoken to their family members. This led to patients making multiple phone calls to their family members, which the researchers felt originated from anxiety. Second, patients often wanted to speak to their family members at different times of the day or night, but family members were not necessarily available. Therefore, researchers asked the ten participating family members to pre-record video messages on their phones, which were then uploaded to the iPad for patients to view. These pre-recorded messages could be played at any time and as often as needed, providing patients with reassurance, comfort and support from familiar faces and voices. They were played to patients when they seemed anxious and asked to speak to their family members.
The data analysis identified three main barriers to the implementation of virtual care interventions for hospitalised older adults with dementia:
• Lack of familiarity with the technology.
• Difficulties with operating the device.
• Privacy and connectivity issues.
Table 3 details these barriers as well as the strategies identified to overcome them.
A lack of familiarity with the technology was a common theme across participant groups. Staff, patients and family members all mentioned discomfort and inexperience in using the iPad and apps. For example, focus group participants explained:
‘We want training to learn how to do it right. I need the step-by-step instruction in the toolkit to help. I use a different phone, so I am not familiar with the Apple iPad’ (Nurse 3).
‘The information and resources need to be ready online, always available. I need to have something that I can use to tell the family how to record a video, what to say, and how to send it to us to upload’ (Unit clerk 1).
Many staff members mentioned that they were frustrated with the technology and needed on-the-spot support. One of the nurses explained:
‘The messenger didn’t work, and I don’t know why. I tried Zoom and there was no sound. It was a waste of time’ (Nurse 8).
Another issue with the technology was the complexity of operating the iPad, since this requires connecting to the internet, setting up the audio and video functions, and entering a username and password. Several staff members stated that they felt confident using the iPad when there was a technology-savvy team member present.
The stakeholders emphasised the importance of exploring the technology with family members and finding apps based on patients’ interests, such as games, videos and music. One of the two interviewed nurses mentioned that they would search online for music their patients enjoyed and play it for them on the iPad. The author observed staff singing and dancing with patients to music played on the iPad. Some nurses started noting personalised information about favourite apps in their patients’ care plan. One of the care staff mentioned:
‘Mrs Wong’s daughter told me that her mom likes the mah-jong game. Now we have the game on the iPad, and she can play the game. It is so nice to see her play and I play with her sometimes’ (Care staff 4).
Focus group participants discussed new ideas for using iPads to deliver person-centred care. One of the rehabilitation assistants had asked patients and their families what places they would like to visit. He had then searched for those places on YouTube and created virtual cycling tours, which he would play on the iPad to encourage patients to engage in cycling exercises. One of the patients said:
‘The scenery helps. Watching the video, biking through the forest makes the exercise much more fun. It kind of made me want to keep going. Now I am tired’ (Patient 5).
Figure 1 shows a patient engaged in a video-supported cycling exercise.
Another commonly reported barrier was the difficulties experienced when operating the iPad. Patients with decreased mobility found it challenging to simultaneously hold and use the iPad, relying on staff to hold the device for them while they used it. A participating nurse commented on the challenges involved in setting up the equipment:
‘See, it is hard to get to the right angle for the patient to watch [the iPad]. I have to use a basin to build an iPad holder’ (Nurse 17).
Strategies to overcome these barriers included adding a mechanical arm to hold the iPad and installing the iPad on a mobile stand on wheels built by the biomedical engineers at one of the hospitals. This addressed the issue of holding the iPad and adjusting its angle. Figure 2 shows an iPad with a mechanical arm and mobile stand.
Concerns around privacy were raised by some focus group participants. One nurse commented:
‘We need to organise the family videos in albums and label them, so I know I don’t show the wrong video to the wrong patient’ (Nurse 20).
To protect the privacy of patients and families, only staff members directly involved in the care of an individual patient were given access to the pre-recorded family video messages. These messages were stored in a password-protected family album saved exclusively on the iPad used by the patient. Between each individual patient use, the iPad and its mount would be disinfected and securely stored. Furthermore, patients and families were asked to determine what should happen, after discharge from hospital, to their video messages before these would be deleted from the iPad. For example, if the patient was to be discharged to a care home, the messages could be sent to a device at that care home, thereby encouraging care home staff to use the same virtual care intervention.
Another frequently reported issue was suboptimal connectivity. In both hospitals, certain areas had a more stable internet connection than others, while some areas had no connectivity at all.
Based on participants’ experiences, particularly nurses’ experiences when testing the strategies, the researchers produced a toolkit consisting of four videos, a leaflet for family carers and a pocket card for nurses. This was undertaken in collaboration with the patient and family partners. The toolkit offers strategies that can assist hospital staff in implementing virtual care interventions. The toolkit is specifically concerned with developing pre-recorded family video messages and showing them to patients on an iPad. It can be accessed on the VCHRI Ipad Project website.
In the videos, a patient provides step-by-step instructions on how to record a family video for people with dementia, and describes his perceptions of the stressful nature of hospital wards for people with dementia. A family member explains how a personalised video message from the family can reassure patients. Finally, the nurse leader interviewed as a stakeholder provides insights into the practical experiences of nurses who have used virtual care interventions to address responsive behaviours in older people with dementia in hospital.
The leaflet for family carers explains the rationale for the use of pre-recorded personalised video messages from families and includes tips for creating them. The pocket card for nurses, which can be easily attached to a lanyard for quick reference, contains practical bedside guidelines in the form of a short mnemonic.
Older people and the healthcare professionals caring for them often lack access to digital resources. During times of physical distancing, this lack of access to digital resources may lead hospitalised older people to experience social exclusion (Xie et al 2020). Since March 2020, the two hospitals where this study was conducted have had to restrict visits to prevent the spread of COVID-19. The pandemic has created an opportunity for healthcare teams to increase awareness of the potential benefits of using digital resources in the care of older people (British Society of Gerontology 2020).
In this study, some patients used the iPad to communicate with family members in a variety of locations, including with children and grandchildren living overseas. In one case, family members, some of whom lived outside Canada, were able to connect with their hospitalised relative in his last days of life. Some patients had never used an iPad before but were keen to try, which shows the importance of not assuming that older people with dementia would not want, or would not be able to learn, to use technology. Figure 3 shows a patient using an iPad for the first time.
In addition to video calls with families, the iPads were used to engage patients in activities such as watching pre-recorded messages from their families, listening to music or playing digital games. Some family members used the technology to send music playlists for their hospitalised relative. One family member of a patient who felt an emotional attachment to their pets included the pets in their pre-recorded message.
As reported by Barbosa Neves et al (2019), technology adoption is influenced by social experience and expectations, and future research needs to investigate the potential benefits, for people with dementia, of virtual pet visits. To support the effective use of technology and enhance person-centredness, staff members need to familiarise themselves with patients’ interests and obtain information from family members on their hobbies, tastes and habits.
Some staff used the iPad to play digital games with patients. Some family members who had received videos of their hospitalised relative enjoying a digital game sent emails expressing their gratitude, and their relief from feelings of anxiety and guilt. These positive experiences of using an iPad to play digital games with hospitalised older people with dementia reflect those of Cutler et al (2016), who found that digital gaming can promote mental, physical and social stimulation among people with dementia in the community setting. Figure 4 shows a staff member and patient playing a digital game.
Participants frequently mentioned the need for training. While touchscreen technology has been used to support the assessment of patients with dementia, its use for leisure activities or activities of daily living is a more recent development and therefore requires guidance (Joddrell and Astell 2016). In this study, participating nurses, who had varying levels of skill and experience, found that training and ad hoc support were crucial for achieving familiarity with the iPad.
Patients with decreased mobility found it challenging to simultaneously hold and use the iPad. Nurses reported that the mechanical arm and mobile stand improved accessibility, and prevented iPads from being dropped. Future research could investigate the use of telepresence robots (remote-controlled, wheeled devices connected to the internet). Other technical challenges included suboptimal connectivity, the high battery power consumption of complex apps and malfunctioning software (Moyle et al 2014, Evans et al 2017).
Privacy was a concern for some participants because of the personal nature of the family video messages. Lack of privacy when using digital tools may arise from factors including insufficient encryption, transfer and processing of information in areas with varying regulations, and human error allowing unintentional access (Marceglia et al 2012). More efforts to find ways of protecting digital healthcare data are required. In this study, only staff members directly involved in the care of an individual patient had access to that patient’s pre-recorded family messages. For continuity of care, patients and families should be given the option of continuing to use their video messages after discharge to a care home.
The generalisability of findings is limited because data came from two urban hospitals only. Future studies would need to include rural hospitals and long-term care settings for comparison. Another limitation was that patient outcomes, such as loneliness, social isolation and quality of life, were not measured before or after the virtual care interventions.
Using an iPad has the potential to enable hospitalised older people with dementia to connect with their family and take part in activities that promote person-centred care. This is particularly important when physical distancing leads to social isolation, such as during the COVID-19 pandemic. More investment in virtual care interventions is required to address the needs of hospitalised older people with dementia to connect with their family and take part in meaningful activities, particularly at times when hospital visits are restricted.
• Virtual care interventions can support hospitalised older people with dementia to stay connected with their family members
• It is essential for families to remain connected with their hospitalised relatives with dementia so that they continue to have a role as care partners
• More research is needed to investigate the potential of virtual care interventions as a non-pharmacological means of supporting the psychosocial well-being of patients with dementia in hospital
• Hospital staff require training, support and resources to optimise the use of virtual care interventions in clinical practice
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