1 Introduction

1.1 Background and Challenges in Healthcare Services

Society is facing vast challenges regarding the compliance between people in need for healthcare and resources available to meet these needs [1,2,3,4]. Representatives from public as well as private sector have pointed at digitalization and technological interventions as solutions to the “care crisis” [5,6,7], but implementation of new technologies and the associated changes of the services are characterized by multiple challenges [8]. Contextual factors such as organizational issues, technological infrastructure and human actions represent such challenges [5, 9, 10]. Human actions are often a result of the individuals’ affective and emotional responses to the surrounding circumstances. The dark side of technology is a concept used to describe “a broad collection of ‘negative’ phenomena that are associated with the use of IT, and that have the potential to infringe the well-being of individuals, organizations and societies” [11]. It seems to be a duality between uncovering the dark side of technology and the individuals’ responses on the one hand and the ability to facilitate for learning and development of skills on the other hand. The increased demand for healthcare and new ways of providing healthcare services are factors that entails consequences for working life, workplace practice and necessary occupational requirements [12, 13]. Even if there are high expectations to the impact of digitalization and the introduction of technology, the success rate has until now been referred to as low [14]. According to Barakat [15], the absence of needed knowledge and skills among healthcare professionals regarding the use of technology represents a barrier to the digitalization of the sector and to the opportunity of reclaiming the expected impact. The value of technical competencies is underscored [13], and Lapão [16] states that the “development of digital skills by health workers is critical”. In an era characterized by an increasing amount of workplaces demanding complex skills and mastery of new technologies, here is a need for organizations to integrate learning as part of practice and to make the workplace the locus of learning [17].

The emphasize on learning among healthcare professionals as an issue beyond traditional education, creates a need for integrating work and learning [18, 19]. Hattinger, Eriksson, Malmskiöld and Svensson [20] describe work-integrated learning as “a combination of education and practice in the workplace”. Work-integrated learning is summarized to concern the development of skills needed when improving the way work is provided, as well as developing the work organization itself [21]. Work-integrated learning is seen as situated [22]. Situated learning is implying that learning outcome and the opportunity for learning offered the employees are affected by the learning environment and the learning affordances at the actual workplace [21]. Affordances provided by the workplace are situational factors like activities, interpersonal dynamics, rules and norms of practice that provide opportunities and invite the employees to engage as learners [23,24,25,26]. Examples of affordances include providing the employees with access to video instructions demonstrating the use of a new device or utility, or by providing a work schedule with integrated time for professional reflection. The managers are responsible for facilitating an upskilling of the professionals, supporting and motivating them to engage in learning situations at the workplace [13]. To be able to facilitate the affordances best suited for the professionals to learn, it is decisive to understand how individuals learn and what might be a barrier to learning [27].

Each individuals’ acceptance of technology is reported as an important predictor to whether or not to start and to continue to use technology as part of work [28]. In many social contexts, affect and emotional responses are critical factors in human decisions, behavior and action [29, 30]. The awareness of professionals’ affective and emotional responses to digitalization and technology can enable work-integrated learning through affordances that match the individuals’ responses. Being unaware of affective responses can result in dark sides of technology. In addition to the potential of infringing the well-being of individuals, organizations and societies, the dark side of technology may lead to dissatisfaction, low morale, decreased work quality and resistance [31], poor job engagement and information overload [32]. Consequently, it may also represent a barrier to the development of digital skills and work-integrated learning. When studying “Two Decades of the Dark Side in the Information System Basket”, Pirkkalainen and Salo [32] identified a need for further studies that can contribute to the identification of aspects decisive when planning for workplace affordances and work-integrated learning.

The interest in “dark side-research” increases and will be an important contribution when developing interventions and workplace affordances aiming at reducing the barriers to work-integrated learning as well as the challenges related to the digitalization of the healthcare services [32]. The Technology Acceptance Model (TAM) has been used in various studies when analyzing implementation of IT and personnel’s acceptance of technology (e.g. [33]). The model are focusing on cognitive reactions and factors influencing an individual’s intention to use new technology [34]. It has mainly been used in studies with a quantitative approach, and some have called attention to its limitation due to impact factors involved in the acceptance of health information technology [33]. In this paper we will explore a range of managers’ and professionals’ emotions, moods and feelings related to digitalization and new ways of providing healthcare services, as well as the professionals’ knowledge and experiences. According to Zhang [29], “a robust understanding of affect may also have practical implications for design, acceptance, use, and management of ICTs”. Zhang’s affective response model (ARM) will be used as a systematic approach and framework to gain knowledge of how professionals and managers experience and experience digitization of municipal health services [29]. Using ARM will contribute to an identification of aspects decisive when planning for workplace affordances and work-integrated learning. The research question is: How can knowledge about dark sides of technology reduce barriers to work-integrated learning?

In Sect. 2 we present a short explanation of The Affective Response Model (ARM) with its taxonomy of five dimensions describing different perspectives on stimulus to affective responses. The methodological approach for the study is presented in Sect. 3. Section 4 consists of results from the focus groups, before discussing how knowledge about dark sides of technology can reduce barriers to work-integrated learning in Sect. 5. In Sect. 6 we will present concluding reflections.

2 The Affective Response Model (ARM)

2.1 Need for Knowledge

The way of providing healthcare services is within an ongoing translation according to digitalization and introduction of technology, with the demand for knowledge and work-integrated learning for healthcare professionals as one of the barriers. Digitalization and changes in the healthcare services creates a demand for new knowledge, and new knowledge represents a push factor for development of the services. Learning and new knowledge are decisive when changing work practices in healthcare organizations.

2.2 Conceptualizing Affective Responses Through the Taxonomy of ARM

The ARM-model consists of two parts; 1) a taxonomy of five dimensions for conceptualizing various types of affective responses and 2) a set of propositions that describe the relationships among various types of affective concepts, resulting in a nomological network [29]. According to Agogo & Hess [30] the five dimensions of the ARM-model provide a taxonomy which can be helpful when differentiating affective concepts. In this paper the analysis will concentrate on the first part of ARM with the taxonomy aiming at conceptualizing the affective responses professionals and managers in healthcare services experience when digitalizing workplaces and developing the ways of providing the services. According to Zhang [29], emotions, moods and feelings are included in the description of the umbrella term affect. Affect “can explain a significant amount of variance in one’s cognition and behavior…” [29], and that is why it is important to obtain an understanding of affect. The taxonomy of the five dimensions provides a theoretically bounded framework, and that framework can be a help when trying to understand the meaning of affective concepts related to different kinds of human interaction with information and communication technology (ICT). When applying the taxonomy of affective concepts in an ICT context, the main interest is related to the human interaction with technology and ICT. The technology and ICT may act like an object or it may be the interaction as a behavior representing the stimulus. The definition of stimulus applied by Zhang [29] is “as something or some event in one’s environment that person reacts or respond to” (Fig. 1).

Fig. 1.
figure 1

Illustration of ARM-model (based on Zhang [29])

Full size image

Residing Dimension

In the first dimension of the taxonomy, Zhang [29] describes three categories of referent objects (residing dimension). In the case when the person itself represents the object, it implies that the person gets in a mood or has a negative attitude against technology without being in contact with any contact with or awareness of any stimulus. When ICT provokes a response “regardless of who perceives or interprets it” [29], it often means that the design or attribute of the technology causes the response and that the stimulus is within the ICT/technology. The last example of referent object in the residing dimension is when the response appears to be residing between a person and an ICT stimulus. When the affective concept is situated between a person and ICT it means that the affective response of one person could vary according to which the ICT representing the stimulus. On the other hand, the same ICT stimulus could provoke different affective responses for different persons.

Temporal Dimension

Agogo and Hess [30] refers to affective responses that could be both state-like and trait-like. The terms state-like and trait-like are connected to time and the value of the affective concepts are constrained by time [29]. A trait-like concept can be exemplified by a personality trait as a stable value that appears in the same way in similar situations consistently. Concepts characterized as state-like are temporary values that relates to a certain condition or environment where a person experience an affect related to ICT.

Stimulus Specificity – Object vs. Behavior Stimulus

In the third dimension of ARM, the stimulus is divided into the two aspects object and behavior. According to Agogo & Hess [30], the object stimulus refer to situations where the response is related directly to the technology. Thrift [35] uses toys as an example of an object stimulus. A toy represents an object stimulus when advertisement is presenting it as an object in itself, not giving any focus on how it is possible to interact with the toy (Ibid.) The aspect of behavior as the specificity for the stimulus appears when a person experiences a response due to a “behavior on objects”. While a person getting nervous by seeing a computer exemplifies the object stimulus, a person experiencing the stimulus in relation to action is an example of the behavior stimulus.

Stimulus Specificity – Particular vs. General Stimulus

The difference between general and particular stimuli imply that a person can experience one kind of affective response when exposed to a particular ICT like Google Docs, but confronted with an opinion of technology for collaboration online in general, the same person may experience a negative affective response.

Dimension of Process vs. Outcome

The last of the dimensions in the ARM-model concerns the time of evaluation, and as a consequence, the basis for the affective response. Process-based affective responses or evaluations often appears like an immediate response to an encounter with ICT. When the interaction with the technology endures over some time, the response will be based on the outcome of the experience.

Practical Implications for the Use of the ARM-Model

The ARM-model and the taxonomy of five dimensions can be used to better understand the reasons for, and the sources of certain affective responses.

3 Methodological Approach

3.1 Qualitative Approach and Participants

The study of professionals’ and managers’ knowledge and experiences, emotions, moods and feelings related to digitalization and new ways of providing healthcare services, is based on data collected through a preliminary project and the initial phase of a longitudinal study called eTeam. The eTeam project is an Interreg Sweden-Norway project aiming at promoting collaboration and exchange of knowledge related to digitalization of the healthcare sector and new ways of providing services between representatives from municipalities, academia and private sector. When exploring professionals’ affective responses and the dark sides of technology, the study emphasizes on interpreting and seeing through the eyes of the research participants. This approach, focusing on the participants’ description of their experiences and perceptions in the context of digitalization and new ways of providing healthcare services, motivates for a qualitative approach [36, 37].

The collection of data took place within the framework of the eTeam project, and interviews in focus groups were used as the method. Collaboration and the exchange of experiences are essential factors in the eTeam project, and by using the focus group method, we were able to include several participants representing different municipalities from both sides of the southern border between Norway and Sweden. The participants had a variety of professional backgrounds, different positions in the organizations and varying degree of experience with digitalization and development of new ways to provide healthcare services. Independent of different backgrounds, the focus groups facilitated interaction in the different groups when they were questioned on topics related to their experiences [37]. Participating in focus groups may result in a feeling of group pressure to agree, and may therefore limit the participants from presenting controversies [38]. On the other hand, it is a suitable method for revealing what the participants may agree upon and their common experiences, but different viewpoints and experiences may also emerge. Conducting focus groups facilitate the mobilization and activation of the participants in a way that is not possible in individual interviews [39]. Interaction in the groups contributed to new insight that we most probably not have had access to through other methods. Furthermore, it was important to get knowledge about the different participants’ experiences and affective responses at an individual level, but at the same time that knowledge was meant to be the starting point when planning for workplace affordances and work-integrated learning on an organizational level.

The municipalities were included based on that they were in process of digitalizing services, implementing technology and developing new ways of providing healthcare. With one exception, these are rural municipalities with more densely populated centers. Scandinavian healthcare services are predominantly public, organized by the municipalities and funded by taxes. Three rounds of focus groups were conducted. From two to ten persons participated in each group, but the average number of participants were eight to ten. In the first round, the groups were organized nationally on each side of the border. Some of the groups were composed of managers within healthcare services, whilst professionals like assistant nurses, nurses and physical and occupational therapists working close to the patients and users, participated in the others. The composition of the groups with the professionals aimed at including different occupations in order to identify and discuss different professional perspectives. Moreover, one interview was conducted with two participants from an IT department. In the next two rounds, the participants were organized in mixed groups with Norwegian and Swedish participants, and the groups were composed of both managers and professionals. In order to access the participants, contact persons in the municipalities recruited the participants. The criterion was that the participants should be involved in digitalization processes or that they were to be involved at a later stage. They all signed an informed consent.

3.2 Data Analysis

The interviews with the different focus groups were transcribed and data were analyzed using content analysis. Conventional content analysis describes a phenomenon by developing codes through multiple readings of the interviews. Such an inductive approach helps discover meaningful underlying patterns [40]. To reduce the risk of misinterpretations of the data due to the researchers’ preunderstanding, all researchers discussed in detail the findings and their systematization during the analysis process [41]. The findings and themes crystallized through the content analysis were then applied to the Affective Response Model as a systematic approach to understand how to predict and understand the participants’ responses to technology and ICT. Applying the main themes from the analysis of the findings into the taxonomy of the five dimensions of the ARM-model, made it possible to differentiate affective concepts from the participants’ knowledge and experience.

4 Results

4.1 Summarized Analysis of Results

The analysis of the focus group interviews identifies various barriers for both work-integrated learning as well as digitalization of the healthcare services. The participants’ points at challenges and dark sides of technology originated from the changing needs in the work practice when digitalizing the services. They have experienced many small-scale implementation projects with varied outcome, and the situation is characterized by a constantly introduction to new technologies. Some of the municipalities’ healthcare organizations are aware of the demand for knowledge to facilitate the digitalization and development of the services, but at the same time, they identify shortcomings related to strategies necessary if the healthcare sector should concentrate and push development of services fitted for the future. Through exploring the professionals’ and managers’ knowledge and experiences related to digitalization and new ways of providing healthcare services, different responses to ICT were identified. Lack of understanding of ICT and technology, limited possibility for collaboration and teamwork and lack of opportunity for training and learning were all elements that were crystallized from the content analysis.

Understanding of and Attitudes to ICT and Technology

There are differences in how the professionals perceive the ongoing digitalization with introduction of ICT and technology. Some refer to technologies as technical artifacts they have to handle, and have to learn to handle. Others refer to them more according to their functions, for example as “smart house”, providing the opportunity to be connected to things and people and to be able to monitor, raise alarms and communicate. One of the participants gave an example of a patient having the opportunity to call and speak to a nurse out of the ordinary visits. In all three rounds and in all groups there were participants sharing negative experiences with ICT, but at the same time, they expressed to have an all over positive attitude to digitalization and the technology introduced as part of that process. Several of the managers had experiences with female professionals, age of 50–60 years old, having a negative attitude to ICT and technology in general. According to the same managers, the digital development and lack of technological knowledge and experience in this group were the explanation for the negativity. Both managers and professionals perceived the patients as quite positive to the technology, and it was referred to several patients above 80 years in age paying their invoice on the internet as well as using Skype for communication.

Some professionals are aware of that they have to change the routines of how to perform their work, related to the digitalization and development of new ways of providing healthcare services. The professionals’ talk about how time they earlier used on providing care directly to the patients, they now have to spend on providing technical support to the patients and their relatives who are dealing with security alarms and monitoring their disease at a distance. Some of the professionals express a dilemma related to technologies providing opportunities for better control of the patients and their diseases and the reliability gets better, when simultaneously the same technology requires an increasingly amount of resources from the professionals and the organizations. One of the nurses expressed her frustration and said that if more patients are given security alarms that they use to call for help and need support to administrate, the professionals have to change the way they work to be able to respond all the calls and provide both support on technology on top of the ordinary healthcare service. Based on their experiences from work, the participants talked about a need for developing competence related to ICT and technology. Not all professionals are accustomed to use ICT and other technologies such as digital devices or computers in their work. In order to be able to digitalize the healthcare services they expressed a need to learn and understand more about the functionality of the specific technology introduced and how the new technology could communicate with systems already in place. At the same time, several of the participants expressed to have competence related to technology, and they told about professionals in their workplace handling ICT and technology in a competent way. Therefore, the knowledge as well as the need for learning among the professionals seems to be extremely varied.

Because of the introduction of ICT and other technologies, both managers and professionals participating in the groups knew colleagues experiencing the new conditions for work as a threat to themselves and to their own work. Being afraid of what is unknown was a statement that were repeated in various groups. The participants that had been working with digitalization for a while told about how they had experienced colleagues, by learning and gaining more understanding, beginning to perceive ICT and other technologies as positive opportunities for their work and for the patients. Frequent change of technologies resulted in frustration for many professionals. They talked about how the frequent change of devices made it difficult for the professionals to be updated and to have knowledge and understanding of all existing technologies. One of the participants said that in situations where the professionals do not know the technologies; it is difficult for them to provide support to the patient and to facilitate the intended use in the patient’s home. Some of the participants also expressed their frustration related to the professionals’ being responsible for the technology and its functionality when placed in the patients’ homes. They were also engaged by discussions related to technology from a private marked, and shared experiences of having to help patients with technology that were nor provided by the healthcare services. As one of the participants expressed: “… every single person over 65 years of age is soon better equipped to use ICT and other technology than professionals in the healthcare services”.

Collaboration and Teamwork

Through the discussions, it appeared that the majority of the participants experience a lack of collaboration and arenas for practicing teamwork. When the participants were talking about teamwork, it was a common view that teamwork should involve different stakeholders like different departments in the healthcare services, the department responsible for IT and digitalization, as well as stakeholders from private sector, patients and relatives. Both managers and professionals pointed at a “common language” as a prerequisite for collaboration, and they concluded that it is often a lack of such a vocabulary. The Norwegian Labour and Welfare Administrations (NAV) and their technical aids center was one of the examples of a very important collaborator for the municipal healthcare services. Even if the technical aids center were seen as an important partner, the participants mentioned various barriers to the interaction with them. The technical aids center are providing different utilities and tools to patients and people living with disabilities, but several of the professionals expressed to be uncertain about what utilities the center could offer and what rules and laws that regulated the rights of different patients and different diagnosis. The experienced lack of collaboration was not only tangible related to different sectors like healthcare and the technical aids center, but as well within the healthcare services. The participants talked about how different professional roles are authorized to prescribe different kinds of technical aid and services. A physiotherapist explained it as “there are different prescribers for different utilities and tools, depending on who is responsible for the expenses and budget”. In all the groups, they had focus on the necessity of more collaboration and they talked about how different professions and different roles could complement each other with knowledge and experiences. Participants from one municipality shared their experiences with groups that were built up by different professions representing different departments. These groups have a mandate to work with digitalization and development of services together, independent of the traditional working lines. A nurse expressed that “we need a sort of care technician, who are able to supervise and support the caring staff”. In lack of the role “care technician”, the same participant said that if the workplace provide arenas where interdisciplinary teams may collaborate, it would facilitate sharing of knowledge for both managers and professionals.

As described in the previous section, many participants felt frustration related to all the resources they had to spend on supporting and guiding of both colleagues, patients and relatives when introducing technology. They called for more collaboration with instances like public libraries and schools since they meant that they had a defined responsibility for public education.

Learning, Training and Competence Development

Some of the managers talked about the need for a new type of changes in the healthcare services. According to those managers, both managers and professionals are used to constantly changes, but they felt the actual demands for developing healthcare services for the future without having the answer of the concrete needs of the future, much more challenging. Several participants point at the importance of developing more competence among the managers. Professionals in different groups agreed that the professionals’ ability to learn and to increase their knowledge about digitalization and development of services for the future depends on the knowledge of the managers.

The overall experience among the participants is that the persons, who work in departments where technology is introduced, receive specific training on how to use a given technology. The professionals’ perceived outcome of specific training varied, but many of them referred to the way training was organized as a challenge. It was a widespread experience that one or two, more or less random chosen colleagues received training and were given the responsibility for sharing knowledge with the rest of the professionals. Professionals required more quality assurance regarding the internal training related to specific technologies. Thus, the individual learning processes were characterized by trial and error. As a response to the demand for learning and training, some of the managers explained that they organized visits to departments that already had experience with technology in addition to the specific training. The same managers added that their department had established routines to dedicate 1–2 days a year focusing on new technology and related training needs. Other managers referred to positive experiences with video-recorded instructions and manuals going along with the introduction of a new technological device. According to the managers, professionals were satisfied with the opportunity to use video instructions. The positive experience with video instructions were related to the possibility to watch the video one or several times according to their individual needs. Both managers and professionals shared stories about the significant differences in learning capabilities among the persons working in the healthcare services. Some managers had experiences with professionals having problems reading traditional manuals and instructions. They pointed at language skills and age as additional challenges. Some of the participants had experiences with eLearning afforded as a tool for learning and increasing of knowledge, but both the managers and the professionals argued that eLearning depended on a lot off initiative from each individual that were going to attend the eLearning course. It appeared to be a widespread understanding that the best effect of learning could be achieved through learning and training organized and structured in line with issues the professionals themselves experience as particularly challenging. One of the participating nurses expressed that “it is a difference between the general knowledge you need to provide a professional work and the specific knowledge you need at the actual workplace”.

5 Discussion

5.1 Summarizing of Results

The aim of this paper is to explore knowledge and experiences with digitalization and development of new ways of providing healthcare services among managers and professionals in municipal healthcare services. Through the participant’s discussions and by analyzing the results emotions, moods and other responses to ICY and technology are identified. The results show that the professionals lack understanding of innovative technologies and together with their differences in attitudes to the technologies, challenges will arise when digitalizing the services and the processes were the healthcare services for the future are to be developed. The results also imply that both professionals and managers are in lack of possibilities and arenas were they could collaborate and work in teams. According to our findings, there are an articulated need for opportunities for learning and development of knowledge. The demand for learning and knowledge is not answered, and the result may be an experience of the dark sides of technology and negative responses towards digitalization and development of new ways of providing healthcare services. Knowledge, experiences, emotions and moods are identified through the analysis of the focus groups, but also by the participants in the groups underway in the process with the three rounds of focus groups. In the following section, the results will be discussed in light of the ARM-model and its taxonomy of five dimensions.

5.2 Affective Responses to Digitalization and Introduction of Technology

The understanding of and attitude to digitalization and introduction of ICT and other technologies may be related to different dimensions in the ARM-model depending on each individual. Some participants referred to the introduction of technology at their workplace as “something” they just had to take into use, and that associates with the 4th dimension when the stimulus and the effective response is connected to technology in general. Little attention on specific technologies can be related to what the ARM-model describes as a general dimension, which means that the affective response to technology “is applicable to a general class of technologies” [30]. When the technology is referred to in general terms, it may be more difficult to make plans for learning affordances and it may indicate a need for learning on a more general, superior level. Organizing for work-integrated learning at the workplace demand on the one side suitable affordances provided by the workplace, and on the other side it is dependent on the engagement of the individuals working there [24]. The workplace affordances are decisive for the individual engagement, and the “right” affordances may motive to engagement. Female professionals at the age over 50 years old were reported to be a group with several examples of negative attitude to ICT and technology. Since the digitalization of the healthcare sector is a relative new phenomenon, the negative attitude is likely to be explained as a response that “is just there”. A response “just being there” indicates that it is residing within the person independent of a concrete technology. A person with a response connected to the residing dimension where the person itself represents the referent object, it is also likely that the person refers to technology in general terms as in the 4th dimension. Many participants talked about being afraid of the unknown. That type of affective response may be connected to the concept were the referent object of the residing dimension lays in the intersection of person and technology. The person feels afraid, not because of his or her personality or stable mood and the fear is not a result of a technological stimulus. The fear lies in sort of an intersection between the technology and the person, meaning that another technology may or may not provoke the same response. And the same technology may or may not result in the same affective response for another person [29].

Planning for workplace affordances will be challenging when there are persons with the described attitude to technology. Looking into the temporal dimension will be off interest to identify if the attitude and the affective responses are trait-like or state-like. If the person itself represents the referent object and they assume a distance to the technology, it is probably a permanent, trait-like response. Facing affective responses that are trait-like, means that the managers or the persons facilitating the affordance will have to prepare for a more systematic approach than if the response were only fleeting connected to a certain situation. Affective responses can be both state-like and trait-like, and according to Agogo and Hess [30] a trait-like response can change to a state-like when introducing systematic programs to reduce for example affective responses like computer anxiety. That mechanism were also discussed in the groups when the participants claimed learning and more knowledge would reduce the feeling of fear and uncertainty. Even if a trait-like response may represent a more challenging attitude to change, the advantage is the predictability. Having good knowledge about the concept of a persons’ or a groups’ affective response may be helpful when planning for affordances and for work-integrated learning. Through the focus groups it appeared that all the participants had experiences of the dark sides of technology, but in spite of negative experiences the majority expressed to have an all over positive attitude to digitalization and technology. In light of the process- and outcome-based dimension, the “duality” of the all over experience may indicate that they have some negative experiences related to the process-based evaluation of the digitalization, whilst their all over satisfaction is related to an outcome-based evaluation.

The dark side of technology is reflected through the frustration they feel when having to prioritize support on ICT and other technologies to colleagues, patients and relatives at the expense of the time traditionally used to more typical caring tasks together with the patient. The experience of “loosing” the possibility to spend time with the patients aligns with a study of Mort, Finch and May [42], concluding that introduction of technology is likely to lead to a bigger distance between patient and those providing the healthcare services and to a objectification of the patient [42]. The ones that feel frustration just thinking about the technology, directs their responses to the technology as a device representing something that makes it difficult to carry out their work as they are used to. The other expression of affective response in the 3rd dimension can appear when the person are to use a computer, and the stimulus will be “using computers” [29]. When the behavior and interaction with the technology are focused, it may be easier for the professionals to see value in the process of digitalization and introduction of technology. Interacting with a technology may provoke positive affective response by developing a new form of patient-provider relationship on the basis of sharing data, prescribing therapies, asking for advice through ICT [43].

Among the participants, there were a unison view that lack of knowledge represent a barrier for the digitalization of the healthcare services, and an experienced shortage of knowledge will result in a negative response when evaluating the use of technology in a process-based manner, seldom or never reaching an measurable outcome. A parallel problematic may be related to the experienced lack of arenas practicing teamwork and collaboration. Struggle and difficulties along the process, makes it challenging to reach an outcome, that may lead to new insight and a further development of both knowledge and collaboration opportunities. When professionals have negative experiences with technology as a medium for collaboration, it will create a negative affective response to the intersection of person and technology stimulus [30]. The negative affective response formed by the person or professionals’ response to the stimulus might have a negative effect on the collaboration per se, even if ICT and information systems for healthcare expected to support collaboration and teamwork [44]. In alignment with the experienced lack of collaboration, the participant’s points at a need for a common language. Related to the group “other stakeholders”, the participants from the municipalities wishes to increase their collaboration with the technical aids center. The participants’ experiencing not having a common language or other qualifications necessary for collaborating, will consequently experience the dark sides of technology. That may easy become a situation where the person finds him or herself on the wane with no positive responses to technology, and the challenges related to engage in learning and knowledge development.

An average of the participants were pointing at the importance of learning more and developing more knowledge and generic competencies that are useful across different clinical context [45]. In addition to the experienced need for generic competence, both managers and professionals expressed a need for a new, more specific type of knowledge. In accordance to Barakat [15] and Lapão [16], the new type of knowledge can be characterized as state-like because the response were actuated due to a fleeting situation dominated by lack of knowledge related to ICT, technology and the ability to contribute to continuously development of the services. In the focus groups, the participants presented some examples of affordances aiming at facilitating learning at the workplace. In the example with the eLearning courses, the affective response were related to a specific technology and it is easier to evaluate both the process and the outcome when it relates to a specific technology. When developing knowledge and especially in relation with video-recorded instructions and eLearning, the response will be connected to a specific behavior with the technology [30]. The overall affective responses to the eLearning courses were negative. The technology, both the process- and the outcome-based evaluation, as well as technology as an object and the behavior with the technology are easy to follow, and still the participants do not find any motivation to engage in eLearning. The organizational training, were the instructors are randomly pointed out and the professionals often felt that they were supposed to learn by trial and error, leads to affective responses as the dark sides of technology. The process-based evaluation will be negative because the professionals experience too much problems in their interaction and “behavior” with the technology. In those two examples, the workplace affordances are not fitted with the needs of the professionals.

6 Conclusive Reflections

Challenges related to learning and knowledge are identified and analyzed by using the ARM-model. The challenges originate from the changing needs in the work practice when digitalizing the healthcare services. Small scale projects were technology is introduces are often conducted to try out different technologies, whereas the experiences are very varied. The importance of workplace affordances that are in line with the professionals needs are decisive. The affective responses and the consequences those responses will have on each individual’s motivation to engage in learning at the workplace, as well as the well-being of individuals, organizations and societies, will depend highly on how managers and professionals experience the quality of the learning environment facilitated by the workplace affordances and enhancement of competence. Powerlessness and avoidance of responsibility may be examples of affective responses in situations where there is lack of a common language that enables collaboration, clarification of which department and which roles who are responsible for decisions related to use and prescription of technology as part of the healthcare service.

A learning environment, knowledge and competence is decisive when it comes to the process of digitalization the healthcare services and introducing technology and new ways of providing the services. Knowledge about the dark side of technology and use of ICT is important in a society where managers and professionals in healthcare services have to relate to new technologies and new ways of providing services constantly.

This paper is a contribution to the identification of a systematic way to increase knowledge about the affective responses of managers and professionals in municipal healthcare services. That knowledge are decisive when planning and organizing for workplace affordances and work-integrated learning to be able to shape the affordances in a way that engage the different individuals. A limitation for in the study was that many of the participants had limited experience with ICT and other technologies, and that made the foundation of their contribution equally restricted. Further studies should focus on the connection between the use of ARM as a systematic approach to knowledge about affective responses and how it should be used in practice to increase the effective output when organizing for work-integrated learning.