In recent years, the traditional call button by the bedside has been replaced with a series of developments in resident monitoring devices for long-term care (LTC) settings. Electronic monitoring technologies help the staff to determine when a resident is leaving a bed or chair, is exiting a room or the facility, or has a need that requires immediate attention. This family of products includes the following:
* Electronic door locks that open by code;
* Electronic eyes or sensors that indicate an open door or a passing person;
* "Alert tags" that are fastened to the resident's clothing;
* Video surveillance cameras;
* Pressure sensitive or magnetic strips placed on the mattress, chair, and /or door that sound an alarm when dislodged; and
* Position change alarms that attach to the resident's thigh and sound an alarm if that resident changes body position (eg, by trying to exit a bed).
Location monitoring devices are important to LTC facilities because they increase residents' autonomy and help nurses and aides care for higher risk residents. They are currently being used in LTC facilities as "anti-wandering," "falls prevention," or "alert" devices, and in place of restraints. However, research on the relationship between these technologies and their intended users and subjects (residents and staff members) has not kept pace with their rapid development. The purpose of this study is to investigate attitudes of the care staff toward location monitoring technologies in LTC facilities.
REVIEW OF LITERATURE
Research on this aspect of monitoring technology is virtually nonexistent. There are, however, four bodies of literature that are pertinent to the present study. First, due to the increasing prevalence of Alzheimer's disease, we have witnessed a growing body of literature on the physical design of facilities for persons with dementing illness (Calkins, 1988; Cohen, 1990; Coons, 1991; Gutman, 1992; Ohta, 1988).
A central issue is whether institutionalized cognitively impaired persons should have "special care units" dedicated to their specific needs. Because monitoring technology is an environmental feature, there has been discussion of the usefulness of these devices, but recommendations have generally not been based on empirical data. One exception is the work conducted by Martino-Saltzman and associates (1991) on travel behaviors of cognitively impaired residents.
A second but much smaller body of literature exists on the use of technology in health care environments (not necessarily LTC environments). The more general articles addressed issues of the "patient versus the machine," or technology as a shaping force in today's medical care (Benett, 1977; Durbach, 1984). Specific technologies used in health care environments also have been studied, such as environmental control units, automated versus conventional vital signs measurement technologies, and robots (Campbell-Heider, 1988; Hard, 1991; Symington, 1986). Most of these studies attempted to assess care professionals' attitudes toward the particular technologies and, for the most part, indicated that the staff responses are favorable. To date, no such studies have appeared on resident location monitoring technologies.
A third body of literature addresses the relationship between staff attitudes and behaviors in nursing homes. Many aspects of geriatric nursing have been explored - including morale, burnout and staff turnover, attitudes toward the aged, and associations between care staff member attitudes and the incidence of falls (Harris, 1989; Kahana, 1984; Schwartz, 1974).
The fourth and most closely related literature to this study involves the use of physical restraints in nursing homes. Due to current legislation in the United States (Omnibus Budget Reconciliation Act [OBRA] regulations), there has been well-publicized debate on many important issues surrounding the use of physical restraints in care facilities. Principal topics in the literature included resident behavior (such as wandering and aggression) and staff member distress; the role of environmental modification as an alternative to restraints; and nurses' attitudes toward restraint use (Brower, 1991; Everitt, 1991; Rader, 1991; Scherer, 1991; Watzke, 1991). A thorough review of related literature is in an article by Evans and Strumpf (1989).
Although several of the physical restraint articles described the types of resident location monitoring devices of interest to the present study, empirical research that focused directly on care staffs' perceptions of such devices was not uncovered. However, the latter topic has been deemed important, given that these technologies are appearing in large numbers of care facilities and are often being marketed as "the solution" to facilities' wandering and falls problems. Moreover, it is the care staff who is interacting with, and responding to, such devices.
Based on the available research that has addressed issues relevant to this field of study, two domains of variables can be identified as potential determinants of attitudes towards monitoring technology. The first domain entails characteristics of the individual and includes age, level of education, and ancestry /ethnicity. Younger and better educated health care workers are expected to have more positive attitudes towards technology. Ethnic differences may be important due to differential conceptions of technology across cultures and is particularly relevant to work in health care settings.
The second domain relates to the health care occupation and the work milieu. These include health care occupation (eg, nurse, administrator, or aide), amount of time working at that position, and level of technology being used in the facility. One would expect health care workers who do more hands-on care with residents to view monitoring technology more favorably. Also, exposure to more advanced technology would likely have a positive effect on attitudes regarding that technology, assuming it is useful.
A self-report survey was assembled and divided into two sections: a) background, demographic information (9 items); and b) use of and attitudes toward resident location monitoring technologies (34 items). The survey was piloted and revised based on the feedback of 16 professionals: 2 representatives of companies that sold such monitoring devices, 12 nurses, and 2 gerontological researchers.
A convenience sample of 10 care facilities from the Greater Vancouver area participated in the study: 8 intermediate care facilities, 1 shortstay geriatric assessment unit, and 1 extended care unit. Eight of the facilities were nonprofit and 2 were private. The range of number of beds was 31 to 300 (M = 151). Participation in the study was solicited through the care directors and administrators of each facility.
Specific instructions concerning the self-administered questionnaire were given to all participants. Respondents were assured that they would remain anonymous, their participation was totally voluntary, and their participation (or lack of) would in no way affect their work situation.
Boxes with blank surveys were placed at appropriate stations in each facility, as well as self-addressed envelopes returnable to the researchers. Each facility was given approximately 2 weeks to collect the completed, sealed surveys, which were then mailed by facility staff members to the researchers. This method of data collection was determined to be most effective by the researchers and the administration of each facility.
A total of 152 care staff members completed the survey. A response rate of 35% was calculated (occasionally, staff members were not allowed to participate). For the present report, seven independent respondent variables were selected for analysis:
* Ancestry/ Ethnicity;
* Number of years lived in Canada;
* Number of months worked in health care (nursing or other); and
* Level of technology of the facility.
It should be noted that a small number of care staff members were males (<5%), making divisions by gender problematic.
For these analyses, registered nurses (RNs) and licensed practical nurses (LPNs) were combined into one job group (n = 86); care aides were the other (n = 66). The average age of the total sample was 40. The sample was 61% white and 39% nonwhite. Approximately 73% of the nonwhite subjects reported Asian ancestry. It also should be noted that there were equal numbers of white and nonwhite care aides in this sample (50% in each), whereas the RNs/ LPNs had a higher percentage of whites (70%) compared with nonwhites (30%).
Other differences that might be expected in this sample were that RNs/ LPNs had worked twice as long as care aides in health care (16 years versus 8 years). Similarities worth noting were that white and nonwhite staff members had worked about the same number of years in health care.
Finally, the variable measuring technology levels in the facility was based on subjects' responses to a checklist of the assorted resident monitoring technologies that are on the market today - namely, those devices that they believed were currently being used on their floor. A majority of the respondents (81%) reported a "high tech" work environment. The remaining 29% were considered to be low in terms of sophistication of monitoring devices.
Development of Dependent Variables
The survey contained 18 original items based on Likert response sets, which measured a broad spectrum of attitudinal dimensions of the care staff's perceptions of resident location monitoring technologies. An exploratory factor analysis was performed to generate subscales. The Table presents the wordings of the items and the results of the factor analysis. Four scales were constructed. Scale 1, termed Total Value, tapped perceptions of the value of technology to staff work performance, the financial value for the respondent's facility, and the effects of technology on residents' well-being.
Technology Attitude Scales and Results from Factor Analysis
Scale 2, Facility Liability, comprised respondents' perceptions of caregivers', relatives', and visitors' views toward technology, and whether the respondent believed such devices had actually prevented wandering and /or falling incidents in the facility. (If such devices are genuinely appreciated by relatives and they actually do prevent serious events, such as falls or wandering, one could argue such devices have the potential to reduce a facility's liability.)
Scale 3, Resident Care, reflected perceptions of the effects of such devices on two important aspects of nursing care: residents' confusion, agitation, and /or frustrated behaviors, and their independence/autonomy. For this scale, pro-technology respondents would disagree with both statements - ie, they would state that they believed such devices neither increased confusion, agitation, and /or frustration, nor interfered with residents' autonomy.
Scale 4, Legitimacy, was interpreted as the care staff's perceived legitimacy of such devices. Only one item was on this scale; respondents were asked to state whether they believed "guidelines" (eg, as dictated by the Ministry of Health) existed for the use of such technologies. No such guidelines exist in British Columbia. It was presumed that agreement (belief that such guidelines existed) indicated a perception of greater legitimacy for these devices, but also may measure lack of knowledge about their guidelines.
All the independent variables (except education) displayed significant differences (p<.05) on at least one of the four attitude scales. For the scale measuring Total Value of the devices, younger staff members, nonwhite staff members, care aides, and staff members from facilities with higher technology reported significantly more positive attitudes than their counterparts. For the scale measuring Facility Liability, younger staff members, staff members with less experience, and staff members from higher technological facilities reported more positive responses toward such technology.
Younger respondents, white respondents, and RNs/LPNs were significantly more positive than their counterparts with respect to perceived effects of such technology on residents' confusion, agitated behaviors and independence/autonomy. For the Legitimacy scale, younger, nonwhite, care aides, and less experienced care staff members perceived the devices as more legitimate.
To provide information on the relative importance of the independent variables while accounting for the effect of the other independent variables, multiple regression techniques were used. Respondents' sociodemographic variables (age, ancestry, and education) were entered as a group in the first step followed by the employment characteristics (technology level of the facility, job title, and months working in health care settings).
The regression results for the Total Value scale showed that only ancestry showed a statistically significant relationship among the block of sociodemographic variables. The nonwhite workers in the facility tended to have a more positive overall evaluation of their facility's technology. The inclusion of the employment variables in the subsequent step reveals that the technology level of the facility was the only significant predictor of this scale (Total Value). Persons working in facilities with higher levels of technology tended to articulate more positive overall attitudes towards location monitoring technology within their facility.
None of the sociodemographic characteristics displayed significant associations for Facility Liability. Of the employment factors, only technological level of the facility yielded a significant association. Employees who held the view that technology reduced facility liability tended to work in facilities that were higher in monitoring technology.
When analyzing the Resident Care scale, only white health care workers were shown to have more positive attitudes on this dimension. No other variables exhibited a statistically significant relationship with the dependent variable Resident Care.
The ancestry of the employee showed a significant association for the Legitimacy scale. Controlling for age and education, nonwhites tended to believe in hypothetic ethical guidelines for the use of technological devices. When employment indicators are considered, a statistically significant relationship arises for job title and ancestry remains important. Thus, aides and being nonwhite result in more positive evaluations of this technology.
This study was intended as an initial exploration into the use of resident monitoring technologies in LTC facilities. Several interesting findings emerged from the data analysis. It should be noted that the responses for the attitude items suggested that attitudes are predominantly positive towards these devices; there was not much discontent among the care staff with the use of these technologies in their work environments. This finding coincides with research indicating that health care workers' attitudes tend to be basically supportive of modern technologies (eg, automated vital signs technology and environmental control technology).
A fair amount of skepticism, however, is articulated informally by nurses and other health care workers concerning the relative benefits of new technology in the LTC industry. This opinion may be explained in part by the excessive work demands that are placed on individuals working with typical LTC residents - that is, they perceive the learning of how to operate a new device as an additional burden.
It would appear that the ethnicity of the health care worker, and to a lesser degree his or her age and education, are more important than the type of job in deteirnining attitude toward monitoring technologies in the facility. Furthermore, ethnic background and the level of technology in the facility are the main factors affecting these attitudinal dimensions. The exception is for the scale measuring legitimacy, which exhibited a strong relationship with both ancestry and job title. Being nonwhite and being a care aide contributed to a greater belief in officiai ethical guidelines surrounding the technology in their facility.
It is significant that persons in facilities using more modern monitoring technologies appeared to have more favorable attitudes. This suggests that the technologies are to some extent beneficial. Nonwhites were more positive on two of the attitudinal domains; this suggests that sophisticated monitoring technology may have differential impact for employees from different cultures. This point must be addressed when attempts are made to assess the effects of technology on care staffs or for inservice programs that educate staff members on workrelated technology. These findings are particularly relevant to the LTC industry in North America, where significant portions of care aide workers are nonwhite.
In the face of society's growing fascination with modern technology, it must not be forgotten that it is people who interact with and control technology. It is important to identify and evaluate the advantages and potential deleterious effects of technology to ensure resident autonomy and other dimensions of humane care. Therefore, it is necessary to place nurses and other front-line health care workers in the center of the policymaking process that determines the technological versus human composition of a given LTC facility.
Overall, care staffs' attitudes towards monitoring technology appear to be complex and only partly explained by the factors analyzed in this study. The four attitudinal dimensions identified represent a comprehensive model for evaluating technology in institutional environments. These dimensions include the overall value of the technology, its impact on a facility's liability, its effect on the quality of care on residents, and whether use of the devices in question is ethical. Evaluating location monitoring devices, as well as other innovative technology, is deemed a critical - but often ignored - exercise. Ideally, assessment of the interfacing of technology with residents, staff members, and management should be undertaken before the technology is widely adopted.
Two limitations should be identified in the present study. First, the 10 facilities selected for this research may not be representative of intermediate care facilities throughout British Columbia, Canada, or North America. Second, the sample size was purposefully limited due to the exploratory nature of this study; nevertheless, the findings justify further investigations on the topic. For example, it would be beneficial to study whether the ancestry effects reported are applicable to other health care technologies, and how staff members view these devices in comparison to the use of physical and/or chemical restraints.
Another potentially important variable that was not addressed in this study is administration attitudes/ policies toward such issues as physical restraints, resident autonomy, and /or human versus technologic care.
Clearly, "attitudes" toward monitoring devices represent only one possible domain of inquiry. Analysis into the efficacy of these devices also warrants attention. We have seen no empirical studies looking at whether the technological devices in this study do what they are purported to do, especially devices that are marketed for falls prevention. When comprehensive data are available that encompass a broader set of environmental and human variables and that include the care staff, family caregivers, and residents, we will be in a better position to accurately assess monitoring technology in the LTC environment.
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Technology Attitude Scales and Results from Factor Analysis