Nowadays, technological products and other innovations are being used more frequently in the health care sector [1-3] to minimize physical strain, such as lifting patients or transporting beds, and encourage ergonomic approaches during nursing tasks. Nurses need to use these innovations during patient care to manage various health care challenges, such as the increasing demand and complexity of health care [4,5]. An example of a technological product, which will be referred to as a “nursing technological innovation” in this paper, is the TrulyEasy clamp, designed for convenient 1-handed adjustment of the arterial line to the correct height [3]. Another example of a technological product is LineConnector, a product designed to efficiently organize infusion lines and prevent tangling [3].

Unfortunately, technological solutions aimed at solving nursing issues do not always align with daily nursing practice [2,6]. A potential explanation for this lies in the top-down approach used during the development and implementation of many innovations. Policy makers may prioritize regulatory and payment interests, while technicians focus on the functionality of innovations, without fully understanding the user perspectives and the nursing context [6-8]. Consequently, some solutions may inadequately align with the needs of the nursing profession, leading to limited impact on nursing practice [2,6]. Improving the adoption of innovations in nursing practice can be addressed in the development and implementation phase of these innovations through stakeholder participation [1,5,9-12].

A growing number of health care centers are facilitating an environment that allows stakeholders to participate in the development and implementation of nursing technological innovations [1,6,9,10,12]. This involvement, also called cocreation [13], with a bottom-up approach [8], involves an interaction in which various stakeholders work together to produce an outcome that is valued by all stakeholders involved [13]. The bottom-up approach allows stakeholders to share their knowledge or opinions about issues presented in daily activities and suggest potential solutions [8,14]. This approach can support the development of nursing technological innovations that may have an impact on nursing care [1,5,9-12]. FlushEgg is an example of a cocreated nursing technological innovation. Nurses reported experiencing challenges and discomfort while flushing the narrow central lines in neonates. Therefore, a syringe attachment was designed to enhance comfort in the palm during the application of pressure [3]. Another example of a cocreated nursing technological innovation is KoosGuard, which includes a holder that can be placed in the bed through which the cables and infusion lines are guided without becoming tangled or pinched [3].

However, the bottom-up approach requires nurses to invest time, which is challenging considering many nurses face time constraints [15,16]. If these nursing technological innovations lack the required quality, this could result in decreased application in nursing practice [2,6]. Furthermore, a poorly developed nursing technological innovation could lead to resistance from nurses, resulting in a negative attitude toward these innovations [9,17]. To fully use the potential of innovations in nursing practice, the innovations need to be adequately designed, which requires the involvement of nurses [9,18]. Despite the increasing involvement of nurses in the cocreation of nursing technological innovations, little is known about how this approach and its resulting innovations are experienced by nurses. Therefore, this study seeks to explore the experience resulting from the bottom-up approach of cocreation with nurses and the resulting nursing technological innovations developed through this approach. The perspectives of nurses, both as cocreators and end users, and their managers are key to understanding the impact of this collaborative process. These results could offer a deeper insight into how nurses, both as cocreators and end users, along with their managers, perceive the bottom-up cocreation approach and its resulting nursing technological innovations. A comprehensive understanding of their experiences, both positive and negative, can significantly contribute to the overarching goal of enhancing patient care and nursing practice, making it safer and more effective.

This study explores nurses’ and their managers’ experiences with a bottom-up cocreation approach in order to assess the impact of this way of working and the resulting nursing technological innovations in an academic hospital. This insight can also inform decisions on whether the bottom-up cocreation approach should be more widely disseminated.

This study used an exploratory, descriptive, qualitative research design using individual interviews conducted at an academic hospital in the Netherlands between February and April 2023. This design facilitated the exploration of participants’ experiences, which were further analyzed through a thematic analysis and subsequently through a strengths, weaknesses, opportunities, and threats (SWOT) analysis [19]. The methods and subsequent results were reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [20].

The study population consisted of three subgroups: (1) nurses with experience in cocreation, (2) nurses with experience as end users, and (3) health care managers from the nursing departments at an academic hospital where the innovations were implemented. In addition, all eligible nurses and managers were required to have at least 1 year of experience within the nursing department where the innovations were implemented. The 1-year experience criterion ensured that nurses and managers were sufficiently familiar with the innovations and context. The setting comprised an innovation department established within the academic hospital.

To gain more understanding and in-depth information from a broader perspective, a heterogeneous group of nurses and their health care managers were included through purposive sampling [19,21,22]. Potential nurse cocreators and managers for this study were recruited and informed via an email by OH about participating in the interviews. Interested individuals were required to actively contact SvS by email. Upon receiving an email, SvS responded with a participant information letter and an informed consent form. Once participants agreed to participate in the study, interviews were scheduled at a mutually convenient time. For the nurse end users, SvS visited the nursing departments where nursing technological innovations were integrated into nursing practice. Interested nurse end users were able to participate in an interview during their shifts at a time convenient for them. The nurse end users were informed via a participant information letter. After informed consent was given, the interviews started. The face-to-face interviews were conducted at the academic hospital.

A total of 14 to 20 participants were required to obtain saturation of knowledge with a heterogeneous sample group [19]. Therefore, the aim of this study was to include at least 14 participants [19]. The study involved 15 participants, including 10 (67%) women and 5 (33%) men.

Data were collected through semistructured interviews using an interview guide based on literature and expert opinions [19]. The interview guide covered various topics (Table 1), including the participants’ attitude [23] toward technology, the bottom-up cocreation approach, and the nursing technological innovations developed through this approach. It also explored the acceptance [9,10,23], usability [12,23], and adoption [10,23] of these innovations in nursing care as well as their impact on patient care and nursing practice [1,11,12,24]. Demographic characteristics (age, gender, and specialization), along with the adoption rate, provided an overview and background information of the participants in this study. The adoption rate proposed by Rogers [25] allowed the measurement of individuals’ attitudes toward innovations, providing valuable insights into how the participants generally perceive and approach innovations. The adoption rate according to Rogers [25] was measured by asking the participants which category they identified with. They could choose one of the following five categories: (1) driven by change and introduction of innovations, (2) leading in adopting innovations, (3) deliberately adopting innovations, (4) adoption is an economic necessity and a response to social peer pressure, and (5) have a traditional view and are more skeptical about innovations [25]. A pilot test was conducted to refine the interview guide and involved expert assessment and field testing with one participant. After the interviews, the first author created memos recording thoughts that arose due to the interviews [19]. The interviews were audio recorded and conducted by SvS, a nurse with no prior experience at the hospital where the research took place. SvS was trained in conducting interviews. Throughout the data collection process, discussions were held with the research team, including investigators SvS, TvH, and OH, to refine the interview questions and ensure that they effectively addressed the research question.

The semistructured interviews were transcribed verbatim [19]. A 6-step thematic analysis approach (Table 2) was applied using ATLAS.ti software (version 23; Lumivero) [26]. Open coding and constant comparison techniques were used during the analysis [19]. An iterative process was used between data collection and data analysis. Refining the interview questions made the collection of the data more focused and specific as the process developed [19]. Audio recordings were transcribed, read, and reread by SvS in order to become familiar with the data. Data were initially coded using open coding by SvS. The 1st, 3rd, 6th, and 10th transcripts were coded separately, both by SvS and TvH. The initial codes of SvS and TvH were compared and discussed until consensus was reached. Main themes were generated through an iterative process, including constant comparison, and further elaborated and finalized by SvS, TvH, and OH. A codebook was used for insights into coding and code development [19].

In addition to the thematic analysis, we performed a secondary analysis using the SWOT matrix. This secondary analysis was carried out to make the data more accessible for the readers and support strategic changes within an organization. The SWOT analysis has been shown to be a valid method in previous studies for facilitating data interpretation for readers and informing strategic planning and decision-making in practice [27,28]. In several meetings, detailed examples of the results, with related quotes of the main themes, were discussed and analyzed and subsequently linked to a component of the SWOT matrix.

Different techniques were used to enhance trustworthiness [19]. The credibility of this study was established by the investigators by creating a nonjudgmental ambiance during the semistructured interviews to obtain the participants’ perspective. The chance for bias was reduced by transcribing the content of the interviews verbatim. Member checking was used to ensure the accuracy of the transcripts, with participants reviewing the transcripts to validate their thoughts and ideas [19]. The performed member check resulted in minimal textual changes to the data.

Memos were reported during data collection and analysis to support the investigation process and the thoughts that had occurred to the investigator. The conformability of the interpretation and credibility of the data were both enhanced by investigator triangulation during the data analysis and peer feedback during researcher meetings, including the investigators SvS, TvH, OH, and HSMK. Due to peer feedback, potential meanings and a wider range of perspectives were revealed. Reflexivity, ensured by the investigator’s critical view of the interview process and comments from other investigators, increased depth and improved accuracy.

A thick description was pursued to ensure the transferability of this study through the diversity of the population base, the number of participants, and the length of the interviews for imitability. To enhance the reflexivity and transparency of the investigators, a logbook was kept, detailing all changes and decisions made throughout the process of this study [19].

Throughout this study, the principles of the Declaration of Helsinki and the code of conduct for health research were followed [29,30]. The study was examined and approved by the medical ethics review committee of the Erasmus Medical Center for a nonmedical scientific research application (MEC-2023-0021). Participants were informed and invited to the study by OH. They received the investigator’s email and had 1 week to express interest. Nonresponders received a reminder. The investigator sent a participant information letter and informed consent upon contact. Participants could ask further questions via email. Interviews were scheduled after participants confirmed their approval. Before the interview, they provided written informed consent. The participants did not receive any compensation for their participation in the study. During the study, data collection was conducted with confidentiality, and data were processed anonymously according to the European Union General Data Protection Regulation [29]. Only the investigators SvS, TvH, OH, and HSMK had access to the source data.

The duration of the interviews ranged from 26 to 62 minutes, with an average duration of 44 (SD 10.8) minutes. Participants’ ages ranged from 20 to 67 years. Various departments, including the intensive care unit, children’s ward, and the recovery department, were represented in the study. Table 3 presents detailed demographic information, including gender, age range, department, adoption rate, number of nurses participating as cocreators and end users, and the number of health care managers.

In this study, we sought to explore hospital nurses’ experience with a bottom-up cocreation approach and the resulting nursing technological innovations developed through this approach. Notably, through a SWOT matrix, we mainly revealed positive experiences of participants cocreating nursing technological innovations, with several strengths and opportunities. Participants’ experiences can be described in 3 themes: enhanced attractiveness of the nursing profession, feeling involved due to a cocreation environment, and experienced benefits and challenges in using cocreated products. The findings indicate that participants found the nursing technological innovations easily applicable in nursing practice due to their user-friendly design, the ability to enhance nursing efficiency, patient safety, and time-saving potential during nursing work. A collaborative culture may lead to higher work satisfaction among nurses, inspire cocreation, and promote nursing pride.

This study shows how cocreating nursing technological innovations positively impacts the attractiveness of the nursing profession. The attractiveness of the nursing profession was enhanced by nurses finding joy in their roles, feeling a sense of pride, and being taken seriously in their work. This aligns with findings from a cross-sectional study, which emphasizes the significance of decision-making involvement in health care services, such as equipment, technologies, and processes for employment preferences of nursing students [31]. In addition, it aligns with a systematic review indicating that an increase in career opportunities and challenges positively impacts nurse retention. It reduces nurses’ desire to leave a particular workplace [32].

Furthermore, this study emphasizes several collaboration advances due to a cocreation environment within the organization, such as clear communication and teamwork among nurses, designers, and technically oriented students. Moreover, a cocreation environment within the organization contributed to knowledge exchange, product distribution, and external production. An in-depth case study [14] reinforced the importance of an innovative environment within the organization. It could increase the diffusion of nurse-led innovations within and outside the organization. Particularly, managers seem to have an important role in collaborating and communicating with each other about innovations and supporting working methods in nursing departments. Existing literature [33,34] reinforces the notion that supportive leadership is crucial for fostering a culture of innovation and enhancing the sustainability and impact of health care innovation settings.

In addition, this study shows that innovations cocreated with nurses led to multiple benefits for nursing practice. Cocreated nursing technological innovations were described as user-friendly, highly practical, and easy to integrate into nursing tasks, consistent with findings from a quasi-experimental study [35]. In this quasi-experimental study, trained innovative nurses were able to identify issues in nursing practice and apply creative thinking strategies to create innovative products that matched their nursing work routines. Furthermore, the cocreated nursing technological innovations met nursing quality requirements and reduced the need for improvised solutions, thereby minimizing inconvenient situations in nursing practice. Patient safety was also enhanced by the cocreated products, which prevented issues such as infusion line entanglement and reduced the risk of wound contamination. The incubator traffic light is an example from the literature of a cocreated nursing technological innovation that meets quality standards and enhances patient safety. The incubator traffic light features a visual feedback system for neonatal incubators designed to enhance hand hygiene compliance [1,2]. Incubators with the incubator traffic light visual feedback system demonstrated significantly higher compliance with the correct drying times compared to those without this feature. This could potentially enhance patient safety by reducing infection rates in neonatal intensive care units [1]. Although the cocreated nursing technological innovations offered several advantages, the study also encountered certain challenges in their use, for example, flaws in the design of the innovations, which hindered their effectiveness or ability to make changes in the nursing routines. This study shows that changes in nursing processes may increase the risk of reverting to old routines, which aligns with findings from a cross-sectional survey that indicated how changes in nursing work processes could influence established work habits [36].

While this study did not include patients or parents directly, the participants acknowledged the significance of their perspective during the innovation process. It was mentioned that some of the cocreated innovations were developed in collaboration with patients and parents, resulting in innovations aligning with their expectations and needs. This is consistent with existing literature, where patients, family caregivers, and clinicians cocreated a mobile health app for heart failure self-management tailored to the specific health care context [37]. Furthermore, it matches with a qualitative co-design article including family, physicians, researchers, patients, and industry partners. The study revealed important differences between the participants’ preference for functional requirements of a mobile health app [38].

Limitations of the study include its single-site focus on a specific academic hospital and limited transferability to other health care settings [19]. Furthermore, there may be a sampling bias, as interested individuals were required to actively contact the investigator via email to participate in this study. These individuals might have been more likely than other professionals to embrace the innovations and encourage their adoption within their teams. In addition, all the participants scored themselves above average on the adoption rate scale (Table 3), and 10 (67%) of the 15 participants considered themselves to be “innovators” [25]. Literature shows that only 2.5% of the population belongs to the group of innovators [25]. This suggests a potential bias in the participant group. Including nurses as cocreators may have introduced selection bias, as their enthusiasm and assertiveness toward innovations may have influenced the results in a more positive manner [39]. Finally, the sample size consisted of 6 (40%) nurses as cocreators, 5 (33%) nurses as end users, and 4 (27%) managers. The limited insights from the managers’ perspective may affect the comprehensiveness of the findings in the study [19].

The findings of this study suggest several implications. Health care organizations could consider adopting the bottom-up cocreation approach with nurses as it has the potential to enhance nurses’ work satisfaction, a sense of pride among nurses, and adoptable nursing technological innovations in nursing care. Furthermore, cocreation can contribute to accessible collaborations between stakeholders inside and outside the organization. In addition, cocreation with nurses has the potential to facilitate the development of innovations that enhance the efficiency of nursing work. Simple, professional, and time-saving innovations created through this approach could improve nursing practices.

Further research is recommended to explore the impact of the bottom-up cocreation approach and the resulting nursing technological innovations in other health care centers, aiming to improve the transferability of this way of working. Moreover, to better address patients’ expectations and needs during the cocreation process and resulting innovations, further research is recommended to investigate their experiences throughout the cocreation process and its outcomes.

This study highlights substantial positive experiences of cocreating nursing technological innovations in nursing care. The findings underscore that cocreation with nurses enhances the appeal of the nursing profession. Participants perceived cocreation as enjoyable, leading to heightened work satisfaction and a sense of pride in their nursing role. Moreover, cocreation with nurses fosters the development of nursing technological innovations that align with nursing practice challenges, thereby facilitating their adoption within nursing care. Ultimately, embracing a culture of cocreation has the potential to foster ongoing improvements and innovations in nursing care, further contributing to the professionalization of the field.