Motivation.

The use of DIT-Tech was initially significantly facilitated by the motivation of staff and family members for supporting residents’ use particularly to enhance their engagement in leisure activities. Prior to the implementation of the tablets, resident, staff and family member participants noted that the remote access and auto-answer video call features differentiated DIT-Tech from other technologies and thus, were excited about their use. They perceived the tablets, especially the games on these, as promoting cognitive stimulation, social engagement, and increasing resident enjoyment. One care partner noted

“Presence is important, or at least things to keep her active are quite important to her current state, her behavioral state. That’s where the tablet actually is very handy” (ID I-09, Care Partner, Spouse, Male, 64).

Following distribution of the tablets, staff members and family care partners were highly motivated by the ability of DIT-Tech to offer personalized experiences to residents based on individual interests. For example, games and applications, as well as music and video playlists, were downloaded based on individual preferences. The tablets also supported various functions that met resident needs, such as communication tools (e.g., Skype, WhatsApp), and access to personalized content (e.g., films, sports, and news). One staff member noted, “For [one resident] it was so nice to just have that tablet., He can set himself up, do whatever he wants on it, which is nice.” (ID C-01, Staff, Female, 22) Thus, staff and care partner participants were motivated by their own desire to improve the well-being and quality of life of LTCH residents. They perceived DIT-Tech as a supplement to caregiving routines and recreation efforts. Care partners in particular expressed gratitude for how DIT-Tech provided opportunities for families to engage in activities together, highlighting the value of intergenerational connections facilitated by advanced technology:

“Well, I like to see my son and him doing something together on it. That’s been great. I’d like to thank the team for that, for offering that kind of more advanced technology to a group of folks who maybe wouldn’t get to access it. I think that intergenerational bridging, that’s been great” (ID D-09, Care Partner, Child, Female, 47)

Resistance.

Staff resistance was identified as a key barrier to implementation prior to the tablet starting. Many LTCH staff were not interested in using new technology. Their reluctance was due, in part, to past negative experiences with technologies that increased their workload. One staff participant recounted assisting residents with their personal technology and noted,

“It can get frustrating to use them as an older generation and everything and understanding because I know it takes some time […] when they have the questions, just to explain it and go through it with them patiently” (ID D-01, Staff, Female, age n/a).

Moreover, some staff were hesitant to deviate from familiar methods and routines. This resistance stemmed from past use of technology that was ineffective in supporting the leisure activities of residents, or beliefs that older adults cannot, or choose not to, use technology. One of the participants reported:, “I heard a staff member say, “Why do they have this? They’re [residents] not going to use it” (ID C-02, Staff, Female, 33). Similar ageist perspectives regarding older adults and technology were notable in several staff and care partner interviews.

Prior to the implementation period, some staff and care partner participants reported limited experience and confidence in using tablets, highlighting their lack of technological literacy as a primary factor contributing to their resistance. They perceived tablets as complex devices that required additional training and support. The increased workload associated with introducing new technology and the associated activities, was a particular concern expressed during follow up interviews with participants working in homes that were coping with staff shortages. However, in facilities with designated resources for technology support (e.g., designated IT staff roles, technology savvy recreation staff), resistance was considerably lower. One staff participant shared that where there is no formal technological support:

“It’s going to be a little bit of a struggle, not understanding what’s technically wrong with the technology itself. If something is defective or anything like that, just trying everything and making sure that we’ve done everything to make sure that it’s troubleshooted and it’s working properly.” (ID D-01, Staff, Female, age n/a).

Some participants continued to express doubts about the effectiveness of tablets in enhancing communication and engagement with residents during the study period. This skepticism played a part in the resistance and reluctance to adopt this technology. One staff participant noted:

“The first instinct from [residents with cognitive impairment] using it, they find it a bit difficult understanding because the interface is very different for them. They’re not used to it, and most of the residents haven’t really actually had computers in their previous lives, so them using a tablet is like the next step beyond a computer, and that can be very confusing” (ID I-03, Staff, Male, 35)

Some staff described being particularly overwhelmed by existing clinical and administrative duties before the introduction of DIT-Tech. Learning to use a new technology was seen as adding to their workloads and as a result, this led to lower use. Moreover, some staff users felt their workload was higher than that of non-users, without appropriate compensation. One participant explained,

“The negatives are that the staff always have to be there to operate it for them. Like, I don’t think any of them, I can’t think of a single resident that could operate any of the technology themselves.” (ID E-02, Staff, Female, 35)

The demands of assisting multiple residents with the tablets, coupled with the need to address technology-related challenges during a shift, contributed to staff time constraints and limited their availability to fully utilize DIT-Tech. These issues were sometimes compounded by a lack of hands-on training, resulting in staff expressing frustration with colleagues and contributing to a negative perception of the technology. One staff participant described:

From my knowledge, the staff members, when you bring new technology stuff in, they always find it harder. They have to learn all these new rules and how to use it, and they sometimes find-- These tablets, for example, are smaller, and they can easily get lost if you’re not careful, and they have to learn a whole new range of how they interface with it and whatnot (ID I-03, Staff, Male, 35).

Personalization to meet recreational needs.

Staff participants noted during both the pre-intervention and follow up interviews that the ability to personalize the features of DIT-Tech improved its overall acceptance among users. Providing each resident with their own personal device, allowed staff to modify the recreational activities for each resident by selecting activities tailored to their individual preferences. This adaptability supported various communication methods (e.g., talk to text), making it easier for staff to support tablet use. Moreover, the personalizing of tablets was perceived as improving workflow efficiency, by equipping the tablets with applications and tools that matched residents’ needs. This was perceived as helping to overcome administrative burdens and enhance time management, allowing staff to allocate more time to resident recreational routines. On the other hand, for some staff, the need to download specific applications was perceived as increasing their workload.

Similarly, care partners noted benefits from the personalization of the tablets, providing examples of tailored leisure activities and content that aligned with the interests and preferences of their care recipient. One care partner explained,

“I’ve loaded a Bell Fibe app on it, and I can put her beloved Blue Jays on l-- watch the Blue Jays, or a tennis match, or things that she was really active in, that still strikes a memory chord with her and that she really enjoys escaping in that way.” (IDI-09 Care Partner, Spouse, Male,64).

Some care partners described incorporating video chat applications used by multiple family members and friends, such as WhatsApp and Facebook Messenger, to help residents maintain and expand their social networks. This offered the convenience of audio/ video calls and chatting without having to rely on family or staff. This was particularly valuable for residents with limited English proficiency, financial constraints for long-distance calls, or barriers to communication within the LTCH (e.g., unable to hold a phone).For example:

“With the tablet, you are able to also have a conversation for more than 5, 10 minutes. Maybe half an hour, 45 minutes. That’s also a huge difference because when you call long distance it’s also a matter of how much you’re paying for that long distance call” (ID I-08, Care Partner, Sibling, Female, age n/a).

Care partners encouraged activities that provided cognitive stimulation, selecting and personalizing applications that challenge memory, problem-solving or creativity. This personalization, including access to preferred music, religious services, and first language content, empowered residents by offering them a sense of ownership over the tablet. Care partners and residents reported having a “personal” device was highly valued as it did not require sharing with other residents. One care partner shared:

“That’s a big deal. What’s set out to the TV is not interesting. [Resident is] a little unique in that she’s only just turned 60. The content that might appease somebody in their 80s or 90s is not the same content that interests her. Being able to personalize and give her sporting events, which is what she’d always liked to watch, is a big deal” (ID I-09, Care Partner, Spouse, Male, 64).

Likewise, one resident shared that they appreciated the fact that they can choose their favourite movies to watch, rather than just watching the ones the LTCH provides:

“I’m pretty sure that [residents] watch it all the time. They watch that movie every day, the English Fellow. Anyways, you can get to choose the movies. They love the movies. It keeps someone busy while they’re in isolation” (ID G-09, Resident, Female, 70).

Usability.

The usability and ease of use of the technology were crucial factors in its implementation and depended on the prior experience of staff, care partners and residents with tablet devices. A few participants noted that the various applications on the tablet posed significant barriers to adoption. Barriers included counterintuitive navigation for downloading new applications, and unclear instructions for troubleshooting from the LTCH and the DiT-Tech research team. Despite some training organized by management and the research team to familiarize staff and care partners with the system, certain resident participants struggled to use DIT-Tech. One care partner said:

“He [resident] was an engineer back in the day. He loves to know how things work and especially with the dawn of the internet and all of that in the last couple of decades in particular, he was quite interested in trying to master it and be part of it and all of that. At this point in his life, it just was a little bit too difficult.” (ID I-06, Care Partner, Child, Female, 66).

Conversely, for participants with previous tablet experience, features like simple icons, remote control and interactions were perceived as beneficial, facilitating adoption of the new system. One care partner noted the perceived ease of use from the resident’s perspective:

“I guess we were wondering its ease of use and all of that, but as it turns out, from his point of view, [the dial-in and remote-control elements] were very passive” (ID I-06, Care Partner, Child Female, 66).

Participants who found DIT-Tech user-friendly noted intuitive controls, and clear instructions, that helped them quickly learn and become proficient in its use.

Care partners highlighted several distinctive features of DIT-Tech, including the large 10-inch screen, which helped residents with visual impairments in using the tablet more autonomously, and engage more than with smaller smartphone screens or audio-only devices. The protective rubber case, which could be used as a stand, and the tablet’s portability, allowing residents to use it beyond their rooms, were also appreciated. For residents with difficulties using the touchscreen (such as those with hand tremors), stylus pens were made available upon request, and the Google Assist voice command feature proved invaluable in such instances. This voice-command functionality enabled some residents to independently access content on platforms like YouTube and search for online materials, enhancing their independence and engagement with the technology.

Integration Into workflow processes.

During the follow up interviews, some staff described incorporating the tablets into their daily routines through regular use and making a conscious effort to discuss DIT-Tech with family and residents to familiarize them with the technology. One staff participant noted:

“What I found was that trying to schedule the tablet into the full day was tricky because you have to sit with the resident for X amount of time to get them to fully test it. I had to set aside time throughout the week regularly so they [resident] would get familiar with it because they were having a hard time getting used to it. Constantly seeing them every single day or every couple of days just to really get used to be the extra step, which was hard to implement into regular whole day of activity programming.” (ID I-03, Staff, Male, 35)

Despite their efforts, care partners and residents often did not want to ask staff to help them use the technology due to perceived time constraints experienced by staff and their desire to not further burden them. One care partner explained: “I wouldn’t want to per se impose that on the staff because I know that the staff has so many things to do with all the other residents” (ID I-08, Care Partner, Sibling, Female, age n/a)

To mitigate this, staff sometimes pre-loaded the tablets with personalized playlists, videos, or interactive apps and requested volunteers or family members to spend quality time with residents using the tablets. This collaborative approach allowed staff to focus on their primary care responsibilities while ensuring that residents had access to leisure opportunities facilitated through the DIT-Tech.

Technology support.

The presence of technical support staff during working hours played a crucial role in addressing system-related issues such as connecting to the internet and downloading new applications promptly. Furthermore, staff, residents and care partners reported broader factors like unstable Wi-Fi quality and the influence of online security firewalls, significantly impacted the accessibility and usability of DIT-Tech. Staff had access to technical support from the research team through group meetings, emails and telephone calls as needed. In some LTCHs, informal technology support was provided by staff members who were more familiar with technology and assisting others in system use. This fostered a sense of reliability and prompt resolution of technical problems and requests. One staff member noted:

“I know I had one tablet that was having problems with opening any of the programming by itself. When I couldn’t get it to work, I just called [colleague] to come down” (ID D-01, Staff, Female, age n/a)

Care partner participants benefitted from LTCH staff support with DIT-Tech, as staff support minimized downtime and frustration for themselves and residents. It empowered care partners to explore the tablet functionalities, experiment with different features, and gradually develop their skills and familiarity with the device to support resident use. Staff and care partners also highlighted the value of the research team’s ability to remotely access the tablets to provide prompt and effective support and troubleshooting.

Poor fit between the organization and management and the technology.

Staff believed the biggest barrier to implementation was misalignment with the overall goals, structure, and management practices of the LTCHs. Staff reported frustration as they did not think management thoroughly considered their needs, resources, and capabilities when deciding to implement DIT-Tech. One participant noted that the culture of LTCHs was,

“Trying to pack in as many things as you can for them [residents] as possible during your day” (ID C--03, Staff, Female, 55).

Frontline staff noted that insufficient communication and collaboration between the technology and recreation departments and other organizational units, hindered the integration of DIT-Tech into existing workflows or management practices.

Numerous participants noted that management failed to effectively communicate the benefits and rationale for using DIT-Tech and thus, were unsure as to why they were instructed to use it. Moreover, some participants raised concerns about the sustainability of new interventions, and felt it was not worth incorporating the tablets into practice if their use would be discontinued in the near future. This contributed to a reluctance to fully embrace and integrate the technology into daily practices.

Staff and care partners participants noted that they did not have privacy concerns with tablet use and they were appreciative of management concerns for privacy when using Skype. All research sites were provided signs to post on room doors and within resident rooms to notify those entering that video streaming may be in progress. One participant explained:

“There is a notice on the wall, ‘Attention all staff. When providing personal care please ensure a resident’s tablet is placed out of view as Skype video calls may occur at any time. Thank you.’ That was appreciated to see that” (ID-03, Staff, Female, 58).

However, some staff did have concerns about being watched as they worked:

“They definitely are more aware and some are more comfortable with it than others because when I’ve called, if they come in whatever, bring my parents a snack, most of them will just say hello to me. Whereas some try to run away because they don’t want to be in the back. I think for some people, there is some confusion about it recording, versus just being a video call” (ID G-03, Staff, Female, 53).