Descriptions of the three selected innovations from the Netherlands that have been adopted and adapted in SSWI are presented in an additional text box file (see Additional file 1). The analysis revealed four key characteristics that have impacted the processes of adoption and adaption over time and which we identify as: Being a governmental-designated pilot organization, Taking a hybrid top-down and bottom-up approach, Differences between contextual values and values embedded in the innovations, and building trust and informal relationships with foreign experts.
Being a governmental-designated pilot organization
Suzhou Social Welfare Institute (SSWI), has been designated by the Chinese government as a pioneer organization with the objective to explore cooperation with the Netherlands to overcome challenges of an aging society [16, 22]. This approach in which the central government carefully chooses and promulgates local experiments (known as pilots) to address national issues is regularly practiced in China [29]. Over time, SSWI has been elevated pilot organization to model organization, and to serve as a template for other health institutions to follow. Pilot and model organizations receive support from the Chinese government and have to meet the expectations that come with this special status [30].
The governmental support included funding and access to foreign contacts with the Dutch government, which enabled to visit the Netherlands, participate in professional training programs in The Netherlands, and invite Dutch professionals to assist in innovation implementation at SSWI.
“For nearly 24 years, our institution has sent nearly 50 professionals to study in the Netherlands. The money comes from the government of Suzhou.” (Chinese).
Especially sponsored visits in the Netherlands have initially enabled SSWI to observe Dutch innovations in elderly care and then bring those innovations back to their institution. For instance, during a visit to the nursing home “Vrederust” in The Hague, The Netherlands, SSWI noticed the architectural design of a central courtyard surrounded by rooms in a large, circular building. This layout feature enables care providers to have a panoramic view of the surroundings as they walk inside and promotes a sense of social connectedness among the elderly. This design also aimed to reduce feeling of social isolation by the inhabitants, as experienced in traditional hospital-based designs with long corridors and small, cramped rooms on both sides. Inspired by the innovative design concept, SSWI took several photos, and 2 years later, Dutch visitors encountered a Chinese version of the design at SSWI. They noticed that there was much resemblance with the Dutch design, but some features had been adapted.
“This is a copy of a Dutch nursing home, with some Chinese elements inside.” (Dutch).
The original design in the Netherlands intentionally avoids any resemblances with hospitals, to promote that the nursing home feels like “home” to its residents. However, SSWI choose to combine the design of a Dutch nursing home with some features of a Chinese hospital, like a nursing station.
“A framework of a nursing home plus a hospital.” (Dutch).
“The nursing station is placed at the head, and the physical therapist’s clinic is at the tail for medical operations. The nursing station is a place for doctors and nurses to work, and the other end is a rehabilitation place.” (Dutch).
This adaptation can be attributed to expectations from the government, according to our Chinese respondents. As a pilot organization, SSWI is not only supported but also expected to align its practices with national policy and regulations. The 14th 5-year plan [31] emphasizes the national policy of integrating medical and elderly care. That signals to health organizations to combine medical and elderly care instead of choosing between them.
“The references of all aspects in the entire care process are equally important, compliance with various implementation standards issued by the national policy, service standards of nursing homes, and relevant professional standards and guidance of care.”(Chinese).
Another example of how the role of being a pilot organization and later a model organization, impacted adaptation regards the compliance to the regulation that care professionals must wear uniforms. During a visit in 2007, Dutch professionals saw all care providers in SSWI wear white uniforms, and then suggested to change this practice to make the nursing home less hospital like. In Dutch elderly care organizations, professionals don’t wear uniforms, as these may create a sense of distance and impersonality.
“Before this international exchange, we all wore white working uniforms, which gave a feeling of being cold in hospitals. It was very obvious that employees are employees, and the elderly are the elderly.”(Chinese).
In the following years, SSWI adopted the practice of not wearing uniforms as much as possible. However, Chinese regulations mandated that professionals in health organizations wear uniforms. Within the limits of these regulations, SSWI then offered a variety of colors and styles for the uniforms.
“Our nurses’ uniforms were originally white, but now they have changed to blue. Caregivers’ uniforms were also white, but now in pink and red. Also, different styles are available to choose from.”(Chinese).
“Now it is like in a foreign institution, you can wear your own clothing. However, professionals, such as doctors and nurses, must wear uniforms in China to indicate that they are doctors and nurses. This improvement of ours is the biggest change since the China-Dutch exchange.”(Chinese).
A hybrid top-down and bottom-up approach
Some earlier studies [9] have shown a typical Chinese approach to innovation which combines top-down procedures to stimulate adoption and bottom-up adaptations to tailor innovations in the local context. In our study, we observed a similar hybrid approach.
The first step in this process is what is called; top structuring [32]. Leaders at SSWI, inspired by innovations they witnessed during international visits to various Dutch organizations, selected innovations that they expect will fit their aims and their local context. After filtering out innovations or elements that seemed to be incompatible with their local context or required uncontrollable radical changes, leaders selected and combined different elements of various innovations from different organizations. These new configurations were then seen as ready to be implemented.
“As mentioned in the Three Kingdoms Chronicle, a Chinese classic work, if you can draw on wisdom in different forms, from different sources, then you are invincible.”(Chinese).
“In fact, we adopted some management methods or applied some technologies, because the context allows it to happen.”(Chinese).
Top structuring for example played a role in SSWI’s introduction of person-centered care for the elderly. SSWI leaders visited over 5 health organizations in the Netherlands where they witnessed a variety of innovative practices. Then, leaders selected various elements from different Dutch organizations. For instance, they drew inspiration from GGZingeest, a mental health hospital in Amsterdam, for the practice of making individualized care plans. Additionally, the idea of building an interactive experience room (explained in quotation below) was inspired by a nursing home in Goeree Overflakkee. The use of Plan-Do-Check-Act (PDCA) as an instrumental tool was influenced by online webinars involving multiple Dutch health organizations. These practices were combined into an innovation package consisting of individualized care plans, specialized facilities (e.g., interactive experience room), supported by PDCA for quality assessment and improvement.
“The nursing home provides elderly residents with a multi-sensory interactive boat house. In this interactive experience boat house, the elderly can simulate sailing on the sea and there are multimedia sounds, simulating the sound of the boat, waves, and seagulls. Many of the elderly on the island (in the Netherlands) had work experience at seaports when they were young, and later developed dementia symptoms. The interactive boat house can further enhance their sensory experience and also help them recall their past lives.”(Chinese).
“In fact, this idea is similar to our institution’s interactive experience room. Our organization also has an interactive experience device which enables the elderly to engage in virtual driving experiences within the famous landmark of Suzhou-Guancheng Street.”(Chinese).
Upon the creation of the innovation package, institution leaders established explicit goals for its implementation. Although top structuring initially filters out some innovations that may not fit the local context, the implementation of the innovative package may still encounter contextual challenges which may require further adaptations during the implementation. This therefore initiates the second stage: bottom-up adaptions, where the employees on the working floor strive to make necessary changes to innovations and find solutions to collaboratively achieve pre-determined goals.
“.There are still some difficulties in the implementation process.”(Chinese).
“When the goal of the leadership is clear, then social workers can communicate with other departments and work together to make this work. The leadership’s support gives us confidence.” (Chinese).
The pre-determined goals often are open-ended and leave room for interpretation. Employees are thus often expected to comprehend and interpret implicit intensions and create solutions to translate the blueprint into reality. For instance, one of the pre-determined goals was to incorporate a PDCA cycle from a Dutch audit framework to evaluate the quality of healthcare and the organization of healthcare while meeting ‘corresponding requirements’. During the bottom-up adaption, ‘meeting corresponding requirements’ was interpreted as aligning with Health Commission’s examination requirements centering on human performance evaluation. With the pre-determined top down goals in mind, the adaptation led to partial adoption of the 12 component Dutch audit system, focusing on human resource management components (as stated in the document of the Symposium of China-Japan-Netherlands Elders’ Nursing Home Management; see Additional file 4).
“The leader’ goal of utilizing PDCA is to identify and resolve problems, establishing a closed-loop quality management approach, and meeting the examination requirements set by the Health Commission.” (Chinese).
“The inspection contents revolve around performance evaluation requirements. This is also consistent with the ultimate goal of our management.’ (Chinese).
Differences between contextual values and values embedded in the innovations
According to our respondents, some innovations introduced by SSWI are based on values that may not inherently align with the clinical orientation for organizing care, commonly encountered in the context of Chinese nursing homes such as SSWI [33].
The clinical orientation encompasses values concerning care, skills and professional roles. At the care level, the clinical orientation emphasizes physical health and needs of the elderly rather than mental, psychological and social wellbeing [33]. This disease-centered approach contrasts with a person-centeredness approach that value a holistic perspective on the demands of the elderly [34, 35]. The clinical orientation thus implied values that differed from the values embedded in person-centered care that SSWI intended to introduce.
“The service may tend to focus more on the basic physical needs of the elderly, and not pay enough attention to the deeper psychological and social needs, leading to declined experience for the elderly and a lack of depth in nursing services.” (Chinese).
At the same time different forms of care in China are more focused on groups then on individuals.
“Previously, their plans were for groups, not for individuals. All people with dementia and psychiatric problems are treated in the same way. They have to get up at the same time, they have to eat at the same time. When they came back, already sitting there waiting for their medicines. They had to directly take the medicine. And then they all went for lunch, and they all wear the same shoes. They went to sleep at the same time.”(Dutch).
To adopt person-centered care for the elderly, a fundamental transition in values of good care thus appeared essential. It involved recognizing the elderly as whole individuals with multidimensional demands. Furthermore, it involved engaging the elderly as active participants in the care provisioning, empowering them to be “co-designer” and “joint-decision maker” rather than viewing them as passive “service recipients” [34, 35].
At the skill level, a clinical orientation may lead to emphasizing hard skills such as medical treatment and technology over soft skills such as communication and empathy. According to our respondents, the (originally less developed) communication skills indeed appeared essential for the successful implementation of person-centered care.
“We find it is difficult to talk with our service recipients, especially with psychiatric patients. Sometimes it is just hard to grasp.” (Chinese).
“If you don’t ask the elderly what the problems and demands are, then you cannot make anything individual care.” (Dutch).
The clinical orientation also shows through valuing and appreciating care providers with hard skills (e.g., doctors and nurses) more than care professionals with soft skills (e.g., caregivers and social workers). Professionals with soft skills experienced lower status, as manifested through lower payment and heavier workloads.
“They must feed these people well in half an hour, what can you do?” (Dutch).
“Those caregivers often work hard for money to support their family, but they receive the least payment within the entire organization.” (Dutch).
“They spend the most time with the elderly, so their opinions on how things can be improved should have been asked. They don’t get used to being asked about and sharing their professional opinions.” (Dutch).
Therefore, the original decision making and care provision dynamics within care teams in which care professionals with various skills collaborate was dominated by doctors. These dynamics consequently presented challenges to the introduction of multidisciplinary care team led by social workers which aimed to promote person centered care. The difficulty experienced by social workers to assume team leadership has been especially challenging.
“Doctors have always been regarded as ‘primary leaders’. The first thing that you need is to respect each other’s profession. It is about equality, seeing each other’s profession and knowledge. You know something and I know something, both very necessary. You both have some skills. This is the first step.” (Dutch).
While being supported by continuous organization wide training and education programs, the shift away from the clinical orientation took longer than expected. The process of joint comprehension of the importance of a holistic approach and committing to this approach advanced gradually.
“Some staff may not have a complete understanding of the person-centered care philosophy. We may still be influenced by traditional ideas and practices. Nursing work is highly practical, so our staff may focus more on technical operation rather than humanistic care.” (Chinese).
The gradual, step-by-step approach eventually taken by SSWI started with introducing the role of social workers in elderly care in 2001. This first step aimed to address insufficiency of attention for the elderly residents’ social and emotional demands. Social workers then started to play a role in identifying the elderly residents’ demands, intensifying communicating, providing companionship, and designing social activities for the elderly. They also managed the involvement of the support network of the elderly, such as their families, to develop individual care plans and to help providing emotional support for the elderly.
Some rehabilitation and entertainment activities will be arranged, such as taking a walk and making Chinese knots.” (Chinese).
“He was very upset without any appetite, and his daughter was abroad and international travel was too difficult during that time (due to pandemic). So we arranged video calls for him with his daughter to make him feel better.” (Chinese).
A decade after the first step of introducing social workers, SSWI extended the role of social workers to coordinating the care provided by professionals from various disciplines in function of the personal demands of the elderly. As a result, in 2012, SSWI took the second step, to completely adopt the innovation of social worker led multidisciplinary care teams [34]. This innovation has remained the standard practice since.
Building trust and informal relationships with foreign experts
The foreign expert network, established through a three-year governmental agreement in 1996 has expanded over more than 2 decades. This network operates through the active engagement of Dutch experts for longer term collaborations. The strength of the relationships that develop over this longer term appears to play a crucial role in navigating the complexities of adopting and adapting Dutch innovations in elderly care in the Chinese context.
Initially, invited Dutch experts shared their expertise while supporting SSWI in the process of adoption and implementation of Dutch innovations in elderly care. Many Dutch respondents were impressed by the Chinese hospitality and interest, which helped to develop a relationship of mutual trust.
“Once we arrived, there were all staff outside to welcome us, and then it was a big dinner welcome. The director clears all his agenda, and everything is for us. I can learn from this….” (Dutch).
Gradually, the interactions extended beyond formal meetings to relatively informal settings such as shared dinners and conversations over tea and coffee. Over time, the Dutch experts became trusted allies in the innovation processes of SSWI and some became to be considered as friends, committed to helping SSWI adopt and implement innovations.
“You have coffee at 10 pm after dinner, some people gone, and suddenly you have the real talk. At the second half the dinner, you often had real talks too.” (Dutch).
“You see their passion, compassion, commitment, really helps.”(Chinese).
The trust built within the long-term network, has enabled opportunities for collaborations beyond Dutch health organizations. SSWI has then expanded its partnerships to include Dutch universities and health enterprises since 2010.
“What also helps, is to create more organizations involved in that, and then it becomes stronger.”(Dutch)_.
“Over the past 20 years, we have witnessed the growth of collaboration and the development of Sino-Dutch friendship.” (Chinese).
The longstanding relationships facilitated the iterative processes of adoption and adaption and developed into a continuous knowledge exchange between Suzhou and the Netherlands. It enabled SSWI to continuously learn new innovations and further familiarize themselves with adopted innovations and improve throughout the different stages of the implementation process.
“…We have exchanged a lot about innovations, individualized care, working with social workers, care for patients with dementia patients’ rights, etc. Whenever the opportunity arises, we invite experts from various fields to teach in our institution or sent our staff to the Netherlands. ”(Chinese).
“They later, continuously asked a lot of questions about social workers.”(Dutch).
By interacting with Dutch experts, SSWI received technical support and according to our respondents developed a better understanding of the values embedded in the selected innovations. Such deeper understanding may be crucial for complex innovations like person-centered care for the elderly [36].
In 2010, for instance, the practice of making individualized care plans for the elderly was introduced in SSWI. Initially, SSWI faced challenges in implementing this practice, due to a lack of understanding of “individuality” and unfamiliarity with tailored care provider-the elderly communication techniques, as discussed in the previous section.
Recognizing the need for professional support and guidance, some of our Dutch respondents were invited to help for a three-month period at SSWI. Their expertise in making individualized nursing plans and their understanding of the importance of respecting the elderly’s individuality and effective communication was according to our respondents beneficial. The Dutch experts conducted training sessions especially for nurses who encountered difficulties in communicating with the elderly with mental issues. Those trainings focused both on how to ask questions, fostering meaningful interactions with the elderly, and on periodic evaluation of care plans.
“I showed them how to make a plan in the three months. I found they didn’t evaluate the plan regularly. One thing I told nurses is that if you want to make the plans that you need to make a conversation with the patients regularly to see if this plan works.” (Dutch).
“You have to understand, two people who both have diabetes can have totally different care plans. Although they both need insulin, they are different as individuals with different habits, preferences, beliefs…” (Dutch).
“Regarding personalized renovation, we now have different rooms in Chinese, European, and South Asian styles, with a focus on green plants and landscape design, eliminating labeling. You can also make your room decoration, put something made by yourself. They can decorate their own rooms based on personal preferences.”(Chinese).
“The elderly can place an order, and our chef will make the dish.”(Chinese).
In 2019, SSWI explored a next level in person-centered care, expanding the scope of individual decision-making beyond matters such as clothing, food and room decoration. This involved shared decision making on clinical matters and possible advancements in patient rights. There have been ongoing exchanges regarding patient rights, especially for those with dementia, which continued as online webinars during the pandemic. The long-term relationships thus seemed to provide a valuable platform for dialogue in support of continued gradual changes, including conversations about values of care embedded in the selected innovations.
“A topic that has also been talked a lot about is patients’ right. How the law works in the country, and people are not able to decide for themselves… psychiatric patients, the elderly with dementia. Here in the Netherlands, what you can do is really based on the law of patients’ rights. If the patient says no, then you cannot do anything…”(Dutch).
During the implementation and adaption, Dutch experts and professionals have also acted as intermediator between the SSWI leaders and employees, leveraging the built trust to assist the top-down and bottom-up dialogues. For instance, Dutch professionals would observe and hear about implementation challenges from the nurses at SSWI and bring them to the attention of the leaders.
“She (one Dutch respondent), sought feedback from nurses in SSWI, and then told the leader ‘they worked so hard, like one nurse has to manage 20 different patients. So probably the goals should be set lower, bi-weekly evaluation, instead of weekly evaluation. ”(Dutch).
“We also changed our scheduling, more flexible, for nurses.”(Chinese).
As the relationships and trust developed over time, the foreign experts thus also functioned to resolve some of the challenges left unaddressed by the traditional Chinese feedback practices which prioritize relaying positive feedback to the top management.
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