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Background Older people in care may be lonely with insufficient contact if families are unable to visit. Face-to-face contact through video-calls may help reduce loneliness, but little is known about the processes of engaging people in care environments in using video-calls. We aimed to identify the barriers to and facilitators of implementing video-calls for older people in care environments. MethodsA collaborative action research (CAR) approach was taken to implement a video-call intervention in care environments. We undertook five steps of recruitment, planning, implementation, reflection and re-evaluation, in seven care homes and one hospital in the UK. The video-call intervention ‘Skype on Wheels’ (SoW) comprised a wheeled device that could hold an iPad and handset, and used Skype to provide a free video-call service. Care staff were collaborators who implemented the intervention within the care-setting by agreeing the intervention, recruiting older people and their family, and setting up video-calls. Field notes and reflective diaries on observations and conversations with staff, older people and family were maintained over 15 months, and analysed using thematic analysis. ResultsFour care homes implemented the intervention. Eight older people with their respective social contacts made use of video-calls. Older people were able to use SoW with assistance from staff, and enjoyed the use of video-calls to stay better connected with family. However five barriers towards implementation included staff turnover, risk averseness, the SoW design, lack of family commitment and staff attitudes regarding technology. Conclusions The SoW intervention, or something similar, could aid older people to stay better connected with their families in care environments, but if implemented as part of a rigorous evaluation, then co-production of the intervention at each recruitment site may be needed to overcome barriers and maximise engagement.
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R E S E A R C H A R T I C L E Open Access
Video-calls to reduce loneliness and social
isolation within care environments for older
people: an implementation study using
collaborative action research
Sonam Zamir
1*
, Catherine Hagan Hennessy
2
, Adrian H Taylor
3
and Ray B Jones
4
Abstract
Background: Older people in care may be lonely with insufficient contact if families are unable to visit. Face-to-face
contact through video-calls may help reduce loneliness, but little is known about the processes of engaging people in
care environments in using video-calls. We aimed to identify the barriers to and facilitators of implementing video-calls
for older people in care environments.
Methods: A collaborative action research (CAR) approach was taken to implement a video-call intervention in care
environments. We undertook five steps of recruitment, planning, implementation, reflection and re-evaluation, in seven
care homes and one hospital in the UK. The video-call intervention Skype on Wheels(SoW) comprised a wheeled
device that could hold an iPad and handset, and used Skype to provide a free video-call service. Care staff were
collaborators who implemented the intervention within the care-setting by agreeing the intervention, recruiting older
people and their family, and setting up video-calls. Field notes and reflective diaries on observations and conversations
with staff, older people and family were maintained over 15 months, and analysed using thematic analysis.
Results: Four care homes implemented the intervention. Eight older people with their respective social contacts made
use of video-calls. Older people were able to use SoW with assistance from staff, and enjoyed the use of video-calls to
stay better connected with family. However five barriers towards implementation included staff turnover, risk averseness,
the SoW design, lack of family commitment and staff attitudes regarding technology.
Conclusions: The SoW intervention, or something similar, could aid older people to stay better connected with
their families in care environments, but if implemented as part of a rigorous evaluation, then co-production of
the intervention at each recruitment site may be needed to overcome barriers and maximise engagement.
Keywords: Skype, Video-calls, Intervention, Collaborative, Action, Research, Elderly loneliness, Isolation, Care-settings
Background
Loneliness and social isolation among older people may
be detrimental to well-being [1], quality of life [2] and
cognitive decline [3]. Technological interventions have
been developed that may reduce loneliness for dementia
patients through telephone be-friendingprojects [4,5],
and the use of the internet [6,7]. Even so, social media
and emailing provide less personal connectivity than
face-to-face contact with a loved one, and may even add
to the feeling of loneliness and isolation. [8]. Previous
studies have revealed that face-to-face contact through
video-calls may be more useful for older people than
telephone calls or written correspondence in reducing
loneliness [911].Technologies such as iPads are easily
mobile and can be used for video-calls using software
such as Skype, a free tele-service. Older people may be
capable of using iPads and Skype, but not all care environ-
ments provide this technology [12]. There is therefore a
need to better understand the factors influencing the use
* Correspondence: sonam.zamir@plymouth.ac.uk
1
Drake Circus, School of Nursing and Midwifery, University of Plymouth,
Plymouth, Devon PL4 8AA, England
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Zamir et al. BMC Geriatrics (2018) 18:62
https://doi.org/10.1186/s12877-018-0746-y
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
of technology to reduce loneliness and isolation, and how
it may be useful for older people.
Loneliness and social isolation have been defined in
various ways. Researchers now believe that loneliness is
a perceptual concept whereas social isolation is defined
as the lack of structuraland functionalsocial support
[13]. Structural social support is normally assessed by
the size of ones social networks and frequency of con-
tacts within that network. On the other hand, functional
social support is a subjective judgment of the quality or
perceived value of emotional and informational support,
provided by those within their social network [14].
In terms of the quality and perceived value of support,
Porgess social engagement and attachment theory posits
the importance of seeing one anothers faces during
communication [15]. This is because body language in-
fluences both the expression and receptivity of social
cues, consequently reducing perceived social distance. In
particular, use of facial expressions, eye gaze, and head
orientation is important for social engagement, which
can be lost in asynchronous communication and tele-
phone calls. These expressions can be seen as an active
social engagement system reducing psychological distance,
and can influence perception in the engagement of others
[15]. Porgess theory places importance on the role of
face-to-face interaction in maintaining social bonds, and
thus reducing feelings of loneliness and social isolation.
In modern society, face-to-face communication with
family members has declined creating a need to find alter-
native methods to maintain communication. Socialisation
interventions that incorporate face-to-face communica-
tion through video-call technologies and telepresence ro-
bots have been developed, and tested among older people
with and without cognitive impairments [1618]. How-
ever telepresence robots are currently very expensive and
researchers have opted to use low-cost, off-the-shelf tech-
nologies such as Skype to provide communication inter-
ventions for older people [19]. This type of socialisation
intervention may be beneficial and enjoyable among older
people, increasing their social networks over the long-
term [19]. Skype use by adults aged 50 and over has been
effective in treating depression over the long-term [20].
Similarly Mikus and Luz gave low-cost videophones to
frail older residents in care homes, in order to enhance
communication with their families. Although there were a
number of identified technical and design problems, they
demonstrated that videophones were useful and enhanced
social interactions regardless of distance [16]. Boman and
colleaguesmore recent study exploring the usability of
videophones with older adults with dementia, revealed
positive attitudes towards their use perceiving them to be
worthwhile and enjoyable [18].
Retirement, living alone, living in a care environment,
and cognitive ability may be associated with loneliness
and isolation. These same people may also be those least
likely to understand and use the technology. Although
there have been some video-call intervention studies in-
volving the elderly, many studies involve younger older
adults (age 50 and above) that may not be retired, living
in care, have a cognitive impairment and may have a
better understanding of technology [20,21]. This results
in those who most need the intervention often being ex-
cluded from studies.
The challenge for researchers working with older people
in care environments is to develop interventions that, (a)
are complementary to their environment and not burden-
some, (b) promote health, (c) help prevent negative health
outcomes and (d) which carers can deliver. Collaborative
action research (CAR) can be a useful approach for co-
production of health promoting interventions with stake-
holders and in particular, optimising engagement with
older people, their loved ones and care staff (collaborators)
to refine an intervention suited to their needs and envir-
onment [2224]. The process of CAR typically consists of
four major activities; planning, acting, observing and
reflecting all derived from action research that help inform
the feasibility and acceptability of an intervention, using
an iterative process [25,26]. The initial cycle of these four
activities leads to a second cycle (second iteration) in
which the reflections of the previous cycle (first iteration)
inform the plan of the next. This can be particularly useful
in identifying the barriers, facilitators and benefits of an
intervention in cycle one, to further address them in cycle
2 and so forth. The CAR design allows the researchers
and collaborators flexibility to go back and forth between
activities, making it a useful approach in complex care en-
vironments that operate in a nonlinear system, but rather
oscillate to meet the needs of their clients. As the cycles
progress, a greater understanding is developed through
continuous refining of methods, data collection and inter-
pretation together with the collaborators [27]. Although
there are now a number of studies using video-call inter-
ventions with loneliness and isolation as the primary out-
come for older people, there is no research to date that
has used CAR as an approach to implement video-calls
within a care environment. Where some studies demon-
strate good participant engagement with video-calls, espe-
cially for design purposes, there is a better need to
understand the processes of engagement. CAR may be a
useful approach to the design of a complex intervention
with multiple stakeholders effecting that engagement.
The present study fits within the MRC framework for
developing and evaluating complex interventions in that,
it seeks to establish the best way to use digital communi-
cations between older people living in care environments,
and their family members. The intervention Skype on
Wheels(SoW) was a simple mobile device (chassis) com-
prising an iPad to make video-calls using Skype, and a
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telephone handset (Fig. 1). If the intervention can be
shown to be acceptable and feasible, then further studies
can examine the effectiveness for reducing loneliness and
social isolation, and improving health and wellbeing in
older people. The long-term aim of this research is to ex-
plore how best to normalise [28]theuseofvideo-calls
within a care environment, through the identification of
barriers and facilitators to employing video-calls with
older people, staff and family to reduce loneliness and so-
cial isolation. Specifically, the study used the core activities
from action research; observation on reactions and atti-
tudes towards and use of video-calls, planning and set-up
with collaborators, action of using video-calls and reflec-
tion to identify changes needed. Four objectives aligned to
CAR were identified:
1. To assess the feasibility and acceptability of using
SoW among older people in care environments.
Action research allowed thorough planning of SoW
implementation with collaborators to enhance
feasibility and acceptability, with continuous
observation of using video-calls (action) in complex
environments.
2. To identify which older people, in which care
environments are able to make use of video-calls.
Observing who was able to engage in which settings
after carefully planning.
3. To identify any potential design improvements to
SoW or better alternative device methods to deliver
video-calls. Observing how participants reacted to
SoW current design and reflecting with collaborators
on how to meet their needs.
4. To identify the barriers, facilitators and benefits in
using video-calls as perceived by staff, older people
and their family contacts. The reflective process
highlighted in action research enables the
identification of these.
Methods
Design
The current study used the core activities from action
research but with added activities to help better adapt to
the evolving research trajectory (Fig. 2). Activities were
classed as steps taken to achieve intervention implemen-
tation within a cycle: (1) Recruitment of older people
and relevant family. This was facilitated by staff in the
care environment; (2) Planning how best to implement
the intervention. This required collaboration between
the researcher, staff, older people and their family; (3)
Implementation was the action of using video-calls. (4)
Reflection involved feedback and identification of the
barriers to and benefits of using video-calls; (5) Re-
evaluation allowed the researcher and staff to tackle the
identified barriers, and therefore inform a possible sec-
ond cycle of CAR. Observing was an on-going activity
that was implemented throughout the CAR steps, and
so integrated within the cycle. These were employed over
a 15 month study from April 2015. The cycle came to an
end once all sites had entered the re-evaluation step.
Ethics
The study was approved by the Plymouth University eth-
ics committee in December 2013 and NHS in March
2014. All participants gave consent. Collaborators gave
verbal agreement to be part of the study and notified the
researchers if they did not want to provide feedback, or
take part in the study. All collaboratorsinformation was
anonymised. Participation was voluntary and participants
and collaborators were assured of confidentiality.
Recruitment of sites
The study used convenience sampling aiming to recruit
care environments from Devon and Cornwall UK that
had access to the internet. The concept of SoW had
already been developed to some degree through student
design projects led by the fourth author, and discussions
with community hospital matrons and care home man-
agers. One community hospital and six care homes con-
tinued as inheritedsites from the initial work possibly
willing to participate in the current study. Additional
sites were recruited using information gathered from a
service improvement project carried out by the local
Clinical Commissioning Group in 2014. Those care homes
that had either used video-calling previously or expressed
interest in using it, were contacted by email. For those who
responded showing interest, an initial meeting was set up
to further discuss the project. In total, eight sites were re-
cruited over the 15 month period of the study (Table 1).
Participants and collaborators
Altogether, eleven NHS and 21 care home staff were col-
laborators (including staff turnover rates see Table 1),
Fig. 1 SoW device
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and 34 older people (19 residents living in a care home,
and 15 patients admitted into hospital from either a care
home or their own home) and 15 family members were
approached about SoW. Eighteen (53%) older people (8
residents and 10 patients), and nine (60%) family mem-
bers agreed to participate. Cognitive status and individ-
ual chronic conditions were not well documented during
recruitment of older people; however staff preferred to
include individuals without a dementia diagnosis. One
resident was non-verbal and could lip read, and one resi-
dent and three patients showed early signs of cognitive
decline (as reported by staff ). All residents and patients
were aged 65 and over and Caucasian.
Materials
Each site was given the SoW equipment to freely use.
This consisted of an iPad, a SoW device and telephone
handset. Some sites had their own iPad and other sites
were loaned one by the research team. A2 or A3 size
posters advertising video-calls were displayed at each
site, along with information leaflets for participants and
staff.
Procedures
Visits were made to each site every 34 weeks (on aver-
age 6 per site). Each visit represented one of the five steps
in the CAR cycle. (1) Recruitment- staff were collaborators
who helped to identify older people and family members
to use Skype. (2) Planning- testing of equipment and WiFi
connection. Staff training was provided on how to use
Skype. (3) Implementation- staff assisted older people to
use Skype with family. (4) Reflection- staff gave feedback
using feedback sheets (after each Skype call) and face-to-
face meetings with the researcher on barriers to and facili-
tators of the intervention. (5) Re-evaluation-discussion
with staff on how to overcome barriers or to withdraw
from the study.
Since each site varied in the way it was managed and
operated, the number of times each site went through a
step also varied (Table 2). Follow-up on progress and
feedback from staff was also acquired by telephone or
Fig. 2 Action research cycle and revised cycle
Table 1 Participating sites showing method, date of recruitment, care site demographics
CH
Inherited
April 2015
C1
Inherited
April 2015
C2
Inherited
April 2015
C3
Inherited
May 2015
C4
Survey
August 2016
C5
Survey
September 2016
C6
Inherited
May 2016
C7
Inherited
May 2016
No. of care staff at site 60+ 45 40 30 60 15 40 40
Care staff participating 11 4 2 3 3 3 3 3
Staff turnover
a
0% 100% 50% 100% 0% 0% 67% 100%
Education level of staff/ Degree College College College College College College College
Staff wages (hourly)
b
£10+ £8£9 £7.50£9 £7.50£9 £8£9 £7.50£9 £8£9 £8£9
Average no. elderly care
c
15 28 20 28 30 17 40 35
Minimum age of elderly 65+ 65+ 65+ 70+ 65+ 70+ 70+ 65+
Type of care given Acute Dementia Dementia Dementia Dementia Dementia Palliative Dementia
Weekly visits
d
Unknown 40% 25% 25% 30% 95% 30% Unknown
No visits
e
Unknown 15% 10% 15% 15% 1% 10% Unknown
CH Community Hospital Ccare home
a
% of recruited staff that left employment at that site during the study
b
Against UK national minimum wage £7.30
c
From April 2015May 2016
d
Estimated proportion of older people who were usually visited each week by loved one
e
Estimated proportion of older people who usually received no visits over a 4 week period
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email. If a site was having difficulties during a step, an
extra visit would be arranged. There was some repetition
of content within the cycle, such as discussion of how
best to implement the SoW device or recruitment of
participants. As staff went back and forth between the
steps, the intervention became more integrated into
daily routines and staff became more confident in deliv-
ering it.
Data collection
An ethnographic approach consisting of observations,
unstructured interviews, memo writing, feedback forms
and reflective diaries was taken towards data collection
from a small number of cases. Words such as alone,
lonelyand isolatedwere not used during interviews
with older people to avoid increasing feelings of loneli-
ness or isolation. Unstructured interviews allowed the
researcher to build rapport with the participant, render-
ing discussion of this sensitive topic less daunting [25].
The researcher documented all observations in note
form. All conversations between collaborators and par-
ticipants were anonymised, and documented into memos
after each visit in a retrospective format. Additionally, with
permission some conversations were documented in situ
to best capture original quotes. The data were classed
as field notes.
Data analysis
Thematic analysis was used to analyse the field notes by
the first researcher [26]. Saturation sampling was used,
in which observations and interviews stopped when no
new dominant issues were found emerging from the
data. For each set of field notes, Braun and Clarkes six
phases of thematic analysis were used to gather categories
which informed final themes [26]. The naming and check-
ing of the categories, final themes and appropriate quotes
were done by all of the authors. The software package
NVivo version 11 was used to organise and manage the
data.
Results
Usability
Four care homes implemented the SoW intervention
and four withdrew from the study (Table 2). In total
eight older people with their respective family contacts
used video-calls (Fig. 3). From staff feedback, about half
of the residents used video-calls once or twice a month
after implementation. The remainder video-called less
frequently using opportunities such as birthdays, import-
ant family occasions or when close family went on holiday.
Those participants who had been using SoW but were not
doing so at the end of the study had either died (N=1),
moved into respite care (N = 1), had their family members
stop calling (N=2), or did not have access to SoW due to
management changes at the care home (N = 2).
Intervention feasibility and acceptability
Observations on the feasibility and acceptability of SoW
were made by the researcher or by staff, and feedback to
the researcher was provided. Qualitative analysis of the
field notes revealed four themes with sub-categories
(Table 3). Each is discussed below with representative
quotes.
SoW aesthetics
Risk averseness
When the device was introduced to staff in C1, it did
not appear straight forward. The activity co-ordinator
was concerned about the safety of the device. Staff
wheeled the device through the corridors to test its
safety and were reassured that it did not pose a risk.
Similarly, staff at CH refused to allow SoW on site until
they were assured it had adequate safety brakes.
You see this bit here, it sticks outlooks sharp.I
dont know if it will be safe to wheel around the
corridorswe have residents that walk up and down
the narrow corridors I dont want them to get hurt
.lets take this around and see if it can fit through
the corridors without poking anyone.
(Care home, activity co-ordinator)
Table 2 The number of times each site was in a step during the study
Recruitment Planning Implementation Reflection Re-evaluation Withdrew
CH 2 2 0 2 1 Yes
C1 2 2 1 1 1
C2 3 2 0 1 1 Yes
C3 2 1 0 1 1 Yes
C4 2 2 1 2 1
C5 1 1 1 1 1
C6 1 1 1 1 1
C7 1 0 0 0 0 Yes
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Confusing technology
Patients, staff and family at CH reacted positively to the
SoW device. Many of the patients who were well enough
had an inquisitive approach to the device, but patients
varying degrees of ill health affected their ability to talk
with the researcher. The appearance of the SoW device
caused anxiety and confusion among some residents in
the care home environment. Staff reported that one resi-
dent of C1 became scared, anxious and confused as to
why the device was in her room when a video-call was
set up. Nonetheless, her anxiety and confusion ceased
when she saw her family member on the screen, and she
immediately began to make conversation. Staff suggested
that the residents should dress upthe SoW device as it
did not appear user friendly.
It looks scary and not that user friendlymaybe it
should be a bit colourful with some soft material on
it.put some colourful stickers and colourful wrapping
around the poles.
(Care home, activity co-ordinator)
Unanimous feedback reported from all the care homes
that implemented SoW was the non-use of the handset.
The resident participating at C4 could not make use of
the handset as she was hearing impaired and non-verbal;
instead she used sign language to communicate. Further-
more, the activity co-ordinator at C1 explained that the
sound quality was poor, creating difficulty in participat-
ing in a video-call and adding to the confusion of using
a new technology. Nonetheless, staff at C1 and C4 felt
the handset should remain part of the device to help res-
idents to identify that it represents a communication
service. Additionally, many patients at CH were able to
identify SoW for making calls when noticing the handset
and so reducing some confusion around the device. This
could help those with cognitive impairments to make
sense of the intervention.
Fig. 3 Participants and sites involved in the study
Table 3 Identified themes and categories
Themes Categories
1. SoW aesthetics 1.1 Risk averseness
1.2 Confusing technology
2. Attitudes 2.1 Towards technology
2.2 Staff commitment
2.3 Family commitment
2.4 Ageism
3. Care environment 3.1 Patient discharge
3.2 Staff turnover impact
3.3 Normalisation
4. Loneliness & isolation 4.1 Feeling alone
4.2 Capturing feelings
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Staff at C1 reported technical issues with the internet
connection. On one occasion the Skype application
stopped working during a video-call. Staff reported that
this incident created confusion and anxiety for the resi-
dent, since she grew concerned that her family did not
want to speak to her.
The app itself stopped working and the call got cut offI
couldnt make a connection to call back and she became
really anxious and upset.she was thinking why her
family wasntpickingupandIhadtocalmherdown
(Care home, activity co-ordinator)
Staff from C6 explained residents were familiar with a
larger screen and would then be more willing to partici-
pate in a video-call. Residents had a large television in
their rooms that the Skype application could use. When
this alternative was offered to the other care homes, all
staff agreed it would be a good alternative to the SoW,
additionally giving residents with visual impairments the
opportunity to video-call.
They watch TV a lot in their rooms so theyre used to
this type of screensome have never seen an iPad
before it can be a bit confusing for them
(Care home, manager)
Attitudes
Towards technology
Staff at CH requested a dummies guide to Skype(one
A4 sheet) during a training session. Two staff members
in particular felt this would be useful as they were not
familiar with video-calling, and were worried they would
not be able to implement the intervention. The guide was
offered to all of the care homes during the planning step,
but some staff felt it would not be useful. They believed
that staff would not remember to use the guide, or that it
would get misplaced. It was also felt that if they were to
formalise the intervention by assigning detailed instruc-
tions for its use, it would become daunting for staff who
would feel the need to take on yet another skill among
existing duties. As well, use of the guide would reveal and
possibly embarrass any staff who were under-skilled. Staff
attitudes towards using technology were considered an
important outcome measure for a future CAR cycle.
If we start telling staff they need to look at an
instruction guide its like were formalising this too
much. they might get scared and worried that Oh
great this is another thing I need to learn.some staff
might on purpose not look at the sheet because then
well know they arent good with using technology.
(Care home, activity co-ordinator)
At CH, one patient decided not to Skype as she felt
under-skilled in using an iPad, and concerned she would
look sillytrying to use video-calls. Nevertheless, when
it was explained she did not need any skill in using
video-calls, as staff would set up the calls, she was keen
to be part of the project. She still however wanted to
see how other patients would use it. Older peoples lack
of confidence in using technology may thus prevent
participation.
Oh I dont know how to use these complicated
things.Id look silly using it I wouldnt botherI
think its a great idea so interesting but Oh not meif
I see someone else use it then I know.
(Community hospital, patient)
Staff commitment
Staff at CH explained that their busy schedules would
not allow much time to implement SoW. Some care
home managers also felt staff who were less confident in
using SoW were less willing to commit to the project.
Its hard for me .other staff here are really busy and
if they dont really know how to use this they wont
bother muchits too much to have to learn while
doing other things.
(Care home, activity co-ordinator)
Care home staff did not thoroughly engage with the
feedback sheet provided. From the four care homes that
began using the device, only C6 had started to complete
the feedback sheet after some calls. Those staff members
who used the feedback sheet said they were rushed in
doing so, or would complete it later retrospectively. Staff
tended to complete the feedback sheet when there was a
problem related to the call. Staff reported that shorter,
questions relating to specific problems about the call
would be easier to complete. Due to the lack of usage,
the feedback sheet data is not presented in this study as
it made no significant contribution to the results.
Family commitment
Staff from all the homes reported difficulty in getting
family to commit to video-calling. C1, C2 and C4 ex-
plained this was due to family members having busy
schedules, time zone differences for contacts living
abroad, along with technical issues with their own devices
such as poor Wi-Fi connections abroad. In addition, staff
explained residents themselves become too tired in the
evening to Skype call when family members are normally
available. Staff from C4 further reported that residents in
turn became disinterested in the idea of using video-calls.
Most significantly, many of the residentsfamily members
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were themselves over 65 years of age, and lacked the skill
to use Skype, or did not own the relevant technology. C2
found it difficult to encourage family members to join the
project, therefore suspended their participation for a
period, but later decided to withdraw due to the lack of
family interest.
Its not a matter of the residentswe just cant get
family members. With [resident] we tried to set it up
but it didnt happen she didnt bother to be part of it
again because felt a bit let down its no ones fault
though.
(Care home, manager)
Ageism
One family member at CH highlighted the issue of age-
ism evidencing the belief that older people cannot make
use of technology. The family member explained that due
to her mothers age (90+) she would not be able to use any
technology, that she would not want to stay in touch with
her other family members, and that she herself visits her
regularly. In addition, as the care home staff were ultimately
responsible for authorising recruitment of participants to
the project, a number of residents were not approached
and consequently missed the opportunity to join the study.
A common justification was that those residents with de-
mentia will not be able to cope with new technology.
I dont want to involve [residents] because of their
cognitive impairment they wont be able to understand
whats going onIm not sure how they will react so its
best to not.
(Care home, activity co-ordinator)
Similarly, in some of the care homes, those who had
hearing, visual impairments, or were non-verbal were
not approached about the study by staff. Nonetheless,
C4 had successfully recruited one resident who was
non-verbal. This resident was able to communicate with
family using sign language. Staff explained that the resi-
dent now had a way to stay in touch with distant rela-
tives who previously wrote letters or sent text messages,
whereas now the resident was able to see her relatives
and their surroundings in real time, something a tele-
phone call or text message was not able to achieve.
She has family who moved to [abroad] recentlythey
always try to describe how lovely their home isthey
write to hernow she can actually see what it all
looks like and it was greatshe holds up her things to
the screenreally loves ityeah they [family] all use
sign language no issues so far.
(Care home, manager)
Care environment
Patient discharge
In the CH setting, patient hospitalisation would normally
last no more than a couple of weeks, and most would be
discharged after one week. Most patients would have left
the facility by the time the device was presented to them,
family members were contacted, and then set-up to use
video-calls. It is evident that an intervention such as this is
difficult to implement in a short term care-setting. Hospi-
tals may require an alternative method of implementation
in comparison to a long term care-setting.
Staff turnover impact
Four care homes had changes in management and site
staff. This in turn slowed down the progress of the study
due to having periods of no communication between the
researcher and the site, or not being able to visit until
the site was back to its normalrunning. This resulted
in some sites having to revert to the recruitment step
when new staff were appointed. With these changes,
some valuable information was lost such as Skype log in
details, feedback sheets or recruitment posters. Most im-
portantly, however, residents who had been using Skype
were no longer able to.
Normalisation
C1 and C6 provided a busy, activity focused environment
for their residents. Both had daily scheduled activities
where SoW became part of those scheduled activities, and
was integrated on to their activities board and into weekly
newsletters. Staff at these homes felt it would be easier to
normalise the intervention if it was seen as just another
on-going activity that they provided.
I think we will put this up on the activity board with
the restthat way it will just be another normal
thingif its in the newsletter then the families will
also see this.
(Care home, activity co-ordinator)
Loneliness and social isolation
Feeling alone
Although trigger words such as alone,lonelyand iso-
latedwere avoided during conversations with older
people, feelings of being lonely and isolated were made
apparent. Three patients at CH expressed feelings of lone-
liness during interviews with the researcher. One patient
explained she felt bored due to lack of interaction. She be-
came upset that she was in a hospital environment, and
her situation reminded her that her family were far away.
She became tearful, but was hopeful that the SoW device
could help her to reconnect with some of her distant
family as she felt alone in the hospital.
Zamir et al. BMC Geriatrics (2018) 18:62 Page 8 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
I do get boredI dont have anyone to talk toI have
family that visit once in a whileIm here nowIm
not well and I feel aloneI have family I would like to
seeYes I think its a great idea this.
(Community hospital, patient)
The second patient explained that she often sees her
children, but would like to have the chance to see her in-
fant great grandchild. She became slightly upset that she
still had not seen her great grandchild, and felt left out by
her family. She was excited at the thought of being set-up
on SoW where she could finally see her family.
Oh yesmy daughters come to see me even here at
the hospitalbut I havent had the chance to see the
little one yetthats my granddaughters little one
they live too far awayI wish I had the chance to see.
(Community hospital, patient)
The third patient overheard some of the conversations
between the researcher and patients, and was keen to
get set-up on the SoW to reconnect with her family. In
contrast, of the patients who did not want to use SoW,
one explained that she did not want her family members
to see her looking unwell even though she misses
them. She was worried that they would become upset
by her current appearance. Although feelings of loneli-
ness may reduce for some people, families may be-
come distressed as they watch their loved oneshealth
deteriorate.
Capturing feelings
When speaking with older people about the possibilities
of reconnecting with family and friends, feelings of
loneliness and isolation were evident and captured in
field notes. The feedback sheet after each call acted as a
source of documenting any changes in mood such as
feeling happier and less isolated. However, as previously
mentioned, staff members did not record this informa-
tion during the study. It was only identified that some
older people were feeling lonely and isolated through
conversations with the researcher, or by staff identifying
them as being lonely individuals who might be a good
candidate for SoW. Staff from C1 suggested that in
order to best capture these feelings, simplified scales
ought to be developed, as residents have previously
enjoyed completing questionnaires, and it would be an
easier way to document any changes. For future itera-
tions of this study, loneliness and isolation will be con-
sidered as key outcome measures. In addition, some
residents may have been unwell and therefore an im-
portant outcome measure of well-being would be ad-
vantageous to include.
Barriers towards implementation Key aspects of the
results highlight the lack of sustained use of SoW across
sites for various reasons. Five key barriers towards
implementing the intervention were identified (Table 4).
Discussion
This study addressed four objectives. It found that older
people and their family contacts are capable of using
SoW and found it beneficial however, the feasibility of
its use by those with cognitive impairments is yet to be
determined. A long-term care environment may be more
suitable for the on-going use of video-calls by older
people, compared to hospital settings. However, older
people in the hospital environment felt video-calls could
be useful to them, suggesting maybe an alternative ap-
proach in implementation that meets the needs of a hos-
pital environment. There is a need to re-design the SoW
device and provide video-calls on a larger screen as an
alternative, and reduce perceptions of risk towards the
device. Staff reflection identified five key barriers
Table 4 Barriers and suggested next steps
Barriers Suggested next steps (Re-evaluation)
(1) Staff turnover High staff turnover meant lack of sustained use of SoW. There is a need to engage more staff at each site.
(2) Risk averseness Perceptions of the device being unsafe and risky to use in a care environment were noted. There is a need
to conduct a risk assessment on site to demonstrate the safety of the device before use. In addition staff
training to reduce perceptions of risk that override implementation.
(3) Intervention design The SoW device did not appear user-friendly to some residents, therefore staff suggested there is a need to
redesign it. Staff wanted to provide video-calls on a larger screen such as a TV because residents are more
familiar with it, compared to an iPad.
(4) Family commitment Staff reported that some relatives stopped video-calling because they may have been unsure of what to
talk about, therefore a conversation aid is needed. C1, C4, C6 felt there should be additional social contacts
other than family to video-call with to increase their social networks and reduce loneliness.
(5) Staff attitudes towards intervention
implementation
Not all staff members committed to the project. Some staff felt they needed more training in how to use
the intervention. Staff leading the project felt there is a need to target those who are not confident in
using technology without causing embarrassment. Also, adherence to completing the feedback sheet by
staff was low because it was not made a priority.
Zamir et al. BMC Geriatrics (2018) 18:62 Page 9 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
towards the lack of sustained use of video-calls that need
to be addressed through further cycles of action.
Overall the finding that older people are happy and
keen to use video-call technology is consistent with pre-
vious research [1618,27,29]. Relative to other forms of
technology to reduce loneliness for residents such as
telepresence robots [30,31], video-calls are inexpensive.
Telepresence technologies can cost thousands of pounds
which do not reflect the need for cost effective interven-
tions [32]. The current intervention has the potential for
application in a variety of care environments allowing its
routine use. An ethnographic approach employed over a
long-term period across a number of sites gathered a
large, rich dataset through continued observation, reflec-
tion and interviews. Key findings related to lack of sus-
tained and routine use across sites which resulted from
staff engagement and turnover, risk averseness, family
attitudes, the SoW design and loneliness which are dis-
cussed sequentially.
Foremost, the current study had problems with usabil-
ity of SoW and retaining sites throughout the cycle. The
most significant and relevant finding from the field note
data was the staff turnover rates and site drop-outs.
Most care homes were under-staffed with some moving
between sites to help manage the workload and a high
turn-over. Lack of skills, self-efficacy and negative atti-
tudes towards technology may not be the only contribu-
tors as to why staff were not committed to the project.
Staff appeared so short of time that they could not com-
mit to the project regardless of their attitudes and there-
fore was a significant finding explaining the lack of
sustained use across sites. Implementing interventions
can become an onerous task and burdensome for those
care homes that are under staffed, explaining why only
two residents on average per site were using SoW and
some were unable to continue its use. Evidently, video-
calls were a lower priority for busy staff who were focus-
sing on primary care aspects until their care home was
normalised (enough staff working on site). The non-use
of SoW at sites that had dropped out reflects the social
and organisational factors associated with care environ-
ments and intervention implementation. Other than staff
turnover, some researchers believe that stakeholders lack
agreement of what the organising visionof ageing in
placeis for health services alike and so impacts imple-
mentation of such interventions [33]. Even so, where
stakeholders are successful in agreeing to that vision, im-
plementation can be compromised if important barriers
are not over-come [34], in this case the high staff turn-
over and low engagement. Specifically, Greenhalgh and
colleagues emphasise that if the needs of older people
are not adequately met, then care providers should in-
crease resources to support those needs from an organ-
isation standpoint, rather than researcher led [34]. Sites
where SoW was better accepted by staff embodied an ac-
tivity led environment and staff were accustomed to
dedicating time to engage with activities, thus becoming
a normal part of their care duties. It appears that nor-
malisation of an intervention can only occur within a
normalised care environment.
Another contributing barrier towards implementation
of SoW was the perception of risk it posed. Albeit the
nature of care staff working with vulnerable individuals
is to minimise risk however, a risk aversive stance to-
wards adopting a new potentially useful intervention
may override the risk in reducing loneliness. This finding
is not uncommon particularly among technological in-
terventions in UK health settings where the social con-
struction of risk can minimise or halt implementation
into practice [35]. In the current study staff (social ac-
tors) adopted a technical approach towards risk assess-
ment where the risk was placed within the device itself.
That is, risks were found in the design and so it was im-
portant to testSoWs safety to reduce physical harm
[36]. Alternatively, some staff adopted a systematic ap-
proach towards risk assessment where during the imple-
mentation of SoW, risk emerged from the level of
technology acceptance, resources available and manage-
ment of conflicting interests in sustaining it [35,36]. This
further explains the lack of staff engagement and why
some sites withdrew. Taylor and colleaguessuggest that
further research is needed to explore if training can im-
pact on the professional practice of those with less
favourable beliefs about the intervention [22], or need to
explore the predetermined roles and values of care staff
towards technology acceptance. Therefore, capturing staff
attitudes towards video-calls before implementation is
recommended.
Limitations of the study
The finding that family members were unable to commit
to video-calls is a major drawback to an intervention
intended to reconnect families. To date there has been
no research that examines how the lack of family com-
mitment to stay connected with residents in long-term
care, can affect key outcomes such as loneliness and so-
cial isolation. Gauglersfindingsfromasynthesisand
critical review on family involvement in long-term care,
urged that future research should recognise and include
residents without family support, and how external so-
cial contacts can influence key outcomes of the study
[37]. Befriending interventions with older people have
proved valuable in increasing social networks and redu-
cing social isolation [4,5]. The concept of including ex-
ternal social contacts in further CAR cycles has been
identified within the findings of the current study.
The design of SoW was not yet optimal for the resi-
dentsneeds as some found it was an intimidating or
Zamir et al. BMC Geriatrics (2018) 18:62 Page 10 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
even frightening piece of technology. This highlights the
importance of the materiality of technologywhere ma-
terial features of devices such as the shape, colour and
overall likeability can have a powerful influence on the
usability and acceptability of a new intervention [38].
The likeability of the device is important as the way
video-call technology is delivered to a generation who
are not very confident in using it, will directly affect the
number of older people who decide to participate. Older
people may benefit from using video-calls but could re-
ject the opportunity due to the poor design of the inter-
vention. The design needs have been well documented
and the device can be re-designed using focus groups.
The use of focus groups to evaluate internet interven-
tions [39] and video-call technology with older adults
has proved advantageous for other researchers [40].
Moreover, a surprising finding about SoW was that al-
though the handset was not used during calls, it still
helped to identify that SoW was a tele-service. For an
older generation, recognisable props can help make sense
of the intervention. Similarly, the idea of providing Skype
through familiar technology such as TV may increase the
usability of video-calls among older people. Referring back
to the materialityview of interventions, there are socio-
logical implications inferred from iPad use. That is, they
can have cultural meanings where a relatively newer tech-
nology that uses iPads can symbolise modernity, status
and youth especially to an older unexperienced generation
[38]. Others, such as telephone handsets and TVsmay
represent familiarity and simplicity.
Although terms such as lonely, alone,orisolated
were avoided when speaking with older people, some
were still reminded of their situation which undoubtedly
caused some distress. This indicated that individuals
may have in fact been feeling lonely and isolated. Fur-
thermore, video-calls could in turn increase supplemen-
tary negative emotions for families that will see their
loved ones in possible ill health. For that reason hospital
settings where older people are at their most vulnerable
in ill health, may not be a suitable environment to em-
ploy video-calls.
Other notable findings were that staff recruited resi-
dents who had better mental health, were less likely to
have cognitive impairments, would be more responsive
and willing to use video-calls, and with low levels of phys-
ical and sensory impairments. Also, residents with demen-
tia may have been excluded. Care home staff emphasised
the importance of issues concerning capacity and consent
for their residents and wanted to first validate the feasibil-
ity and acceptability of the intervention among those with
no noticeable cognitive decline. Other researchers have
found that those with cognitive impairments do not bene-
fit from being involved in the early developmental stages
of an intervention which could have a negative impact.
That is, poorly functioning technology can cause obfusca-
tion and even frustration for elderly people [32].
Additionally, the mental and physical impairments of
older people were not documented well by staff. For
many older people, changes in mental and physical im-
pairments can be common, thus having an impact on
their ability to use video-calls. Therefore there is a need
to prioritise and emphasise the importance of accurately
documenting this information. Even so, the current
study revealed that some older people with physical im-
pairments such as being non-verbal can still use video-
calls, allowing a more useful method of communication.
It is important to note that due to the target participant
group and study environment, high drop-out rates and
small sample sizes are common for such studies. In
addition, all participants resided in Devon and Cornwall
which are demographically largely white Caucasian, not
allowing for any ethnic diversity within the sample. Al-
though the sample was small, the data collected in the
study was considered sufficient to cover the study aims
and objectives and provide a rich, in-depth account of ex-
periences. Nonetheless, generalisations of the findings
should be carefully made.
Unequivocally, the type of culture and environment
each care home has, such as the type of residents and
their contacts, staff attitudes and resources and the
intervention itself can affect the success of implementa-
tion. This study highlighted the complex reality of
implementing technological interventions into practice
where many of the barriers reflected the social environ-
ment and organisation in which participants resided. It
is known that many interventions will not reach its tar-
get population or the target population may not adopt it
as they are imposed from the outsidedue to the lim-
ited organisational supportor organisational instability
[41]. Consequently, there was a need to study important
participant characteristic of staff skills, working condi-
tions, quality of family networks and readiness of tech-
nology acceptance and organisational change to help
improve intervention implementation.
Conclusion
Institutional and older peoplesparticipation was low due
to high staff turnover, implementation was not possible in
four out of the eight study settings which had accepted to
participate, there was considerable lack of engagement of
families and lack of motivation of the care homesstaff to
complete the study procedures. However, for those older
people who used video-calls they appeared very beneficial.
The findings from this CAR study support the need for
further exploration of video-calls for older people with and
without cognitive impairments in care homes, to optimise
engagement, before any rigorous evaluation of the effect-
iveness of SoW to reduce loneliness and social isolation.
Zamir et al. BMC Geriatrics (2018) 18:62 Page 11 of 13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Abbreviations
CAR: Collaborative action research; SoW: Skype on Wheels
Acknowledgements
We would like to acknowledge and thank the participating companies;
Anchor Trust, Valley View care home and Totnes Community hospital for
being co-researchers of the study.
Funding
This research was partially funded by the National Institute for Health Research
(NIHR) Collaboration for Leadership in Applied Health Research and Care South
West Peninsula. The views expressed are those of the authors and not necessarily
those of the NHS, the NIHR or the Department of Health. The design of the
study, data collection, and analysis, interpretation of data and writing of the
manuscript involved the authors only.
Availability of data and materials
The datasets generated and analysed during the current study are not
publicly available due to care home staff request, but are available from the
corresponding author on reasonable request.
Authorscontributions
SZ: Led on the recruitment of participants in collaboration with staff, data
collection at each site, analysis and interpretation of data, and wrote the first
draft of the manuscript. CHH: Assisted with the qualitative analysis strategies,
and contributed to the critical revision of the manuscript. AHT: Assisted with
study design, and contributed to the critical revision of the manuscript. RJ:
Lead for the project, led on the conception and design of SoW, provided
contacts and survey information for the recruitment of sites, is the first
supervisor for the main researcher, and provided critical revision of manuscript
drafts. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The study was approved by the Plymouth University ethics committee in
December 2013 and NHS in March 2014. Patients and staff gave written
consent. Information sheets were read to patients by the researcher or staff.
Staff were given information sheets in the staff training sessions before SoW
was presented. Residents gave verbal consent to staff and the researcher;
staff noted this down and kept the information on site. The information
sheet and leaflet was read to residents by staff or the researcher. The feedback
sheet included an item asking staff if residents are happy to continue with
participation after each Skype call. Care home staff gave verbal consent and
were given an information sheet and leaflet. Family members were emailed an
information sheet, leaflet and consent form to return. Patients and residents
informed staff or the researcher if they did not want to continue to participate.
All participants had access to RJ, and the board of committee contact if they
wished to cease participation, or informed SZ.
Consent for publication
All participants and staff were made aware that conversations between them
and the researcher would be noted, and quotes may be published in
anonymised form unless they informed the researcher otherwise. This was
explained verbally by SZ or by staff to residents and families. Consent sheets
given to patients, staff and family also explained this. All participants and staffs
were able to give consent. Only direct face-to-face or telephone conversations
with SZ were noted and used as anonymous quotes. These included; NHS
staff, care home managers or activity co-ordinators at each site that were
appointed co-researchers and patients who gave their written consent for
anonymised quotes.
Competing interests
The authors declare that they have no competing interests.
PublishersNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Drake Circus, School of Nursing and Midwifery, University of Plymouth,
Plymouth, Devon PL4 8AA, England.
2
Faculty of Social Sciences, University of
Stirling, Stirling FK9 4LA, Scotland.
3
University of Plymouth Peninsula Schools
of Medicine & Dentistry, ITTC Building, Tamar Science Park, Derriford,
Plymouth, Devon PL6 8BX, England.
4
Drake Circus, School of Nursing and
Midwifery, University of Plymouth, Plymouth, Devon PL4 8AA, England.
Received: 20 April 2017 Accepted: 14 February 2018
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... Among the most used technologies and with better results, video calls were highlighted (29) , as they also allow visual contact, in addition to providing a greater possibility of reducing loneliness when compared to phone calls or written correspondence. Body language influences both the expression and receptivity of social cues, reducing perceived social distance. ...
... Body language influences both the expression and receptivity of social cues, reducing perceived social distance. These expressions can be seen as an active social engagement system that decreases psychological distance and can influence the perception of other people's engagement, therefore reducing feelings of loneliness and social isolation (29,37) . Particularly in modern society, when face-to-face communication has decreased, it becomes necessary to create alternative methods to maintain satisfactory communication (29) . ...
... These expressions can be seen as an active social engagement system that decreases psychological distance and can influence the perception of other people's engagement, therefore reducing feelings of loneliness and social isolation (29,37) . Particularly in modern society, when face-to-face communication has decreased, it becomes necessary to create alternative methods to maintain satisfactory communication (29) . ...
Article
Full-text available
Objective: to synthesize knowledge about the use of social media and the perception of loneliness and/or social isolation in older adults. Method: integrative literature review with primary studies published in full, in Portuguese, English or Spanish, between September 2014 and July 2020 in the databases: American Psychological Association Database, Cumulative Index to Nursing & Allied Health Literature, Latin American and Caribbean Health Sciences Literature databases, Web of Science and PubMed. Results: 11 articles were included, categorized based on the types of technologies: “the use of the Internet”, encompassing social networking sites, the internet and applications; “communication devices”, with the use of smartphones, tablets and iPads and “types of communication” covering the use of interpersonal means of communication in the digital age, such as video calls and emails. There were positive results (63.6%) regarding the use of social media to minimize the perception of loneliness and/or social isolation in the older adults. Conclusion: the scientific evidence shows that the use of digital social media can reduce the perception of loneliness and/or isolation in older adults. Furthermore, the internet can favor greater contact between the older adults and family members and can serve as a source of support, provide a greater sense of belonging in the community and reduce loneliness.
... Family-oriented interventions may be aimed only at family members 15,16 or may involve facilities' residents, 10,17 and staff. 7,10 Interventions may be provided by nurses, 18 social workers, 19 or other healthcare professionals. ...
... 7,10 Interventions may be provided by nurses, 18 social workers, 19 or other healthcare professionals. 15 Interventions may be educational 18 or psychosocial, 19 and may involve telephone calls, 20 video-call, 17 or music therapy. 21 The outcomes of these interventions also vary; among the most frequently reported are resident-family connection and communication, 17,21 family well-being, 10,18 and family burden. ...
... 15 Interventions may be educational 18 or psychosocial, 19 and may involve telephone calls, 20 video-call, 17 or music therapy. 21 The outcomes of these interventions also vary; among the most frequently reported are resident-family connection and communication, 17,21 family well-being, 10,18 and family burden. 16,19 This diversity illustrates the broad scope of familyoriented interventions and the necessity of considering a holistic approach when mapping such a broad concept. ...
Article
Introduction: Family-oriented interventions in long-term care (LTC) residential facilities are heterogenous in design, characteristics, and outcomes. Objectives: To synthesize characteristics (e.g., type, provider, and duration) and outcomes of family-oriented interventions in LTC residential facilities. Methods: We followed the JBI methodology and searched seven databases for quantitative, qualitative, and mixed method studies that reported family-oriented interventions in LTC residential settings for older people; defined in this review as ≥60 years. Interventions that included residents, resident families, health professionals, or any combinations of these three were included if the study reported post-intervention assessment of at least one family-related outcome. Results: Thirteen studies met the inclusion criteria. Interventions were found to be multifaceted, and education was the most common element. Nurses were the most common intervenors, and most interventions had more than one target (residents, resident families, or staff). Most outcomes were related to family involvement, satisfaction with care, quality of life, communication, symptom management, and shared decision making, and none of the studies reported a negative impact. Conclusions: Family-oriented interventions were associated with high care quality and better resident-staff-family partnership. Staff education and staff-family conversation are relatively cheap interventions to help family involvement, facilitate shared decision-making, and improve family satisfaction.
... Television (TV) has a central role in the everyday life of OAs (e.g., serving as a link to the outside world, limiting the feeling of social exclusion) [24], being used as a primary source of information and entertainment [25]. Many authors agree that the TV support offers OAs a much more familiar interface to access new functionalities, thus less anxiogenic, than more recent hardware applications (e.g., smartphones, computers, and tablets) [24,[26][27][28][29]. Using familiar devices could decrease technology anxiety and help OAs to enter the digital era [17]. ...
... Since telecommunication functionalities (e.g., video calls) seem to benefit OAs by increasing social activities and reducing loneliness [37][38][39], and DiTV systems appear to be more familiar to OAs than smartphones or tablets [24,[26][27][28][29], further research about factors of use and acceptance of DiTV should be conducted. Baunstrup and Larsen [40] have carried out a series of interviews and a survey with OAs living alone in their own homes to identify barriers and reasons for the use of DiTV. ...
Article
Full-text available
Increasingly, public health programs are recommending the use of information and communication technologies to address the psychosocial needs of Older Adults (OAs). Recently, several applications that allow access to communication and stimulation functionalities using digital interactive television (DiTV) have been developed. The use of the television interface to access digital services seems to help meet several accessibility and usability needs of OAs. However, its use entails other challenges related to different dimensions (organizational, technological, ethical, etc.). This study aims to identify the factors that enable or hinder the use of DiTV by OAs living in geriatric institutions. A qualitative interview case study was conducted in three French geriatric facilities. A total of 25 semi-structured interviews were carried out with residents and care professionals, between February and April 2022, to identify enablers and barriers to DiTV use. Data were processed using a thematic deductive analysis inspired by a multidimensional Health Technology Assessment model. The analysis showed that DiTV use may be limited by organizational (e.g., workload), technological (e.g., ergonomic issues), human (e.g., health issues), ethical (e.g., privacy), and safety factors (e.g., frustration due to technical problems). A summary of these factors and five recommendations for DiTV implementation in geriatric settings are presented in this paper.
... The present study identified technology as a useful tool to support social connections with families. The finding is in line with previous studies that video telecommunication can be used successfully by a wide range of frail nursing home residents and can enhance family interactions [50,51]. Older people were able to use videophones with assistance from staff and enjoyed the use of video-calls to stay better connected with family [52]. ...
Article
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Older people in nursing homes are at a high risk of being infected by coronavirus disease 2019 (COVID-19). They also experienced nursing home lockdowns that harm their psychological wellbeing. Better support for this vulnerable population requires understanding their perceptions of challenges and coping strategies during the COVID-19 pandemic. A qualitative descriptive study was conducted using semi-structured interviews. Thematic analysis approach was used to analyze the data. Participants were recruited from six nursing homes in three cities in Hunan Province, China. Fourteen nursing home residents participated in the study. Four themes were identified from interviews and described as: mental stress and coping strategies, self-regulation to respond to lockdown, the lack of social connection and coping strategies, and the need for medical care services and coping strategies. This study revealed that nursing home residents perceived stress during the nursing home lockdown, but they reported initiating activities to maintain health and connections with their families and peers. Resilience improvement interventions are necessary to enable residents’ autonomy and develop their resilience in coping with difficulties and hardship during crises. The findings also indicate that a supportive environment with interactions from families, peers, and staffs played a key role in enabling residents’ positive health and wellbeing during the lockdown.
... Previously conducted research documented the aggregated benefits of technologydriven interventions for improving the quality of life of older adults in home care (Akbar et al., 2018). Particularly, video calls are found to reduce loneliness and social isolation among residents of LTC homes (Zamir et al., 2018). Similarly, a systematic review highlighted mental health benefits associated with personcentered care assisted by technology use among older adults with depressive symptoms (Harerimana et al., 2019). ...
Article
Full-text available
In this paper, we explore managers’ and administrators’ perspectives on digital technology use for residents during province-wide lockdowns (June–August 2021) during the COVID-19 pandemic in seven regional long-term care homes (LTC) in Niagara, Canada. Fifteen semi-structured interviews were conducted with participants representing operational, financial, and recreational departments where we discussed their needs and factors influencing the use of digital technology during the phases of increased restrictions on visitors and social isolation. Our findings indicate extensive use of cellular devices including smartphones, however additional iPads were needed to meet the ever-rising demand for virtual connections. Almost all participants revealed supportive leadership, redeployed staff, and community donations as main facilitators for technology use. Barriers related to managing varying elderly cognitive capacities and technical issues affected technology use. Based on our findings, we conclude that financial commitment and community support are integral for future-proofing LTC homes with technological innovations.
... Some residents were unable to hold the electronic tablet without the support of staff members. A solution could be to have the device (iPad or other tablet) supported by a mobile unit, such as that used in another study called 'Skype on Wheels (SoW) Device' 30 in which a familiar telephone handset was also used for sound. A similar installation could be carried out in the long-term care homes and could solve some of these concerns. ...
Article
Visiting restrictions had to be imposed to prevent the spread of the COVID-19 virus and ensure the safety of long-term care home (LTCH) residents. This mixed method study aimed to explore residents’ and family caregivers’ acceptability of electronic tablets used to preserve and promote contact. Semi-structured individual interviews with 13 LTCH residents and 13 family caregivers were done to study their experiences, as well as the challenges and resources encountered in the implementation and use of videoconferencing. They had to rate, on a scale from 0 to 10, each of the 6 Theoretical Framework of Acceptability’ constructs of the acceptability of the intervention. The results confirm acceptability of videoconferencing, giving residents and caregivers the opportunity to talk to and see each other during the pandemic. Videoconferencing had some benefits, such as being less expensive, and taking less time and effort for family caregivers.
... To promote social engagement among IWD, Care4AD provides an option for IWD to connect with their loved ones using video calls. IWD and caregivers found it easy to make the call using the Care4AD platform and useful, as the video call features were adapted to the need of older adults (e.g., adding pictures of the person in the contacts instead of text) [45]. ...
Article
Introduction: The technology-driven solution can reduce the caregiving burden; however, the needs of dementia caregiving are unique, and attitudes towards adopting technology from the perspectives of all the stakeholders involved in dementia caregiving are unclear. This study aims to assess the acceptability and feasibility of a technology-driven platform to facilitate care coordination platform, Care4AD, from the end-user perspective. Methods: Care4AD includes three components: (1) Care4AD app: the app is used by caregivers to coordinate care, monitor physical activity, and schedule reminders; (2) Care4AD tablet: a smart tablet is used by the care recipient to display scheduled reminders; and (3) Care4AD tags: a series of wireless sensor tags attached to various objects of daily care to facilitate monitoring instrumental activities of daily living (IADL) and adherence to scheduled tasks. Stakeholders in caregiving, including 11 experts in dementia care (age: 53.3 ± 8, 73% female), 10 individuals with dementia (IWD) (age: 76.1 ± 7.3, 50% female), and 14 caregivers (age: 66.9 ± 10.6, 75% female) were interviewed to determine perceived ease of use, attitude towards use, and perceived usefulness, based on the technology acceptance model (TAM) questionnaire. Additionally, we assessed technology anxiety and concerns with data sharing by caregivers and IWD. The interviews were conducted through videoconferencing or in-person meetings. The interview was composed of open-ended questions, a demonstration of the proposed Care4AD platform, and a survey based on TAM. Results: Compared to the neutral response, stakeholders showed significantly higher acceptance (70-100% satisfied to highly satisfied, p < 0.05) for all components of the TAM. Among IWD, age (r = -0.68, p = 0.03) and for caregivers the perceived ease of use (r = 0.73, p < 0.01) were significant predictors of attitude towards using the technology. Interestingly, neither concerns about data sharing nor educational level were limiting factors in the acceptability of the system in our sample. Conclusion: Overall, the results support a high perception of usefulness, ease of use, and attitude towards using Care4AD. The key barriers to adopting such technology are the age of IWD and the caregiver's perception of ease of use. Future studies are warranted to explore the effectiveness of such a platform to reduce caregiver stress and improve the quality of life and independence of IWD.
Article
Objectives: Despite social engagement being a robust predictor of wellbeing for older adults living in residential care, social programming ceased during the COVID-19 pandemic to abide by social distancing guidelines. Consequently, a tablet-based program called the Java Music Club-Digital (JMC-D) was developed. The JMC-D enables residents to engage with peers through discussion and singing from the safety of their own rooms. This study investigated the likability and usability of the JMC-D for older adults living in residential care and recreation staff. Methods: Data was collected through semi-structured interviews and focus groups with seven residents and three recreation coordinators. Interviews were analyzed using thematic analysis. Results: Three themes emerged: 1) Addressing a need, 2) Factors that affect virtual social connection, and 3) Usability. Interest in future participation in the JMC-D program varied depending on certain personal characteristics including comfort with computers, openness to new experiences, and existing social network. Conclusion: Findings suggest that the JMC-D is likeable and usable for residents and recreation coordinators. Clinical implications: Study findings can be applied by researchers and residential care staff who wish to increase the use of virtual social programs to improve the psychosocial health of residents. Constructive feedback was incorporated into the platform.
Article
Background There is a compelling need for an innovative and creative approach to promote social connectedness among older adults to optimize their well-being and quality of life. One possible solution may be through a digital intergenerational program. Objective This realist review aimed to identify existing digital intergenerational programs that were used to reduce loneliness or social isolation among older adults and analyze them in terms of strategy, context, mechanisms, and outcomes. Methods We performed a realist review with an extensive search of published and gray literature. For scholarly literature, we searched PubMed, Embase, CINAHL, PsycINFO (Ovid), and Social Sciences Citation Index databases for articles published between January 2000 to August 2020. A grey literature search was performed using the Google search engine, and the search was completed in May 2021. We included programs that evaluated digital intergenerational programs for older adults, which described outcomes of loneliness or social isolation. We included quantitative, mixed methods, and qualitative studies, as well as relevant theoretical papers, policy documents, and implementation documents. The studies were appraised based on their relevance and rigor. We synthesized the available evidence from the literature into Strategy-Context-Mechanism-Outcome (S-C-M-O) configurations to better understand what, when, and how programs work. Results A total of 31 documents reporting 27 digital intergenerational programs were reviewed. Our final results identified 4 S-C-M-O configurations. For S-C-M-O configuration 1, we found that for community-dwelling older adults, provision of access to and training in digital technology may increase older adults’ self-efficacy in digital devices and therefore increase the use of digital communication with family. In S-C-M-O configuration 2, digital psychosocial support and educational interventions from nurses were found to be useful in reducing loneliness among community-dwelling older adults. In S-C-M-O configuration 3, a video call with a student or family was found to reduce loneliness among older adults residing in long-term residential care facilities. Finally, for S-C-M-O configuration 4, we found that behavioral activation provided through videoconferencing by a lay coach may be useful in reducing loneliness among older adults who are lonely. However, as almost half (11/27, 41%) of the included programs only reported quantitative results, this review focused on screening the discussion section of publications to identify author opinions or any qualitative information to elucidate the mechanisms of how programs work. Conclusions This review identified the key strategy, context, and mechanism influencing the success of programs that promote intergenerational interaction through digital means. This review revealed that different strategies should be adopted for different groups of older adults (eg, older adults who are lonely, older adults who reside in long-term residential care facilities, and community-dwelling older adults). The S-C-M-O configurations should be considered when designing and implementing digital intergenerational programs for older adults.
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Current research surrounding infertility is focused primarily on women alone, thus removing men from the fertility equation. However, alternative research has indicated that, although men also experience infertility, there is a paucity of research on men. Therefore, very little is understood about the experiences of infertility from the male perspective. This study adopted a qualitative approach in an attempt to explore the infertility experience from the perspective of men. Fifteen men who had experienced infertility were interviewed to explore their experiences. Interpretative phenomenological analysis was used to analyse the data. Five superordinate themes were developed, and these included: (1) the influence of society on infertility; (2) feeling unacknowledged; (3) natural verses assisted conception; (4) emotional reactions; and (5) improving the infertility experience. The findings of this research indicated that men experience infertility as a mentally, physically and socially demanding condition. Comparisons to previous research have been made, and future research is proposed.
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BACKGROUND: The aging of the population is an inexorable change that challenges governments and societies in every developed country. Based on clinical and empirical data, social isolation is found to be prevalent among elderly people, and it has negative consequences on the elderly's psychological and physical health. Targeting social isolation has become a focus area for policy and practice. Evidence indicates that contemporary information and communication technologies (ICT) have the potential to prevent or reduce the social isolation of elderly people via various mechanisms.
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Introduction: Apathy, agitated behaviours, loneliness and depression are common consequences of dementia. This trial aims to evaluate the effect of a robotic animal on behavioural and psychological symptoms of dementia in people with dementia living in long-term aged care. Methods and analysis: A cluster-randomised controlled trial with three treatment groups: PARO (robotic animal), Plush-Toy (non-robotic PARO) or Usual Care (Control). The nursing home sites are Australian Government approved and accredited facilities of 60 or more beds. The sites are located in South-East Queensland, Australia. A sample of 380 adults with a diagnosis of dementia, aged 60 years or older living in one of the participating facilities will be recruited. The intervention consists of three individual 15 min non-facilitated sessions with PARO or Plush-Toy per week, for a period of 10 weeks. The primary outcomes of interest are improvement in agitation, mood states and engagement. Secondary outcomes include sleep duration, step count, change in psychotropic medication use, change in treatment costs, and staff and family perceptions of PARO or Plush-Toy. Video data will be analysed using Noldus XT Pocket Observer; descriptive statistics will be used for participants' demographics and outcome measures; cluster and individual level analyses to test all hypotheses and Generalised Linear Models for cluster level and Generalised Estimation Equations and/or Multi-level Modeling for individual level data. Ethics and dissemination: The study participants or their proxy will provide written informed consent. The Griffith University Human Research Ethics Committee has approved the study (NRS/03/14/HREC). The results of the study will provide evidence of the efficacy of a robotic animal as a psychosocial treatment for the behavioural and psychological symptoms of dementia. Findings will be presented at local and international conference meetings and published in peer-reviewed journals. Trial registration number: Australian and New Zealand Clinical Trials Registry number ACTRN12614000508673 date registered 13/05/2014.
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We report findings from a study that set out to explore the experience of older people living with assisted living technologies and care services. We find that successful ‘ageing in place’ is socially and collaboratively accomplished – ‘co-produced’ – day-to-day by the efforts of older people, and their formal and informal networks of carers (e.g. family, friends, neighbours). First, we reveal how ‘bricolage’ allows care recipients and family members to customise assisted living technologies to individual needs. We argue that making customisation easier through better design must be part of making assisted living technologies ‘work’. Second, we draw attention to the importance of formal and informal carers establishing and maintaining mutual awareness of the older person’s circumstances day-to-day so they can act in a concerted and coordinated way when problems arise. Unfortunately, neither the design of most current assisted living technologies, nor the ways care services are typically configured, acknowledges these realities of ageing in place. We conclude that rather than more ‘advanced’ technologies, the success of ageing in place programmes will depend on effortful alignments in the technical, organisational and social configuration of support.
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Loneliness in older people is associated with poor health-related quality of life (HRQoL). We undertook a parallel-group randomised controlled trial to evaluate the effectiveness and cost-effectiveness of telephone befriending for the maintenance of HRQoL in older people. An internal pilot tested the feasibility of the trial and intervention. Participants aged >74 years, with good cognitive function, living independently in one UK city were recruited through general practices and other sources, then randomised to: (1) 6 weeks of short one-to-one telephone calls, followed by 12 weeks of group telephone calls with up to six participants, led by a trained volunteer facilitator; or (2) a control group. The main trial required the recruitment of 248 participants in a 1-year accrual window, of whom 124 were to receive telephone befriending. The pilot specified three success criteria which had to be met in order to progress the main trial to completion: recruitment of 68 participants in 95 days; retention of 80% participants at 6 months; successful delivery of telephone befriending by local franchise of national charity. The primary clinical outcome was the Short Form (36) Health Instrument (SF-36) Mental Health (MH) dimension score collected by telephone 6 months following randomisation. We informed 9,579 older people about the study. Seventy consenting participants were randomised to the pilot in 95 days, with 56 (80%) providing valid primary outcome data (26 intervention, 30 control). Twenty-four participants randomly allocated to the research arm actually received telephone befriending due to poor recruitment and retention of volunteer facilitators. The trial was closed early as a result. The mean 6-month SF-36 MH scores were 78 (SD 18) and 71 (SD 21) for the intervention and control groups, respectively (mean difference, 7; 95% CI, -3 to 16). Recruitment and retention of participants to a definitive trial with a recruitment window of 1 year is feasible. For the voluntary sector to recruit sufficient volunteers to match demand for telephone befriending created by trial recruitment would require the study to be run in more than one major population centre, and/or involve dedicated management of volunteers.Trial registration: ISRCTN28645428.
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Persons with dementia might have considerable difficulties in using an ordinary telephone. Being able to use the telephone can be very important in order to maintain their social network, getting stimulation and for reaching help when needed. Therefore, persons with dementia might need an easy-to-use videophone to prevent social isolation and to feel safe and independent. This study reports the evaluation of the usability of a touch-screen videophone mock-up for persons with dementia and their significant others. Four persons with dementia and their significant others tested the videophone mock-up at a living laboratory. In order to gain knowledge of the participants' with dementia ability to use their own computers and telephones, interviews and observations were conducted. Overall, the participants had a very positive attitude towards the videophone. The participants with dementia perceived that it was useful, enjoyable and easy to use, although they initially had difficulties in understanding how to handle some functions, thus indicating that the design needs to be further developed to be more intuitive. The findings suggest that the videophone has the potential to enable telephone calls without assistance and add quality in communication.
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Low-cost and no-cost software-based video tools may be a feasible and effective way to provide some telemedicine services, particularly in low-resource settings. One of the most popular tools is Skype; it is freely available, may be installed on many types of devices, and is easy to use by clinicians and patients. While a previous review found no evidence in favor of, or against the clinical use of Skype, anecdotally it is believed to be widely used in healthcare for providing clinical services. However, the range of clinical applications in which Skype has been used has not been described. We aimed to identify and summarize the clinical applications of Skype. We reviewed the literature to identify studies that reported the use of Skype in clinical care or clinical education. We searched three electronic databases using the single search term "Skype". We found 239 unique articles. Twenty seven of the articles met our criteria for further review. The use of Skype was most prevalent in the management of chronic diseases such as cardiovascular diseases and diabetes, followed by educational and speech and language pathology applications. Most reported uses were in developed countries. In all but one case, Skype was reported by the authors to be feasible and to have benefit. However, while Skype may be a pragmatic approach to providing telemedicine services, in the absence of formal studies, the clinical and economic benefits remain unclear. Copyright © 2015. Published by Elsevier Ireland Ltd.
Article
This article focuses on the importance of social engagement and the behavioral and neurophysiological mechanisms that allow individuals to reduce psychological and physical distance. A model of social engagement derived from the Polyvagal Theory is presented. The model emphasizes phylogeny as an organizing principle and includes the following points: (1) there are well-defined neural circuits to support social engagement behaviors and the defensive strategies of fight, flight, and freeze; (2) these neural circuits form a phylogenetically organized hierarchy; (3) without being dependent on conscious awareness, the nervous system evaluates risk in the environment and regulates the expression of adaptive behavior to match the neuroception of a safe, dangerous, or life-threatening environment; (4) social engagement behaviors and the benefits of the physiological states associated with social support require a neuroception of safety; (5) social behaviors associated with nursing, reproduction, and the formation of strong pair bonds require immobilization without fear; and (6) immobilization without fear is mediated by a co-opting of the neural circuit regulating defensive freezing behaviors through the involvement of oxytocin, a neuropeptide in mammals involved in the formation of social bonds. The model provides a phylogenetic interpretation of the neural mechanisms mediating the behavioral and physiological features associated with stress and several psychiatric disorders.
Article
We explore the potential of teleoperated androids, which are embodied telecommunication media with humanlike appearances. By conducting a pilot study, we investigated how Telenoid, a teleoperated android designed as a minimalistic human, affects people in the real world when it is employed to express telepresence and a sense of 'being there'. Our exploratory study focused on the social aspects of the android robot, which might facilitate communication between the elderly and Telenoid's operator. This new way of creating social relationships can be used to solve a problem in society, the social isolation of senior citizens. It has become a major issue even in Denmark that is known as one of countries with advanced welfare systems. In this pilot study at Danish homes, we found that the elderly with or without dementia showed positive attitudes toward Telenoid and developed various dialogue strategies. Contrary to the issue of revulsion that can be caused by humanlike robots and the negative reactions by non-users in media reports, we discuss potentials and challenges of the android's embodiment for social inclusion of senior citizens in telecommunications.
Article
Focus groups provide a means for participants in research to take on a greater role in the evaluation of the research and planning of its various stages. The role and outcomes of focus groups conducted with participants in a World Wide Web Project in literacy assessment and intervention are reported. Thirteen individuals with severe communication impairments participated in one of three focus groups. The groups were held after an assessment of reading skills and a trial period of intervention as part of the Web Project. The aim of the focus groups was to obtain feedback from participants about their involvement in the project and to discuss strategies for the next stage of the intervention. The focus groups offered a forum for participants to talk about what they did and did not like about the assessment and trial intervention. The discussions provided information about issues of both a practical and emotional nature that might have otherwise been unavailable to the researchers. Brainstorming of strategies provided valuable input for the next stage of the project and involved both the researchers and participants in a form of participatory action research.