Introduction
E-health, defined as digital healthcare services enabling remote contact between patient and caregiver, has gained increased attention in scientific research during the recent decades. Given the rapid pace of technological progress and the ever-changing nature of work, health care professionals constantly need to learn new technologies (Agrawal & Prabakaran, 2020; Carlander, 2021; Samuelson et al., 2022). Such learning can take place in different ways. Over the past thirty years, theories of work-integrated learning (WIL) have emerged, initially focusing on individual practitioners formal learning as an organized activity in educational settings, only to later widen the scope to include informal learning – learning as a dimension of everyday practice – at individual, group and organizational level. In this thesis, health care professionals’ informal learning is studied.
E-health, at times conceptualized as a place-independent technology liberating health care from its spatial limitations, is analysed from a place perspective, thus contemplating on the importance of place when presumably place-independent technologies are implemented in everyday practice. While the general conditions for primary care in urban and rural areas have been researched to some extent (e.g. Ekman et al., 2019; Kullberg et al., 2018; Lindberg & Carlsson, 2018; Lindberg et al., 2021; Myndigheten för vård och omsorgsanalys, 2021) it remains to explore in what ways these conditions can affect professional learning in an e-health context, thus affecting how technology is used. A perspective that describes the technology as place-independent could suggest that the technology works in a similar way everywhere, a one-size fits all, regardless of where practice is conducted. But with few exceptions (e.g. Currie et al., 2015; Lindberg et al., 2021; Lindberg & Carlsson, 2018; Salemink et al., 2017), e-health in primary care from a place perspective has rarely been studied and problematized. Although the relevance of e-health for rural areas has been identified, there is still a lack of research and knowledge regarding e-health in rural areas (Lindberg & Carlsson, 2018) and the spatial shift that occurs when care moves from a physical to a digital space. In health research, calls for research with place perspectives have been voiced, as health is linked to the social, and the social to a place (Wiles et al., 2009); in this case, what takes place while learning digital health in a social space.
The setting of this study is a rural primary health care center located in Sweden. In the area of the health care center, geographical distances are longer, the population older, and the digital infrastructure to some extent deficient, compared to the national average. The study describes and analyzes healthcare professionals’ learning, use of e-health services and their experience of the potential and limitations of e-health in their rural context. In addition, patients 65 years and older are interviewed, as they form a central part of the care environment described and thus the health care professionals’ everyday learning environment.
Aim and research questions
The overarching purpose of the study is to contribute with an increased understanding of how health care professionals in primary care come to learning and e-health services to use in a health care environment with physical geographical distances, an aging population, and to some extent insufficient digital infrastructure. The following research questions guided the work:
- How can health care professionals’ learning and use of e-health technologies be understood from a place perspective?
- Which opportunities and limitations do e-health pose in rural primary care?
- How are older people's experiences taken into account when e-health services are used and how does the elderly patient (65 years and older) experience an increasingly digital primary care environment?
Method
This study emanates from data produced january 2021 to may 2022 through interviews with health care professionals (N=14) and patients aged 65 years and older (N=14). Health care professionals were recruited from a primary health care center in a rural area in Sweden. Patients were recruited from the same area. The health care professionals comprised of doctors, nurses, assistant nurses, medical secretaries and a health care center manager. Semi-structured interview guides were used during the interviews. The health care professionals were asked questions about individual use of digital health technologies, motivation to use digital health technologies, professional learning and development and experience of digital health in a rural setting. Patients were in a similar fashion asked about individual use of digital health technologies, motivation to use these technologies and their personal relationship to the health care center. All data were analyzed in accordance with constructive grounded theory as described by Charmaz (2017, 2014, 2012, 2005, 2000). This variant of grounded theory has gained influence in recent years and has also become popular in the health sciences (Albert, 2019; Mills et al., 2006). The difference between classical grounded theory and the constructivist-based grounded theory can be seen as a difference in ontology and epistemology. In the constructivist-based theory, unlike the classical grounded theory, the researcher is seen as a co-creator of the empirical material. Through his/her interpretations, the researcher becomes part of what is being studied, which means that the empirical material is subsequent to change. Charmaz (2014) describes constructivist grounded theory as a method that can lead to creative interpretations as the analytical process can contribute with an understanding of both social processes and general events.
Results
During interviews, health care professionals and patients assigns the health care center connotations that are also used to describe the wider setting of the health care practice, the “countryside”; a place with geographical distance but also social proximity, often contrasted and compared with a notion of a more impersonal care in the city. The “personal care” described at the local health care center is made possible due to spatial continuity, in part created by relationships and networks built up over time, in part due to the emotional connections to the health care center as a physical place. For patients, recognition creates a knowledge-based continuity, which in turn provides security and emotional ties between patient and professional. Health care professionals view these relationships as an integral part of creating good care. The emphasis of personal relationships and the importance of the social in care – i.e. informal, spontaneous meetings between patient and nurses – shows how the health care have established a social role in local society. Both professionals and patients describes the health care center as a meeting place, a place with no boundaries for access to health care. However, e-health technologies, for example digital care meetings via videolink, is to a large extent viewed as creating new boundaries. Health care professionals describe how the elderly patient lacks knowledge or is too unaccustomed to use digital tools, why elderly patients opt out of digital care meetings in favor of a physical visit. Interviewed patients, however, describe that they – with variations but to a large extent – are digitally savvy. Instead, opting out of digital care is an expression of active choice. The health care center is an appreciated meeting place that delivers a social, informal and spontaneous dimension of care, dimensions the digital care meeting cannot offer. vii Together with this empirical data, theoretical data of social health, affordances and the importance of third places in local society, shows the relation between place and learning. Gibson's (1979) concept of affordance encompasses the conditions that emanate from a particular place, a place-related action-borne knowledge based on the resources offered in the surrounding environment, thus providing answers to what the environment can offer in regard to its possibilities and limitations. On the superficial level, a coverage map showing the digital infrastructure in the health care centers’ immediate area – showing whether a digital care meeting is at all possible – describes one of the affordances that exist when the health care professionals are faced with the decision to schedule a digital care meeting. On the other hand, there are also more abstract affordances at play: the view of the patient's relationship with the health care center and its professionals, the local role of the health care center, the patient's readiness – i.e. digital literacy – to conduct a digital care meeting and the question of the nature of a “good” care meeting.
Discussion and conclusion
The study highlights the importance of viewing learning from a sociocultural perspective. Although Gibson's (1979) affordances previously have been used in research on learning, it could be argued that this has been done with a narrow interpretation of what constitute an affordance. For example, workplace affordances have been limited to which learning opportunities are easily accessible to workers, the employee's ability to create learning opportunities for themselves, and access to teachers (e.g. Berkhout et al. 2017). But since a workplace cannot be seen as a solitary unit, more studies need to shed light on e-health from a place perspective where health care activities, such as e-health, are seen together with their cultural and social context. To understand what learning is possible, an understanding of place is required. Following a socio-material perspective the affordance cannot be limited to the characteristics of an actor or technology – what it enables – but also something that consists of the relationship between people, technology and the socio-cultural environment, the social practices that the technologies creates and offers. In this case e-health usage is limited by both health care professionals and patients, but in different ways. For health care professionals, the low digital readiness that they perceive among their patients formulates limits to usage. For the patients, however, usage is primarily not a question of lack of knowledge regarding digital health care services, rather, the patients make an active choice in favor of a social, physical visit to the health care center, instead of a perceived anonymous digital health care meeting.
Denna studie belyser vårdprofessioners lärande när e-hälsoverktyg, digitala vårdtjänster som medger distanskontakt mellan patient och vårdgivare, ska komma till användning i en svensk primärvårds- och landsbygdskontext. I fokus står en vårdcentral på landsbygden, där de geografiska avstånden är längre, befolkningen äldre och den digitala infrastrukturen till viss del bristfällig. Studien beskriver och analyserar vårdprofessionernas lärande och användning av e-hälsotjänster och upplevelsen av e-hälsans potential och begränsningar utifrån den egna kontexten. I studien har förutom vårdprofessioner (läkare, sjuksköterskor, undersköterskor, medicinska sekreterare, verksamhetschef) även patienter 65 år och äldre intervjuats, då de utgör en central del i den beskrivna vårdmiljön och därmed också i vårdprofessionernas lärmiljö. Då kunskap om förutsättningarna för e-hälsa på landsbygden och vårdprofessionernas lärande utifrån denna landsbygdskontext fortfarande är bristfällig, är det relevant att belysa e-hälsa utifrån ett lärande- och landsbygdsperspektiv. Den forskningsansats och analysmetod som använts i studien är Charmaz artikulering av grundad teori, konstruktivistisk grundad teori (Charmaz, 2017, 2014, 2012, 2005, 2000), en uppsättning riktlinjer för empirinära, teorigenererande analys. Studiens resultat beskriver hur såväl e-hälsa som lärande är komplexa fenomen som behöver ses i sitt sammanhang. Medan e-hälsa beskrivits som en möjliggörare av platsoberoende vård, visar studien att det finns många platsberoende aspekter att ta hänsyn till för att tekniken ska komma till användning. I studien används begreppet handlingserbjudande (Gibson, 1979:; Billet, 2001a; 2001b) för att illustrera möjligheter till lärande givet platsens förutsättningar, något som ofta formuleras i relation till patienten: vad vårdprofessionerna upplever att patienten kan och vill. Då handlingserbjudandena inte alltid motiverar vårdprofessionerna att använda digitala vårdtjänster, såsom videomöte, får det en direkt effekt på lärandet. För att beskriva kontexten för lärandet och de handlingserbjudanden som står till buds används begreppet ”Tredje plats” (Oldenburg, 1991), en mötesplats som understödjer svaga ix band mellan individer på orten. Hälsocentralen har kommit att bli en uppskattad mötesplats för patienterna som upplever att det fysiska besöket understödjer social hälsa. Studien utmynnar i en modell som hjälper till att skapa förståelse för upplevda begränsningar med e-hälsa på den aktuella platsen, däribland hur föreställningar om det digitala ställs mot föreställningar om det sociala, synen på hälsocentralens roll och synen på vad som är en god och nära vård. Modellen kan dessutom bidra med förståelse för hur det kan se ut när e-hälsa implementeras på andra hälsocentraler på landsbygden.