Keywords

1 Introduction

Many countries with ageing populations need to work on how to incorporate innovations of different forms into the ongoing process of change in social service, support and care of the elderly. Future care provision for the elderly is facing multiple challenges. There is an ongoing change in demographic structure, where proportions as well as numbers of older people with care needs are rapidly increasing, bringing an increased demand for long-term care services [1, 2]. Current supply is considered as insufficient and inadequate in terms of meeting future needs for long-term care [1]. Yet another challenge is difficulties recruiting new work force to health professions [3]. In Sweden the prognosis is a deficit of 100 000 healthcare professionals by 2030 [4]. Including technology in long term care of elderly is an opportunity not only to increase quality of care, but also to maintain care in the future [5]. Some established examples are Internet-based support services that can contribute to elderly people living in their own homes to live their lives with higher levels of independence and electronic devices that increase social inclusion of elderly [6–8]. Another technology useful in care of the elderly, at home or in nursing homes, is sensor technology. Sensor technology retrieves essential information about the individual which can be used by e.g. nursing staff to supplement their own observations, thereby helping them to better understand and tend to the needs of the elderly person [9]. The pilot case that exemplifies the method in this paper tested an innovation based on sensor technology.

A Test Arena Initiative.

In society there is an ongoing trend to bring in new methods, systems or tools to aid the renewal of life situations and work processes as well as to realize the usage and dissemination of those new ideas, methods and techniques. In Sweden, a national initiative to innovate elderly care is taken based on the firm belief that test and demonstration arenas can help companies and organizations to increase their competitiveness, efficiency and quality [10].

Test and demonstration arenas are promising as they create new knowledge that cannot be captured using simulations or small-scale experiments; new partnerships can be developed and complex tests that an individual actor could have difficulties to afford can be realized by cost-sharing and joint learning and developing. The assembly and management of a realistic test arena both related to e.g. technology and real-life observations is costly and therefore impossible for small innovative companies to carry out, especially when testing their first product. To enable relevant and qualitative testing, it is of outmost importance that test facilities are available and functions on a per usage cost [11]. Further, it is sometimes crucial to create an understanding and visibility of potential social benefits thanks to technical innovations in order to develop and spread certain products and services.

Test arenas can move from the very delimited to the extremely wide, from an area which actually has a different main objective, such as a neighborhood, to specifics and details like lab tests of research equipment. A mapping study performed by the Swedish Innovation Agency VINNOVA showed a great mix of research and innovation infrastructure with many different denominations, e.g. test bed, living lab, prototype workshops, pre-incubator and pilot plants to name a few [10].

Moreover, innovations or new ideas may arrive from different actors; e.g. from well-experienced care personnel, from research, as well as from technical innovators. An important matter is that the innovations need to be tested in real-life situations before implemented in elderly care practice, to date an activity hard to achieve.

Norrlandicus is an open innovation and test environment formed as a Living Lab, established in 2013 in Sweden. In Norrlandicus actors aiming to develop health and social care for elderly through innovation, are offered a test and evaluation method as an activity in their intrinsic development process. The method intends to suit tests of not only products, but also services and processes. The objective of the test method is to show whether the innovation adds increased value in a health and social care process for the elderly, and to measure to what extent the innovation is perceived useful by the end-users.

The purpose of this paper is to present the novel test method that is the basis for the test process used in the Living Lab Norrlandicus. The method is exemplified by a pilot case that tested an innovation for an aging population by guidance of quality criteria as well-being, dignity, value for the elderly and usability of the innovation.

The Norrlandicus Living Lab.

As a Living Lab, Norrlandicus consists of a number of test persons in a number of test arenas. A test arena can for example be a nursing home, a sheltered housing or the private homes of older persons living in their own houses. For each innovation to test a specific living lab is created, where the purpose and goal criteria of the innovation are mapped to a suitable setting in the municipality elderly care, i.e. an ad hoc-setting. In the living labs, innovations are tested based on a triangular approach [12] where the elderly, their next of kin and health- and social care staff are not only involved, but are the real test persons and drivers of the test of the innovation. As an aid in the assessment, experts from academia and industry with many years of experience in evaluating usability, health and social care quality, innovation, business models, functionality and health economics are provided within Norrlandicus [13]. Norrlandicus is an ongoing research and development project, partly financed by The Swedish Agency of Innovation Systems, VINNOVA, and the County Administrative Board in Västernorrland. Norrlandicus is owned by a partnership constellation that works to create an environment where industry, academia and expertise in health and social care can meet to develop innovations for future care.

2 Method and Materials

Each innovation in Norrlandicus is assessed via quality measures from the users’ perspectives and for validation purposes. Validation in this context means to examine to which extent the innovation contributes with intended effects to a health and social care process for elderly. The foundation of the novel test method is described along with an example providing more detailed information from a pilot case that tested an innovative tool for investigation of urine incontinence.

Norrlandicus Test Method.

Innovations are tested in Living Labs. For each test an ad hoc environment is selected in an appropriate care facility within the elderly care sector, e.g. a nursing home or a home care district. The authors of the test method work on-site in a multidisciplinary team, with expertise from the domains of caring science, statistics, health informatics and human-computer interaction. The test method as such builds on the “National Values for Social Care of Elderly”, here translated as “Dignity of Life” [14]. Addressing basic health and functional needs is important; a salutogenic approach to health, considering participation and independence, promoting good health and rehabilitation [15], has been a core value in developing the test method. Along with salutogenic values the test method strives to enlighten dignity and well-being as dimensions of Dignity of Life. There is a lack of evaluations following such quality measures in the care sector in general, and a method that measures dignity of life related to innovations in elderly care was until now completely absent. Therefore, this test method is unique as it is based on concepts from Dignity of Life and relates those to a (technical) innovation in elderly care. The evaluation is further guided by a third dimension, quality criteria of the international usability standard, highlighting the usage as a function of the innovation and its defined end-users [16], (Fig. 1).

Fig. 1.
figure 1

Three dimensions of the test method with the core value Dignity of Life

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Based on the concepts of values a few factors were derived, for which the research team developed a number of issues (sets of “items”) with scales for the factors. On a policy level, the questions are general. On the level of details, tests are based on the purpose and potential usability of the specific innovation in its real context, according to the international usability standard [16].

The target audience is older people (65+) with age-related needs. Innovations will affect the elderly, either directly or indirectly. The Norrlandicus method investigates whether the introduction of an innovation in older people’s immediate environment or nursing situation alters the experience of having a dignified life. The aim is to highlight the impact and how the innovation affects the elderly and their closest stakeholders, next of kin and care staff.

The measurements are carried out by the elderly themselves, health and social care staff and/or next of kin together with different academic parts in a multidisciplinary test process. Products and services can be evaluated from three perspectives; the “care customers” (elderly or seniors), their next of kin and health and social care professionals. For evaluation a mixed method is used, to capture quantitative as well as qualitative measures.

Depending on the character of the tested innovation and its purpose, in the pilot case two of the perspectives stated above were considered relevant, namely care customers and professionals.

Quantitative Method - Questionnaires Regarding Usability.

The efficiency and effectiveness can be measured along with user satisfaction of the innovation to demonstrate potential benefit for current care organization, the elderly sector as a whole or for personal use [16]. Structured (statistical) data were collected from a number of the involved staff. The instrument used for this was the System Usability Scale [17, 18] that measures perceived ease of use. Originally created in 1986, it has become an industry standard, with references in over 1300 articles and publications. SUS measurement is intended to cover the products’

  • effectiveness (how well a user can complete a task and achieve their goals),

  • efficiency (how easy/difficult a user fulfills its goal using the product),

  • satisfaction (the level of comfort the user experiences in achieving those goals).

In practical, the SUS measurement consists of 10 statements rated on a 5-point scale according to how much the user agrees or disagrees with the statement. The result can be between 0 and 100, higher scores indicates higher perceived ease of use.

Ten persons among the staff who worked with the elderly test persons during the test period filled out the SUS questionnaire.

Qualitative Method.

A qualitative evaluation was made after the test period. Semi-structured group interviews were conducted with staff that during the test period had used and worked with the innovation [19]. Interviews were made with groups as it was more convenient for the staff and easier for them to fit into their busy schedule than individual interviews. A topic guide was used [19] covering the following three areas: (1) Information about the respondents (occupation, role in the test, how often you have used the innovation), (2) Experiences from using the innovation (usability of the innovation, benefits and problems from the perspectives of staff, the elderly and next of kin) and (3) Comparison with “practice as usual” (daily routines, effects on the working environment, advantages and disadvantages).

Data from interviews were analyzed using qualitative content analysis with a summative approach, where analysis goes beyond mere word counts and also include a latent content analysis [20].

Pilot Case - Setting and Current Practice.

Living lab for the pilot case was a nursing home for elderly, located in rural areas of north Sweden. The nursing home had 40 residents, all with extensive long term care needs. Nursing services were provided 24/7, mostly by assistant nurses and care staff with lower education. In addition, there were three registered nurses with overall nursing- and medical responsibility. Nearly all residents used absorbent products for protection against urine leakage. This nursing home already had good routines for investigation of urine incontinence and subsequent follow-up work, but when the manager and registered nurse were offered to test an innovative tool they accepted immediately.

Nursing home routines for determining the most suitable protective product for each individual included a 72-hour measuring period. For each individual the 72 h measuring period demanded that the staff manually weighted each incontinence product after use. Weight and time of weighing were documented. After 72 h data was analyzed in order to figure out voiding patterns and volumes, which were then used as guidelines when determining which product to choose for each individual.

Pilot Case - The Innovation.

The innovation tested as a pilot case in the Living Lab during November 2014 was a tool for incontinence investigation. The protection product electronically tracked voiding patterns as they occurred over time, in this case 72 h to compare with standard routines.

The product used sensor technology, where data was transmitted wirelessly to a computer. Data was then graphically converted into actionable reports, where nurses in charge of prescribing incontinence products were able to see the exact time and volume of the individuals’ urination. The disposable protective product was shaped like a diaper and had a logger device attached to the front. Upon change of product the logger was disinfected, then attached to a new product (Fig. 2). The purpose of the innovation was to increase accuracy in incontinence investigations. The purpose of the product was to facilitate the process of the 72 h test and optimize the outcome of products to match the needs of each individual.

Fig. 2.
figure 2

Illustration showing the idea of the innovation tested: a disposable protective product with sensors and logger along with an example of graphic report of data. Picture courtesy of © Copyright 2015 Svenska Cellulosa Aktiebolaget SCA.

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3 Results

Quantitative Results - Questionnaires Regarding Usability.

Ten of the staff at the nursing home, one registered nurse and nine assistant nurses, who participated in the practical use of the innovation, completed the usability questionnaire. Three were between 41–50 years and the rest over 50 years, 9/10 had more than 20 years of professional experience. They were positive or very positive to innovations in care and very supportive of this innovation. Besides these answers, the SUS questionnaire revealed their opinions of the usability of the innovation.

The SUS usability score scale ranges from 0 to 100 and the measurement results for the ten nurses who answered these questions about perceived ease of use of the innovation were 87.5, 100, 100, 100, 100, 65, 60, 72.5, 97.5 and 87.5 in assessing usefulness of the innovation (Fig. 3). The result of the ten evaluators was well above the average value calculated on long term use of the scale in situations where the perceived ease of use has been assessed. That mean is 68. The median of this evaluation was 92.5.

Fig. 3.
figure 3

Result of the usability scores of the 10 evaluators

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Qualitative Findings.

Interviews were conducted with seven persons, representing the different professions involved with the test. Assistant nurses were mostly involved in changing the disposable protective product and changing the logger device. The main role of registered nurses was to analyze the graphic information. Determining which protection product that was the most suitable for each person was a team effort including all professions. In the process of analyses of the measurements a representative from the company supported the nursing staff and guided them through the graphical data. Several of the residents participating in this test had dementia and were not able to give verbal input. Therefore, in this pilot case, the staff acted as proxy for the elderly in giving information.

Experiences from Using the Innovation.

The Innovation was Considered Reliable and Useful. Handling it was neither technically advanced nor stressful. Removing the disposable product from the individual was easy, however fastening the product on the individual was somewhat challenging. To ensure correct fastening it was preferable to be two persons working together. Changing the logger was not difficult. Graphic reports were detailed in measuring time and volume for urinating. The staff discovered that in order to optimize use of data, it was necessary to add specific information about each individual, such as cognitive status, mobility, medication etc. Data reports were easy to understand and gave detailed information. The staff appreciated the possibility to follow leakage activity in real time. By being able to put leakage into a context gave even further assistance in choosing the right protection for the individual, and even more valuable in optimizing toilet routines. According to the staff, the residents did not experience wearing the sensor product as different from wearing their ordinary product. Staff felt the innovation contributed to improved quality of life for the residents, as it improved the knowledge about their situation, which was helpful in providing for the needs of the residents. Next of kin did not participate in this test.

Regarding the perceived usability of the web-based tool, the staff created a detailed list of potential improvements of the interface and the interaction. The list was fed back to the responsible of the innovation at the company. Staff from the company also participated during the evaluation of the test, gathering direct information from the test participants.

Comparison with “Practice as Usual”.

According to the Staff, the Major Difference Was that They Went from Guessing to Using Facts. Through exact knowledge about individuals’ leakage they were able to optimize product selection as well as toilet routines. Some differences between working with ‘practice as usual’ and using the innovation are displayed in Table 1.

Table 1. Examples of main differences between practice as usual and using the innovation, as experienced by nursing staff in the living lab.
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The analysis of gathered data led to the following changes for the five test participants: change of the routines occurred in four occasions and change of product occurred in three occasions, all of them to a thinner product.

4 Discussion

Norrlandicus’ test environment and method are based on the conceptual idea that staff and the elderly in each living lab are the ones providing measures regarding an innovation’s success in enhancing quality of life for the elderly. Each innovation (product, service or process) needs to be assessed using quality measures from the users’ point of view. In the pilot case described above the authors wanted to test the method and see if it was possible for the elderly and their care staff to conduct the tests in their natural environment, the Living Lab. We found that the participants were able to provide relevant measures of the innovation. Initially we had anticipated a higher level of information input from the elderly themselves. We may need to re-think how to capture the experiences from the elderly. Using staff or next of kin as proxy may be one way to go, although another study by one of the authors [7] points out the need to allow end-users to participate in the evaluation of the innovation based on their own capacity. This dilemma will be further research and future work within the Norrlandicus Living Lab. This also brings some ethical considerations. Conducting research in settings involving vulnerable subjects is an ethically complex issue. In nursing homes and other forms of elderly care, where the Living Labs are situated, there are several individuals with dementia in the test population. As an actor in close cooperation with nursing- and social sciences, Norrlandicus follows common ethical guidelines [21]. Participation in tests was voluntary. Prior to inclusion in the tests, all participants gave written consent. For participants with dementia, next of kin gave written consent. Another ethical issue to consider was the heavy work load at nursing homes. For Norrlandicus it was essential to minimize disturbance for the staff as well as the residents. Organizing the test, with meetings and research activities in adjustment with staff and resident schedules, shift work and a rather high staff turnover was a time consuming challenge.

Further, healthcare to date has been focused on service for illnesses rather than addressing citizens’ holistic health needs, including e.g. social services, prevention and support for informal care givers [22]. In recent publication, researchers call for the inclusion of social care informatics as an essential part of holistic healthcare, stressing the importance of this emerging field of research [23]. In order to strengthen the role of patients and next of kin, this method focuses on patient-centric provision of care, following the ongoing shift from organization to citizen-centered care [24]. The usability of the intended innovation is another quality measure, a key to failure or success of a product [25].

The expected result from an academic point of view was that Norrlandicus test method as such was validated. The aim is to measure the contribution of the innovation in terms of “Dignity of Life” for the elderly as well as the degree of usability of the innovation. The “Dignity of Life” criteria need to be measured a while after the changes of routines and products have been made and is hence part of the work that lies ahead of us.

Although there is a national initiative supporting deployment of test arenas, it is still not common that test arenas use qualitative values to evaluate the benefit of the tested innovations as is the case of our test method. This method has already attracted interest; however it is yet to experience whether other test arenas will seize the opportunity and start using the Norrlandicus test method.

Expected results from the innovators and the aging society may vary depending on type of innovation. As this method focuses on the quality of life of the elderly and allows for interaction between industry, health and social care and academia there is some ground to claim that the Norrlandicus Living Lab can support in providing real health and social care improvements via technical innovations.

5 Conclusion

Norrlandicus is an open innovation and test arena aiming to meet tomorrow’s needs and contribute to increased quality in healthcare and care for the elderly. In the Living Lab private and public stakeholders are invited to evaluate innovations (products, services and processes) using the Norrlandicus method to determine if they add increased value in a health and social care process for the elderly and to measure to what extent the innovation is perceived useful by the end-users. The success factor lies in the joint testing work between the elderly, the nursing staff and the research team with different specialties. In short, the test method examines the introduction of an innovation in the local environment of the elderly and whether this intervention alters their experience of having/getting a dignified life, while at the same time the method also assesses the usability of the innovation. Future work is to continue refining the test method by conducting pilots and field studies to gather knowledge and experiences from different stakeholders in the aging society.