This study defines a technology bed as a system for fall prevention that notifies the nurses of the patients’ danger with respect to this. We also define dissonance as impaired harmony of nurse and technology in clinical nursing practice. In brief, a dissonance refers to the way that a nurse is not able to collaborate with technology.

This study was conducted between April 2021 and May 2021. We applied a descriptive qualitative design because little is known about the topic of nurses’ practice in relation to a technology bed. The method of data collection and analysis in a descriptive qualitative study allows researchers to stay close to the data by presenting a comprehensive summary of nursing practice using simple language to increase agreement among researchers. The bed used to prevent falls is a technology bed (KA-N1410J, NU-1610, PARAMOUNT, Japan).

Participants were recruited from one rehabilitation hospital with a total of 352 beds separated into seven wards (including 120 beds in a long-term care ward, 192 beds in a medical treatment ward, and 40 beds in a convalescent rehabilitation ward) in the west of Japan (A Hospital). When the beds were full, the number of patients in the ward ranged from 40 to 60, and the number of nursing staff on a day shift was about 12 to 15 (nurse-to-patient ratio of 1 to 13 or 1 to 20, depending on the ward).

The technology beds have been used at A hospital since 2018. There were about 10 technology beds used per ward, though it depended on the patients’ conditions. The technology beds were used for patients whom nurses assessed were of high risk of falling. The technology bed was a low-floor type with a width of 83 cm and a height of 22 cm, and had a nurse call with a length of 3 m. It also alerted nurses of the patient’s movement. If the patient left their bed, the bed-leaving sensor caught the movement, linked it to a nursing call and notified the nurse.

We explained the purpose of the research to the nursing director at A Hospital whom we asked to select an appropriate ward for the survey field.

Inclusion criteria were participants who had experience working at A Hospital for a few years and who worked for patients who used technology beds. Exclusion criteria were associate nurses and those who had never used the technology bed. We requested research cooperation from nurses who worked in the selected wards and met the selection criteria through the nursing director at A Hospital. There were 12 nurses who offered to participate in the study from among the applicable nurses. We interviewed 12 nurses who provided their consent.

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Teikyo University, Faculty of Fukuoka Medical Technology (Teifukurin 20-10). All participants provided written consent.

One researcher conducted face-to-face interviews using a semi structured-interview guide. The face-to-face interviews occurred at a convenient and in a quiet place.

Data were collected using a three-part, semi-structured interview guide (Table 1). The first part of the interview was intended to evaluate the effectiveness and change of the working environment for nurses, such as if working was easier than before when using the technology bed. The second part of the interview was intended to determine the technology's usefulness and/or inconvenience. The third part of the interview was intended to discover how nurses think about the mechanization of nursing work. Open-ended questions were determined by the flow of each interview. All interviews were conducted in the participants’ native language (Japanese).

On average, the interviews lasted slightly over 30 minutes. As agreed by the participants, the interviews were audio-recorded. A survey was also completed with participants which collected data on demographic characteristics.

Individual recorded interviews were transcribed verbatim. Two authors (A and B), working with another author (C), translated Japanese to English and then back-translation occurred for equivalence of meaning.

Thematic analyses were undertaken following the six steps of Braun and Clarke [14], which involved being immersed in the data, having preliminary codes identified, allowing themes to evolve from exploring the codes, then having the themes reexamined and defined and finally the narrative completed.

The magnitude of the effectiveness or ineffectiveness of nursing practice using the technology bed and nurses’ consciousness including a dissonance of nurses toward to technology were characterized in a descriptive interview, the researchers (A, B, and C) checking across multiple information sources within the interviews to establish themes. Interviews were then compared to establish cross-interview patterns. In addition to deep engagement with the transcripts, three researchers (A, B, and C) met biweekly via teleconferencing software to discuss findings or challenges, and as a process of informing each other on the ongoing analysis and increasing the credibility of the results. Finally, six researchers (A, B, C, D, E, and F) revisited each site to observe or discuss the technology via interviews to confirm understanding.

Twelve participants ranging in age from 26 to 62 years were purposively recruited. Table 2 Shows the participants’ characteristics.

Three thematic categories were identified with the synthesis of the analysed data (Table 3): 1. providing a safe environment, 2. limitation of entry into machine care scenes, and 3. nurse’s dilemma. From the data analysis, eight themes highlighted each category: category 1. providing a safe environment, which includes 1) Strategies of fall prevention and 2) decrease nurses’ burden; category 2. limitation of entry into machine care scenes, which includes 3) not good at using technology (all tools must be easy to use), 4) inefficiency such as overengineering, 5) patients feel annoyed by frequent visits by nurses, and 6) limitations of utilization from a nursing perspective; and category 3., nurse’s dilemma, which includes 7) nurse resistance to equipment introduction and 8) ethical issues.

Early detection is important for preventing falls. In this study, many participants were convinced that such a technology bed was effective for preventing falls because the bed let them know before patients stood up. A technology bed that functions to watch and support the patient’s behaviour is desirable. In addition, one of the participants mentioned that it would be better for caregivers to let them know about the movement of patients, such as those with dementia, for preventing falls. Sometimes, patients with dementia act beyond the expectations of nurses, which can be a danger for falls. A previous study showed that patients with dementia had a higher risk of falls as compared with other elderly patients [15]. Although it is a general assessment for nurses to focus more attention on preventing falls in patients with dementia, it can be difficult for nurses to continuously watch these patients because of the multiple tasks they have to perform. The technology bed could support nurses in monitoring patients with dementia to prevent falls.

Previous studies reported that carers were concerned that their care recipients would fall again, and one study found that some carers were equally concerned even if the older persons had not fallen [16, 17]. Nurses are also concerned that patients who had previously experienced falls might fall again, and they monitored such patients constantly. However, nurses have multiple tasks to carry out, and they always must care for patients during their shift. While they care for one patient, they cannot monitor what their other patients are doing. They are always concerned if the other patients move on their own and face a risk of fall, which could be one burden for nurses. If many patients must be cared for and the number of staff is small, tasks beyond the capacity of one nurse will be imposed, which could be a factor in the use of physical restraints. A previous study showed a strong negative correlation between nursing skills and physical restraint use [18]. If patients who are at risk of falling are watched by technology beds, nurses can concentrate on caring for other patients. One of the nurses mentioned that the technology beds monitored the patients with high risk of fall, which gave her a sense of security. Thus, a technology bed could decrease the nurses’ burden of patient fall.

This study showed that the technology bed provides patients with a safe environment in that it informs the nurse of patients’ movements and allows the nurse to check for dangerous behaviour, reducing the nurse’s anxiety about the patient’s fall risk. Nevertheless, it became clear that nurses could not solve the ethical dilemma, and they still had negative concerns that they were not completing their task completely. This study showed that one of the reasons for the nurses’ dilemma was their worry that their frequent visits were a source of annoyance to patients. In addition, although many participants had the intention to provide care by hand, due to the lack of manpower, they faced the dilemma of having to rely on machines. The reason nurses struggle with taking care of many patients on their own without technology support might derive from the nurses’ dilemma. Nurses can feel how patients are cared for by nurses, and if patients feel uncomfortable with nursing care, the nurses might blame themselves for providing insufficient care. In this study, some participants mentioned a negative feeling arising from entering a patients’ room after receiving a notice from the technology bed and found that the patient was annoyed with their visit. Participants were concerned whether their nursing care was not only sufficient for patients but also would not annoy the patients. Contrary to that intention, when the participant’s visit to the patient’s room due to the technology bed warning was unwanted and frustrating for the patient, this could cause the participant’s dilemma of using the technology bed. Additionally, such a dilemma would make nurse fatigue by sensor alarm (alarm fatigue). There would occur dissonance between human nurses and technology here.

Many nursing theories have mentioned that nursing comes from the interaction between the nurse and the patient. However, in clinical practice, there are too many nursing tasks that prevent the nurse from providing rich care for each patient [19]. If the promotion of patient healing derives from the interaction between the nurse and the patient, the nurse needs to further improve the essence of care. According to a previous study, a nurse spends about 5 minutes with a patient in a single care act [20]. Although the interaction between the nurse and the patient may not depend on the length of time spent, 5 minutes might not be enough for patients to tell nurses what they think and feel about their situation or condition. Previous study has suggested that in the Netherlands, integrated technology supports the delegation and coordination of care and is generally well accepted by nurses. The Netherlands nursing staff described the technology as enabling them to perform their work in caring for residents in a calm and peaceful way [21]. Thus, it might be the time to reconsider the most important for nurses to carry out for their patients. It might be necessary to change the mindset of nurses to improve the quality of nursing while relying on technology without carrying out too much work by hand. A previous study also suggests that health care providers and sensor manufacturers must work together more closely to develop dependable, accurate, and user-friendly sensor systems [22]. Technology can alert nurses to an increased risk of falls, but only patients and nurses can take actions that do not cause falls. Therefore, nurses' acceptance of technology and patient understanding of technology might be important in leveraging technology to success in using technology in clinical nursing practice.

Some participants suggested that the technology supported their tasks so that they could concentrate on patient care. There might be conditions in which technology can support the work of nurses. Some participants mentioned that technology could not do the same work as nurses do. For instance, nurses pay attention to the prevention of falls of the patient and, at the same time, observe for other anxious conditions of the patient. Moreover, if necessary, when nurses visit the room to prevent a fall, they also provide care to the patients from various aspects. Another participant mentioned that the technology bed can provide nurses with only one piece of information about the patient’s movement, which is not enough for nurses. Nurses observe patients in a wide variety of ways. If technology supports nursing, it would be meaningless to not incorporate such a wide range of nursing perspectives. One participant pointed out that ‘if the technology is used to give advice to nurses to improve the patient’s contracture, the patient’s self-care ability may be further improved. It is better to have a function that enhances the potential of the patient. Such technologies will work effectively in nursing practice, as improving the patient’s self-care abilities will reduce the risk of falls.

Because of the overlap in individual factors, falling is difficult to predict. It is thus difficult to create a manual for fall prevention. Therefore, it may be necessary to create a system that can respond individually to technical assistance.

Clarifying the roles of nurses and technology would make nurses being overcome a dissonance for technology.