Caregivers' Phase-Specific Roles in Integrating Digital Technologies in Chinese Nursing Homes: Qualitative...

Digital technologies are increasingly introduced into nursing homes to address aging populations and caregiver shortages. Yet their effectiveness is often limited by rigid implementation models that overlook the role of frontline caregivers, the staff who provide hands-on daily care to residents and operate these technologies in practice. While previous studies have questioned deterministic narratives of technology adoption, less attention has been given to how frontline caregivers actively modify and reshape these systems during implementation.

Drawing on domestication theory, this study examines how frontline caregivers in Chinese nursing homes negotiate, adapt, and reconfigure a newly introduced sensor-based detection system, and how their roles emerge and evolve across the full implementation process.

We conducted a 6-month ethnographic study in 2 nursing homes in China. Both facilities operated under a nationally recognized welfare organization and were implementing a sensor-based detection system for fall prevention and round-the-clock monitoring. This system integrated motion sensors, pressure-sensitive mats, wearable trackers, voice-activated alerts, and a centralized data platform. Data collection combined participant observation across different implementation stages, 30 semistructured interviews with frontline caregivers selected through snowball sampling, and analysis of internal documents, including training manuals and meeting minutes. Data analysis proceeded abductively using domestication theory as a guiding framework, with field notes and interview transcripts organized chronologically across the 4 domestication phases, and coded through physical thematic mapping. A multidisciplinary team resolved cases where phase boundaries were ambiguous.

Frontline caregivers did not adopt the sensor system linearly or uniformly. Across the 4 domestication phases, they continuously evaluated, adjusted, and reworked the system at both individual and collective levels. In appropriation, they assessed whether the system was ethically acceptable and technically credible. In objectification, they negotiated where devices belonged, how they should appear, and how they could fit residents' bodies and routines. In incorporation, they synchronized the system with care rhythms and absorbed the burden of system instability through hybrid manual workflows. In conversion, they translated technology use into narratives directed at families, managers, and external visitors, balancing transparency with the protection of resident dignity and privacy. Across all phases, individual judgments were progressively converted into collective norms, including documented placement standards, shift-specific monitoring protocols, and shared institutional language.

This study highlights adaptation, rather than adoption, as the defining feature of effective technology integration in nursing homes. Caregivers' phased and collective labor transforms a rigid monitoring system into a flexible care resource. The findings extend domestication theory beyond household contexts into institutional care settings and call for technology designs that support caregiver customization as well as policies that formally recognize caregivers' tacit expertise.