Organisational readiness for digitalisation in health care: Findings from qualitative research in four EU countries/region

Abstract

Background

Digitalisation in healthcare is progressing more slowly than in other sectors, despite being highly needed and prioritised by the World Health Organization, the European Union, and individual countries. Therefore, investigating readiness for digitalisation across European regions may inform strategies required to accelerate the process.

Objectives

This study explores organisational readiness for digitalisation in healthcare in four different countries/regions: Catalonia (Spain), South Denmark, Italy, and Slovenia.

Methods

An exploratory descriptive qualitative study was conducted and reported according to the COREQ guidelines. Focus groups and individual interviews with 74 healthcare professionals (HCP) and healthcare managers (HCM) from four partner countries/regions were carried out, recorded, transcribed, and thematically analysed.

Results

Four themes summarised organisational readiness for digitalisation, including barriers, facilitators, and drivers of digital transformation: “Organisational Readiness for Digitalisation: Between Potential and Persistent Gaps”; “Convincing Design: Intuitive Technologies for Sustainable Change”; “Barriers to Change: Structural, Cultural, and Professional Obstacles”; and “The Drivers of Transformation: Technological and Organisational Levers for Progress”.

Conclusion

Organisational readiness is shaped by the interplay of technological, organisational, and professional factors. Strengthening organisational readiness for digitalisation requires coordinated investment in digital infrastructure, continuous education and training, supportive leadership, and participatory implementation strategies to ensure sustainable digital transformation.

Introduction

In recent years, the European Union (EU) has recognised the importance of digital health solutions in improving the quality of care and increasing the integration of services to deliver tailored, personalised, effective, and efficient healthcare, ¹ through the adoption of programmes such as EU4Health 2021–2027 ² and DIGITAL. ³ A growing body of evidence supports the need for these developments, including digitalised medical records and clinical notes, which offer multiple benefits for patients, such as strengthening communication, trust in clinicians, and engagement, ⁴ as well as integrating care pathways that facilitate communication across clinicians and organisational levels.

However, the digitalisation of healthcare is progressing slowly due to the complexity of health systems and data protection concerns. ⁵ Literature reviews indicate that healthcare lags behind other industries in adopting Information and Communication Technologies (ICT), despite rapid advances in big data and data analytics. The first two generations of technological change were adopted easily in healthcare settings, but the sector is struggling to implement the third and fourth levels of digitisation, which include several innovations such as the Internet of Things, augmented reality, cybersecurity, big data analytics, smartphone technologies, machine learning, cloud computing, system integration, simulation and modelling, Radio Frequency Identification (RFID) technologies, digital manufacturing, and advanced autonomous robotics. ⁶ Furthermore, the rapid development of digital solutions in health sector challenges healthcare managers (HCMs) and healthcare professionals (HCPs) to adapt to and integrate these technologies into their daily work.^7,8 These technologies promise to improve accessibility and the overall quality of healthcare services, but they also revolutionise the way health professionals interact with patients and organise their workflows. ⁹ Digital transformation also depends on managers capable of leading this complex revolution, which intersects all work processes. ¹⁰ For these reasons, successful implementation requires a clear strategy and collaboration between government, the health sector, and the private sector, ⁵ as well as the capacity of the microsystem to be ready for these transformations.

Readiness to change has been investigated in recent decades across various scientific fields. Specifically, organisational readiness to change is defined as a shared psychological state in which members of an organisation desire to implement change (commitment) and believe they can do so collectively (efficacy). Moreover, readiness can be defined as a shared psychological state in which members exhibit both commitments to implement a change and confidence in their collective ability to do so. ¹¹ Readiness increases when people value the change and believe the organisation has the knowledge, resources, and support necessary to achieve it. When readiness is high, organisations are more likely to initiate change, sustain efforts, and implement new practices effectively. ¹² In the context of digitalisation, this concept has been further examined in response to the observation that most digital innovation initiatives fail because companies are insufficiently prepared. Although modern digital technologies offer unprecedented opportunities for innovation, organisations often lack the psychological, structural, and resource foundations required to translate ideas into concrete products and services.

Digital readiness also refers to an organisation’s overall assessment of its preparedness to produce, adopt, and leverage digital technologies for innovation effectively. The seven key dimensions of readiness include resource flexibility, IT readiness, cognitive readiness, partnership readiness, innovation value (positive attitudes), cultural readiness, and strategic readiness. Together, these dimensions capture and integrate the organisation’s level of preparedness to lead digital transformation.^11,13 In this context, this paper examines organisational readiness regarding digital transformation in the healthcare sector (primary, secondary, and tertiary levels). The aim was to investigate digital transformation readiness as perceived by HCPs and HCMs in four European countries/regions.

Methods

Study design and theoretical framework

An exploratory interpretative qualitative study was conducted^14,15 and is reported here in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. ¹⁶ The complete COREQ checklist is available as Supplemental File 1. This methodological approach was chosen to give direct voice to HCP and HCM participants on issues of immediate practical relevance, enabling an understanding of their perceptions of organisational digital transformation readiness.^14,15

Setting and participants

The study was conducted within the Digital EducationaL involVing hEalth pRofessionals (DELIVER) project, ¹⁷ an Erasmus+ programme of the EU, which aimed to enhance the digital skills of HCPs and support HCMs in the digital transformation. The overall duration of the project was three years, from January 2021 to December 2023. The project consortium comprised four European institutions located in Catalonia (as an autonomous region of Spain), South Denmark, Italy, and Slovenia (see authors).

Initially, a convenience sample was used, targeting primary, secondary, and tertiary healthcare settings, including community health centres, general hospitals, and highly specialised care facilities within each partner’s region. Purposeful sampling ¹⁸ was then employed to promote the involvement of professionals considered key informants regarding the phenomenon under study and to ensure a range of professional backgrounds and working settings. Eligible professionals were: (a) HCPs or HCMs (middle or top managers); (b) actively employed as clinicians or managers in a healthcare facility in one of the partner regions; and (c) willing to participate by providing written informed consent. Excluded professionals were: (a) administrative or non-clinical staff without direct involvement in care delivery or management; and (b) students.

Potential participants were identified and approached by each partner institution according to a purposive sampling strategy. ¹⁸ HCPs and HCMs were selected based on their perceived knowledge of and involvement in the phenomenon under investigation, irrespective of their professional background. Thus, the resulting sample reflects cross-country variability in the professional groups most engaged in digitalisation processes and initiatives. No professional invited refused to participate. Participants were recruited until data saturation was achieved, ¹⁹ defined as the point at which no new meaningful themes emerged from narratives and identified patterns were consistently confirmed across participants. ¹⁹ According to the study protocol, data saturation was considered achieved when analysis of newly collected and verbatim-transcribed interviews no longer generated new codes or themes beyond those already identified in previously collected, transcribed, and analysed interviews. Data saturation was assessed independently by two researchers in each participating country/region and, when disagreements arose, discussed with a third researcher until consensus was reached.

Data collection

Data collection was carried out through focus groups and semi-structured interviews.^20,21 A research protocol with semi-structured data collection questions tailored for interview and focus group in a form of guide was collaboratively developed prior to data collection and then pilot-tested with a sample of HCPs and HCMs to ensure the relevance, feasibility, and applicability of the questions across different national contexts. Following the pilot phase, minor adaptations were made. In line with the aim of the study, the data collection instrument covered two main thematic areas: (a) organisational factors, investigating the organisation's general attitudes towards digitalisation, perceived organisational support for HCPs in using digital technologies, digitalisation strategy, and organisational dimensions including structure, workflows, leadership, and workplace culture; (b) perceived barriers and enablers influencing or required to increase organisational readiness. Only limited demographic data were collected to minimise the risk of compromising anonymity, given the sensitive nature of the topic investigated (e.g., barriers). The interview guide and procedures are provided in the Supplemental File 2.

Data collection took place between September 2022 and December 2022. Each country/region was free to choose the most suitable data collection method according to participants’ preferences. For focus groups, sessions were organised separately for HCPs and HCMs to encourage open discussion within peer groups. Participants unable to attend focus group sessions due to personal reasons (such as distance, limited time, or scheduling difficulties) were offered the opportunity to participate in an individual semi-structured interview using the same data collection guide. In total, the study involved 74 HCPs and HCMs from primary, secondary, and tertiary levels of healthcare, representing different types of health professionals. Participation continued until data saturation was achieved ¹⁹ ; therefore, the number of participants interviewed in each country/region varied, with most from Italy (n=25), followed by Denmark (n=20), Slovenia (n=18), and Catalonia (n=11). The majority were female (82%). As summarised in Table 1, between 5 and 6 HCM and between 6 and 19 HCP were interviewed in each country, with a median year of professional experience ranging from 13 to 20.5.

Table 1.

Characteristics of the participants.

Participants		Countries/regions
		Italy	Catalonia	Denmark	Slovenia
		N=25	N=11	N=20	N=18
Professional profile	HCM	6 (24%)	5 (45%)	5 (25%)	5 (28%)
	HCP: Nurses	12 (48%)	4 (36%)	5 (25%)	5 (28%)
	HCP: Physicians	2 (8%)	1 (9%)	2 (10%)	1 (6%)
	HCP: Physiotherapists	0 (0%)	0 (0%)	3 (15%)	7 (39%)
	HCP: Other (dietitians, technicians)	5 (20%)	1 (9%)	5 (25%)	0 (0%)
Gender	Female	21 (84%)	9 (82%)	16 (80%)	15 (83%)
Years of experience	Median	17.5	13	20	20.5
Care setting	Primary	5 (20%)	6 (55%)	10 (50%)	7 (39%)
	Secondary	11 (44%)	2 (18%)	7 (35%)	4 (22%)
	Tertiary	9 (36%)	3 (27%)	3 (15%)	7 (39%)

Legend. HCP, Healthcare professional; HCM, healthcare manager.

All sessions were conducted remotely using private videoconferencing software and lasted between 30 and 70 minutes. Before each interview, participants received written information about the aims and procedures of the research. Written informed consent was obtained from all participants before data collection began. Sessions were audio-recorded, and transcripts were produced by local research team members in the national language, then translated into English for cross-regional analysis.

Data analysis

Thematic analysis was conducted using Braun and Clarke’s reflexive approach through an iterative, inductive process. ²² As specified in the research protocol, the analysis was designed as a pooled multinational thematic analysis rather than identifying themes at each country level and comparing them across countries or regions; however, in the analysis, codes and quotes for each specific country or region were preserved in order to identify overarching multinational themes and highlight specific variations across countries and regions. Data analysis began with two researchers from each partner institution transcribing the interviews verbatim in the local language and independently familiarising themselves with the data to identify meaningful features and generate initial codes. Discrepancies were resolved through discussion and consensus, with the involvement of a third researcher from the same country or region when needed. The resulting codes were then translated into English following rigorous forward and backward translation procedures. ²³ The translated codes from all participating countries and regions were subsequently pooled into a single dataset and collaboratively examined by the international research team to identify overarching themes that reflected shared patterns of meaning across the entire dataset, rather than country- or region-specific differences. The analysis was conducted manually throughout.

Themes were iteratively reviewed, refined, and labelled during international research meetings involving all partners in the DELIVER research team until consensus was reached on the final thematic structure. To anonymise the quotes, a format was used that included FG (focus group) or I (interview) followed by the country/region in which the focus group took place. An example of the coding tree is provided in Supplemental Table 3.

Research team, reflexivity and rigour

Focus groups and individual interviews were facilitated by designated team members from each partner institution, all of whom are members of the DELIVER project consortium. The research team comprised both female and male researchers with prior experience in research methods and qualifications ranging from master’s to doctoral level. All team members were healthcare researchers or practitioners with established expertise in digital health and healthcare management research or implementation. Data collection was carried out by team members in their respective countries/regions, in the local language. No personal relationship existed between the researchers and participants before the study began. To minimise researchers’ influence and ensure consistency across sites, all team members followed a pre-established shared interview guide. Potential biases related to professional background or institutional affiliation were acknowledged and discussed within each national team throughout data collection and analysis. Regarding the participants, none of the professionals invited to take part in the study declined to participate. While this may suggest a potential selection bias, as those who agreed may have been more digitally engaged, we have acknowledged and discussed this limitation in the transnational meetings, particularly with respect to the transferability of the findings. Moreover, no repeated interviews or focus groups were conducted. Field notes were not collected or analysed, and neither member checking nor the return of transcripts, narratives, or codes to participants for validation was performed.

To ensure rigour in the research process, ²⁴ facilitators followed a shared research protocol and could consult other researchers within the transnational team at any time. Trustworthiness was further supported by independent double-coding of transcripts by two researchers per partner institution, with discrepancies resolved by consensus, and by multiple transnational team meetings at which emerging themes were systematically discussed and cross-checked across all four sites. Furthermore, the theories used to develop the project,^11–13 together with the predefined interview questions (which are described in detail in Supplemental Table 2), served as a guide to facilitate data collection rather than constrain the analysis. The theoretical framework was applied as an analytical lens only at a later stage, primarily during the interpretation of the findings in the Discussion, thereby allowing the inductive thematic analysis to proceed without being driven by predefined theoretical constructs.

Ethical issues

Ethical approval was obtained from the Institutional Review Board of the Department of Medicine, University of Udine, Italy (approval number: 085/2021; date: 22/11/2021). Before each session, all participants received written information about the aims and procedures of the study. Written informed consent was obtained from all participants before data collection began.

Findings

Four distinct themes have emerged: “Organisational Readiness for Digitalisation: Between Potential and Persistent Gaps”, “Convincing Design: Intuitive Technologies for Sustainable Change”, “Barriers to Change: Structural, Cultural, and Professional Obstacles”, and “The Drivers of Transformation: Technological and Organisational Levers for Progress”.

Organisational readiness for digitalisation: Between potential and persistent gaps

Participants highlighted organisational readiness as closely linked to the availability of adequate infrastructure, support, and training opportunities. However, the development and availability of these elements varied considerably across countries/regions.

Healthcare facilities were generally described as well-equipped in Catalonia and Denmark. By contrast, participants from Slovenia and Italy reported challenges related to inadequate technological infrastructure, including a lack of appropriate equipment to support digital solutions and the procurement of insufficient or outdated computers due to budget constraints. As one Italian participant explained, “So instead of having the latest generation, we stop at the generation a little earlier because it allows us to have two more machines than the latest technology” (FG, Italy). Budget limitations were perceived as directly affecting technological investments: “We always have that problem of the budget not being exceeded, and so in order to give more potential, a wider spectrum, we limit ourselves on technology” (FG, Italy).

Even where digital equipment was available, participants reported uneven distribution across healthcare settings. Private and newly established public facilities were often perceived as better equipped, whereas older hospitals were described as relying on obsolete technologies. As one participant noted, “In the hospital I work for, the technology is absolutely obsolete for most of the PCs” (FG, Italy). Furthermore, available technology was not always aligned with clinicians’ needs, both in terms of functionality and quantity. Participants reported that “the hospital’s PCs are absolutely inconsistent with the needs of colleagues […] if you are a nurse and maybe you want to do some research you do not have a computer at all” (FG, Italy), while another stated that “we have two computers at our disposal […] the one we have in clinic is used by five people and we have to input all the services we provide every day” (FG, Slovenia).

Organisational support and training emerged as equally important components of readiness, particularly during the implementation and follow-up phases. In Denmark, participants described how insufficient organisational support undermined the sustainability of digital innovations: “there are often problems in the implementation of new solutions. For example, this video system. We were told to use it. And then there was a long period when we had to find out how to use it, where to use it, and who was in charge. And then it fell to the ground because there was no one to keep it alive” (I, Denmark).

Despite these challenges, participants described digitalisation and paperless work as strategic organisational priorities. For example, one Slovenian focus group reported that “I can easily say that digitisation as such and investing in IT support is a high priority for us” (FG, Slovenia). Similarly, Italian participants highlighted the need to reduce reliance on parallel systems, noting that “We need to overcome the dualisms between digital and paper, digital and analogue” (FG, Italy).

Training deficiencies were particularly evident in Italy and Slovenia. Participants reported that new digital programmes were often introduced through a top-down approach without sufficient preparation of end users. Although training was generally provided at the time of implementation, it was not always extended to newly recruited staff. As one participant explained, “every time a new platform or solution was deployed, existing employees were trained. As for those who joined later, it was like this: we were actually the ones who trained everyone else … those who used these applications were basically in charge of passing on this knowledge to those who came later” (FG, Slovenia). Training activities were also perceived as lacking structure and continuity. Participants reported that “however, it was not structured or systematic training. That is what is missing in my experience” (FG, Italy) and that “where I worked, this was left to the person in charge of you, like some kind of mentor” (FG, Slovenia).

Overall, the findings suggest that organisational readiness for digitalisation is shaped by the interplay of infrastructural capacity, managerial support, and continuous training opportunities. Although digital transformation is widely recognized as a strategic priority across healthcare systems, persistent disparities in resources and implementation support continue to affect professionals’ readiness to engage with digital innovations.

Convincing design: Intuitive technologies for sustainable change

First, participants described the characteristics that digital solutions should have to support organisational readiness. These included intuitive and accessible systems, alignment with clinical reasoning, and training approaches based more on mentoring, practical support, and short videos than on manuals. One Italian focus group reported: “Intuitive, that is why I said accessible. While our work applications are complex, we ask for support for that” (FG in Italy).

Another issue concerned collaboration with external software providers. Although HCPs could participate in software development, later modifications were described as slow and costly because software developers were external to the healthcare organisation. As reported in Slovenia: “The employer is already in favour of change. But most of the time the problem is the software itself… it is the software developer’s responsibility. And that is a significant expense. So, ideas for improvements come up all the time, but usually the answer is that the change is too big and would require changing the entire software product, which is not done by our institution but by the software developer responsible for the institution. Then these things we want to do sometimes take a year. In the meantime, something else comes up or the thing itself already becomes obsolete” (FG in Slovenia), and “That was not the problem, we have always cooperated and also put in our requirements, but then over the years things are added, things change and then the problem is this change in the system” (FG in Slovenia).

Barriers to change: Structural, cultural, and professional obstacles

The barriers most consistently reported by participants emerged at different levels: patient/citizen, professional, organisational, and those linked to the implementation process.

At the patient level, participants described a lack of digital skills and technological understanding as important obstacles, especially in primary care: “one thing is the patients, who are not ready and … and if they do not know how to use it, then you must offer them an alternative, right?” (FG in Slovenia) and “if you say to the citizen, go up in the browser, copy and paste it here. They have no idea what the browser is. It is a huge problem.” (I in Denmark).

At the professional level, barriers included insufficient digital competences, heterogeneous motivation, and resistance to changing established ways of working. This emerged in relation to both skills and attitudes: “ignorance, insufficient knowledge, so that training would certainly be necessary; then there is also personal resistance of employees before any innovation is introduced” (FG in Slovenia). Italian participants also linked this issue to workforce instability, reporting that “there is a huge turnover of the staff in the last two years due to the pandemic and this has threatened our competencies” (FG in Italy). Resistance was not limited to older professionals. As reported in Catalonia, “even in the youngest professionals you can find resistance to change because they adapt quickly to the way we traditionally work” (FG in Catalonia). In Denmark it was noted: “even if I am told I have to, I will not do it if I find it difficult. ” (Iin Denmark). In Slovenia, participants also highlighted age and heterogeneity in baseline knowledge as relevant barriers: “at least two thirds of our staff are old, maybe five or ten years before retirement, and it is going to be very, very difficult to make the turn towards full digitisation. They will not do it.” (FG in Slovenia) and “in a larger institution, there is the issue that employees start with different levels of knowledge. People have different motivations, different views, depending on how much we need it; some people say we do not need it, others think that… you have to take that into account. This creates new obstacles, which is where I see a big obstacle to this introduction” (FG in Slovenia).

At the organisational level, participants described barriers related to planning, prioritization, resource allocation, leadership, and implementation processes. Some participants perceived the digitalisation process as insufficiently planned: “the transition to digital technology was left somewhat to chance and therefore perhaps not included in programmes, training and organisational plans” (FG in Italy). The need for better coordination across organisations also emerged: “we need to find a common language between the organisations to ensure a homogeneous and effective management of data and processes” (FG in Catalonia) and “communication should be prioritized so that digitisation, this thing that brings so many issues and so many challenges in daily work, is put on the list of priorities and we start talking” (FG in Slovenia). Financial and resource constraints were reported as additional barriers. Participants described both limited resources and a lack of adequate needs assessment in allocating them: “I believe that one obstacle may be the unreasoned availability of resources, i.e., the fact of distributing resources, making them available without adequate reasoning behind it, without a real assessment of needs” (FG in Italy) and “as for the high costs, if something has to be implemented for the very first time, it is a significant financial burden” (FG in Slovenia). Leadership was described as a crucial condition for readiness. Where leadership was not fully supportive or was disengaged, digital transformation was perceived as more difficult: “Senior leadership does not accept digitisation” (FG in Slovenia). Another participant added: “I am sure it is just about the lack of interest of management so we do not have it; nobody is pushing it forward… ” (FG in Slovenia).

Participants also highlighted several barriers specifically related to implementation. These included introducing systems in a top-down manner without involving staff, failing to assign clear responsibility for implementation, insufficient time for learning and training, and poor alignment between systems and workflows. In Denmark, it was remarked: “Someone has to take responsibility for making the system fit in order to make it useful and valuable. That is probably the most important thing. And then it should be easy and not make everyday life more cumbersome.” (I in Denmark). In Italy, haste was highlighted as a problem: “Thinking a little about barriers and also listening to colleagues, it comes to mind that one of the first barriers could be haste. In the sense that the idea of wanting immediate results could also be a problem for technology. In my opinion, for technology to be effective and give rapid results in its use, it requires observation time, and I would somehow put training among the barriers.” (FG in Italy). In addition: “If a system does not fit in with the workflows and procedures where it is to be used and thereby makes things more complicated and does not create any value, this reinforces the employees’ anxiety about a new system.” (FG in Italy).

Participants also described important limitations in organisational readiness, raising concerns about confidentiality, privacy, and cyber-security. In particular, “Some professionals are in fear of cyber-attacks and data privacy issues.” (FG in Italy). In Slovenia, participants also described inconsistent uptake of digital solutions after implementation (e.g., “It often happens that only a part of people is diligently on it, while others do not.”; FG in Slovenia).

The drivers of transformation: Technological and organisational levers for progress

Participants identified both technological and organisational enablers of digital readiness for transformation. Technological enablers included rapid solutions for specific procedures, portable devices for bedside use, intuitive interfaces, and secure wireless systems. A Slovenian participant stated: “I would have liked to see us introduce tablets so that we could go from room to room and enter all the activities on the fly.” (FG in Slovenia). Italian and Catalan participants also emphasised usability and practicality: “as a facilitating factor, technology, especially touchless technology. Think how our hospitals have changed with touchless badges” (FG in Italy) and “Sometimes, I find that there is a lot of dedication in the backend development in a project, while in the end, the key is to develop an easy-to-use, comfortable, practical and useful tool” (FG in Catalonia). At the same time, participants underlined that readiness also requires awareness of the limitations and possible negative implications of digital systems: “we need to know also the limitations of such systems and their negative implications, such as being always connected” (FG in Italy).

Organisational enablers included a system-level approach, leadership, IT support, staff involvement, and tailored training. Participants described the need to align local, regional, and national levels of action, as summarised: “…one digital approach exploded at all levels, local, regional, national… ” (FG in Italy). Leadership and access to digital expertise were also seen as central: “this is possible with good leadership, which addresses the fears and reluctance to change among professionals. […] In addition to leadership, we need sufficient budget and professionals who are experts in digital transformation” (FG in Catalonia).

Involving staff from different levels of care and professional groups was described as another enabling condition: “mutual cooperation, so that each level of healthcare has the opportunity to contribute ideas, needs and solutions, because it is also our task to make suggestions. It is not as though others can do everything instead of us.” (FG in Slovenia). Participants also highlighted the importance of having dedicated support staff and available ICT personnel: “the fact of having the support of someone who can help you when you are in difficulty is definitely a facilitating factor because it allows you to move forward and enhances the tool you are using” (FG in Italy).

Training was perceived as more effective when adapted to different learning needs and delivered with sufficient time. In Denmark, it emerged that: “some need to have solutions demonstrated. Some need to see it on screen. There is such a big difference in how people learn. One has to give different choices for learning.” (I in Denmark). Participants also stressed that explaining the benefits of digitalisation could reduce opposition and facilitate uptake: “even the presentation of digitisation… it seems to me that when we hear digitisation, we think it will be more work and more problems, and maybe many people are afraid of one of these things and are against it on an a priori basis. Although once you explain it to them, once you show them the benefits, tell them how it is going to work, everyone accepts in the end and we learn these things.” (FG in Slovenia). Additional facilitating factors included access to tools in the native language for foreign professionals: “the option to use the tool in the native language [for foreign health care professionals] ” (FG in Italy).

Finally, organisational culture was identified as an important element of readiness. Participants suggested that peer norms could either support or undermine implementation. In Denmark, it was noted: “if others say ‘I do not usually do that. I do not use it, so you do not have to either’, new technology will never be implemented.” (I in Denmark).

In conclusion, the overall organisational attitude towards digitalisation was perceived as positive, particularly in light of the impetus provided by the COVID-19 pandemic. The perception was that digitalisation “was not seriously addressed until the beginning of the pandemic, which forced many organisations to digitise in record time” (FG in Catalonia).

Discussion

This study explored the perceived organisational readiness for digital transformation among HCPs and HCMs in four European countries/regions. Four interconnected themes emerged summarised as: (a) organisational readiness for digitalisation, (b) convincing design, (c) barriers to change, and (d) the drivers of transformation. Overall, our findings indicate that organisational readiness is not a “binary state” (ready or not ready), but rather a multifaceted, dynamic condition shaped by a complex interplay of organisational and technological factors. Findings may be interpreted also through the lens of Weiner and colleagues, ¹¹ who defined readiness as a shared psychological state in which members demonstrate both commitments to implement change and confidence in their collective ability to do so. Our results suggest that neither dimension alone is sufficient to sustain digital transformation. Commitment, expressed as positive attitudes and declared organisational priority, was widespread across all four countries/regions, yet it often remained disconnected from the structural conditions necessary to act, such as adequate infrastructure, resources, and training.

First, two novel findings emerged within the overarching descriptive theme of readiness: (a) the presence of an intra-organisational digital divide and (b) the use of “cascade training” as an informal workaround to address digital competence gaps. The infrastructure disparities identified in our study are consistent with previous literature indicating that technological limitations remain a persistent barrier to healthcare digitalisation.^25–28 However, our findings extend current knowledge by highlighting an important local-level dimension of these inequalities. While prior studies have mainly described disparities between countries or healthcare systems,^2,26 participants in our study reported substantial differences within the same institution, where access to digital equipment varied across wards, units, and professional groups. This organisational manifestation of the digital divide where, for example, a healthcare professional in one ward may have limited or no access to a computer while colleagues in another department are adequately equipped – is less visible in macro-level analyses. Our findings therefore suggest that infrastructure planning should address not only system-level resource allocation but also the equitable distribution of digital resources within healthcare organisations. Moreover, while most participants reported a generally positive attitude towards digitalisation, consistent with studies linking workplace attitudes to digital health readiness, ²⁹ our data highlighted an important point: positive attitudes at the management level did not necessarily translate into operational commitment. Participants specifically described a pattern in which leadership expressed verbal endorsement of digital transformation without allocating supporting measures, such as sufficient resources, clear designation of responsibilities, or structured follow-through. This distinction between declarative and substantive commitment extends the findings of Steenkamp and colleagues ³⁰ and Bayat and colleagues, ³¹ suggesting that attitude measures alone may overestimate organisational readiness if not accompanied by analysis of resource mobilisation, also potentially affecting the digital divide.

Unaddressed training needs emerged as one of the most consistently reported barriers. However, our data revealed underlying coping strategies implemented as adaptation strategies at the micro level: in the absence of a structured digital technology training programme for newly hired HCPs, these staff were informally trained in the use of technologies by colleagues who had participated in the original deployment phase. This type of “cascade training” represents an organisational workaround that, while functional in the short term, introduces heterogeneity in knowledge transfer, perpetuates potentially unaddressed gaps, and places an unrecognised additional burden on experienced staff. This extends the analysis of Mabaso and colleagues ³² and Leone and colleagues, ³³ who identified training insufficiency as a barrier, by specifying the informal structural mechanism through which the gap reproduces itself over time.

The need for a “convincing design” in digital technologies emerges as a distinct and underappreciated dimension of organisational readiness. Participants across countries and regions described intuitive, workflow-aligned technology not merely as a facilitator, but as a precondition for adoption. Even in contexts where leadership was supportive and infrastructure adequate, poorly designed tools were reported to undermine implementation and reinforce staff anxiety. These findings add to the work of Patel and colleagues ³⁴ and Heijsters and colleagues, ³⁵ who identified user-friendly applications as facilitators, by shifting the conceptual framing from a positive asset to a necessary condition. Our data further suggest that the burden of software inflexibility – that is, the difficulties in making changes to the software to adapt it to the needs of HCPs after implementation – illustrated by Slovenian participants’ accounts of change requests taking up to a year with external vendors, creates a structural misalignment between clinical needs and technological adaptation. This dynamic has implications for digital procurement policies and supports greater involvement of frontline HCPs in co-design processes from the earliest stages of development. ³⁶

Resistance to change was identified as a barrier at multiple organisational levels, from individual HCPs to management structures, confirming previous evidence.^26,29,35 However, while Slovenian participants described older staff approaching retirement as presenting particular challenges to digital adoption, consistent with Steenkamp and colleagues’ ³⁰ finding of lower readiness in those aged 50 or over, Catalan participants explicitly reported resistance even among younger professionals, attributing this to habituation to traditional working patterns. These findings suggest that age may influence readiness, but factors such as professional socialisation and workflow inertia, rather than generational digital competence per se, may be the more relevant underlying constructs.

At the organisational level, the finding that digitalisation was also characterised by top-down implementation without clear responsibility points to planning deficits that implementation science has long associated with poor sustainability of innovation.^31,37 Privacy and cybersecurity concerns, reported across all four countries/region, added a further layer of ambivalence: even HCPs who were otherwise motivated expressed hesitation linked to uncertainty about data safety. Other studies have also reported that these concerns significantly impact the acceptance of technology, leading to hesitation and reluctance in adopting it,^38–41 suggesting that trust-building and clear communication about data governance are necessary preconditions for readiness.

Participants identified technological and organisational enablers, suggesting that readiness is built not through single interventions but through the simultaneous alignment of multiple conditions. At the technological level, portable, point-of-care solutions (such as tablets and “touchless” interfaces) were consistently valued. This reinforces the earlier argument that intuitive, workflow-integrated design is a precondition for adoption rather than merely a facilitating factor.^34,35 At the organisational level, three enablers emerged as particularly relevant: (a) leadership commitment translated into concrete actions (designating responsibilities, allocating resources, managing resistance)^10,31; (b) HCP involvement in co-design to ensure tools reflect actual clinical reasoning and workflows^35,36; and (c) multi-tiered alignment of digital strategy across local, regional, and national levels. ³⁶ Finally, peer culture emerged as a bidirectional force: where early adopters modelled positive use, uptake was facilitated, while where scepticism was normalised, it spread collectively. This finding further underscores the role of informal social norms in shaping collective readiness. ⁴²

A digitally ready healthcare system also requires readiness among patients. The digital divide may occur not only vertically across macro- and micro-levels of healthcare systems or between professional groups, but also between healthcare professionals and patients. Such disparities may create asymmetries in access, skills, and engagement with digital technologies, potentially limiting the positive impact expected from ongoing digital transformations [e.g., 43]. Therefore, efforts to enhance digital readiness should extend beyond organisational infrastructure and workforce competencies to include strategies that support patients’ digital inclusion and participation.

Limitations

The study has several limitations. First, we examined readiness among healthcare professionals and managers. Including additional stakeholders, such as policymakers and patients who use healthcare services, may provide a more comprehensive understanding of readiness for digital transformation. Each partner country/region was responsible for identifying the professionals to be involved as key informants, based on their knowledge of and engagement in the digitalisation process. As reflected in the findings, the professional composition of the sample varied across countries/regions, as did its size, with saturation reached early in some and requiring more professionals in others. While the different numbers of participants needed to achieve saturation may reflect familiarity with the issues under investigation, the composition of the participants in terms of professional profile and position may have influenced the findings by shaping the range of views represented in each country/region. It may also reflect differences in how digitalisation processes are organised across contexts, with some countries/regions involving more homogeneous professional groups and others engaging a broader range of professionals. Moreover, limited data were collected about respondents’ demographics, preventing their analytical use to ensure anonymity. Transcripts from each partner site reflected only one characteristic of the respondent: HCM or HCP.

Second, data collection occurred at the end of 2022, during and immediately after the COVID-19 pandemic, a period that significantly affected healthcare delivery and accelerated digitalisation. This offered a unique opportunity to explore readiness during a time of intense organisational transformation. While the pandemic may have influenced participants’ perceptions of readiness, several readiness dimensions seem to reflect underlying individual and organisational characteristics that may persist beyond the emergency context. Therefore, the findings offer valuable insights into the readiness of healthcare institutions for digital health implementation, although caution is needed when applying them to non-emergency or current settings, as changes in policies, infrastructure and digital competencies may have occurred since data collection.

Third, methodologically, no member checking, by validating the themes with participants, was performed due to the international nature of the study, which made it challenging to re-engage participants consistently across all participating sites. This limitation was considered acceptable given the rigorous procedures adopted during data collection, coding and team-based analysis. In addition, the themes were generated through a pooled multinational analysis, with some themes being primarily informed by data from only a subset of the participating countries/regions. Future research could adopt cross-country comparative analyses to examine how the identified themes converge or differ across countries.

Conclusions

This study examined how healthcare professionals and their managers perceive organisational readiness for digital transformation across four European countries/regions. The findings show that readiness is shaped by the interaction of technological, organisational, and professional factors, rather than technology alone.

Participants reported significant variability in digital infrastructure. Organisational conditions also played a central role: limited planning, inconsistent support, reliance on mixed paper and digital systems, and lack of structured training represented barriers. Training was also confined to initial implementation phases, leaving newly recruited staff inadequately prepared. Barriers arose at multiple levels, including resistance to change, varying digital competences, workload pressures, and patient-related challenges such as low digital literacy. Privacy and cybersecurity concerns further contributed to uncertainty. Despite these challenges, several enablers were identified: intuitive technologies, portable devices, strong leadership, accessible ICT support, staff involvement, and tailored training approaches. Participants also noted that the COVID-19 pandemic accelerated awareness and uptake of digital solutions.

Strengthening digital readiness requires coordinated investment in infrastructure, continuous training, supportive leadership, and participatory implementation strategies to ensure sustainable digital transformation. At the policy level, structural funds and digital health programmes should prioritise investments that reduce infrastructural disparities across regions, ensuring equitable access to adequate connectivity and cybersecurity capacity. At national and regional levels, health system leaders should develop coordinated digital strategies that include structured and continuous training programmes and integration of intuitive technologies aligned with clinical workflows. At the local level, strong organisational support through leadership engagement is also recommended. Finally, future research should address current gaps through longitudinal and intervention studies capable of examining how digital readiness evolves over time, how specific organisational actions influence adoption, and how crisis versus non-crisis conditions shape digital transformation processes.

ORCID iDs

Mirna Macur https://orcid.org/0009-0003-7631-3038

Alvisa Palese https://orcid.org/0000-0002-3508-844X

Ethical considerations

Ethical approval was obtained by the Institutional Review Board of the Department of Medicine, University of Udine, Italy (approval number: 085/2021; date: 22/11/2021).

Consent to participate

Written informed consent from healthcare professionals and healthcare managers to participate in interviews or focus groups was obtained from all participants. The consent forms were collected and archived by each participating country or regional partner.