Nurses’ perception towards care robots and their work experience with socially assistive technology during COVID-19: A qualitative study

Abstract

This study aimed to explore nurses’ perceptions towards care robots and their work experiences in caring for older adults who use socially assistive technology. This qualitative descriptive study included 18 nurses who cared for older adults with dementia or living alone at home. Interviews via Zoom were conducted, and the collected data were analyzed using inductive content analysis. The three themes were identified: (1) perceived benefits, (2) perceived challenges, and (3) improvements needed to enhance the quality of care. The participants perceived that the care robot and socially assistive technology were useful in caring for older adults during COVID-19. However, they noted that the limited capabilities of the technology and an increased workload negatively impacted the quality of care for older adults. The findings of this study indicated that socially assistive technology and care robots have potential benefits in assisting older adults with dementia or living alone.

Introduction

The global population is progressively aging. The proportion of older adults is expected to increase from 10% in 2022 to 16% in 2050.¹ Socially assistive technology is an effective tool for promoting social support and health among older adults.^{2 , 3} As the older adult population increases, socially assistive technology, including socially assistive robots or care robots, are becoming popular. Socially assistive technology and care robots are available in many shapes and forms, including animal-like, humanoid, and others. Within nursing care, care robots (such as the dog-shaped Aibo, seal-shaped Paro, and humanoid Pepper) have been used worldwide in homes and care facilities for older adults.^{4 , 5} Care robots provide support for daily tasks and can function as companions for the older adults.^{4 , 6} Furthermore, voice-activated speakers are becoming increasingly popular. Internationally, Alexa, Siri, and Google Assistant are among the most well-known smart speakers. A smart speaker is a voice command device that can provide information and entertainment.⁷ In Korea, artificial intelligence-based services such as Aria (a voice command smart speaker) and Care Call are used. Silbot (a humanoid robot used for group-based cognitive training activities that is capable of making facial expressions and dancing by moving its arms) and Hyodol (a doll-shaped care robot that speaks in Korean) are available.⁸

During the coronavirus disease (COVID-19) pandemic, social interactions among older adults decreased, which negatively affected their quality of life and increased their risk of developing depression.⁹ In fact, a recent meta-analysis revealed that the risk of dementia in older adults increases with prolonged loneliness and social isolation.¹⁰ Its findings highlighted the importance of continuing care for older adults who are at risk of social isolation while minimizing cross-infection. Accordingly, some community health centers in Korea implemented free socially assistive technology services for older adults with dementia and who live alone.

A recent scoping review on the use of socially assistive robots revealed that most of the 33 studies included were conducted in nursing home settings, and Paro was the most popular choice.⁴ Studies on older adults have revealed positive effects of Paro on their cognition, depression, emotions, and quality of life.11, 12, 13 Moreover, a Belgian study conducted during the COVID-19 pandemic revealed that socially assistive robots positively improved loneliness and social isolation in older adults.¹⁴ However, the caregivers’ perception of and attitude towards social or care robots are not entirely positive. For instance, one study revealed that caregivers had both positive (e.g., promotion of activities and interactions) and negative (e.g., increased workload) perceptions on the use of Zora (a care robot).¹⁵ Similarly, a scoping review of 19 studies revealed that healthcare workers (nurses and other health and social care workers) had mixed views on the use of socially assistive robots (humanoid and animal-like robots) and were concerned about patient safety and privacy.¹⁶ Furthermore, as the severity of COVID-19 increased, the usage of non-contact services with assistive technology increased.¹⁷ Therefore, life events (such as the COVID-19 pandemic) may positively influence nurses’ perception of the use of socially assistive technology in the care of older adults.

Previous studies that explored the experience of home care nurses in Spain¹⁸ and Norway¹⁹ during the COVID-19 pandemic revealed that these nurses felt valued and feared infecting others. However, studies on nurses who used socially assistive technology in the care of older adults during the pandemic are scarce. In home care settings, nurses would face multiple issues with the sudden introduction of socially assistive technology. The unexpected COVID-19 pandemic left little time to prepare for the care of older adults remotely, and gaps regarding the caregivers’ work experiece with socially assistive technology remain. Additionally, understanding the nurses’ experience during the COVID-19 pandemic is essential to improving the quality of care and advancing the nursing profession. Thus, this study aimed to understand the nurses’ perception of care robots and their work experience with socially assistive technology during the COVID-19 pandemic. We believe that our findings will add to the growing body of evidence in support of adopting socially assistive technology into nursing care to enhance the quality of care for older adults.

Methods

Design

This was a qualitative descriptive study. The qualitative descriptive approach provided a greater insight²⁰ into the participants’ perceptions of care robots and their work experience with socially assistive technology during the COVID-19 pandemic.

Sample

The participants were 18 nurses who worked with older adults. They were recruited through postings on an online community website (https://www.dreamnurse.co.kr/) and by contacting the eligible community health centers. The inclusion criteria were as follows: (1) Nurses working with older adults in the community health settings during the COVID-19 pandemic and (2) Nurses who had a direct and indirect experience with care robots or socially assistive technology. Nurses with less than one year of work experience caring for older adults were excluded. The participants’ age ranged from 25 to 59 years (42.8±12.20 years). The average work experience was 13.4±9.31 years. All except one participant was female. Most participants (n =17) have direct experience with one of socially assistive technology or care robots included in this study. Most (88.8%) were working in the Dementia Centers within the community health centers.

Data collection

This study was approved by the institutional review board (IRB 1041078-202203-HR-062, May 3, 2022) at the first author's university. The study was conducted in conformance with the principles of the Declaration of Helsinki. Participants were informed about the study's aim, and were assured of anonymity and confidentiality. All participants voluntarily provided written informed consent.

Focus groups and individual interviews were conducted via Zoom, a video conferencing platform. An individual interview was conducted when a participant cannot attend a focus group. Data were collected until saturation between May 31 and August 23, 2022. Two researchers with experience in qualitative research conducted the 11 interviews (seven focus group interviews and four individual in-depth interviews). One researcher conducted all interviews as the moderator, whereas the other assisted and took notes during the interviews. Each interview was recorded with the participant's permission and lasted approximately 60 to 120 minutes.

A semi-structured interview guide was used. Following an opening question (“What comes to mind when you think of a care robot?”), the participants were asked the key questions: (1) “How do you feel about care robots?”, (2) “Tell me about your experience with care robots or socially assistive technology?”, (3) “What were the benefits and challenges?”, and (4) “What do you think are needed to improve the quality of care?” Probing questions used to gain clarification included, “Would you elaborate a little more?” At the end of the interview, each participant was asked, “Is there anything else you would like to add?”

Data analysis

The data were analyzed using inductive content analysis.²¹ This method involves the preparing, organizing, and resulting phases. During the preparation phase, the units of analysis were selected. The researchers transcribed the interviews verbatim and checked for accuracy. In the organization phase, open coding was performed using the NVivo 12 Plus software. Coded data were grouped and categorized based on similarities, and differences and the overarching themes were derived from the data through abstraction (Table 1 ). In the last phase, we reported the study's findings with quotations from the participants. To ensure the study's rigor,²² credibility was ensured by the member checking method and by taking field notes during the interviews. The transferability was established by providing a detailed description of the research process. For dependability and confirmability, we developed an audit trail of the research process and checked the consistency of the findings. Furthermore, two researchers cross-checked the findings against the participants’ responses to establish confirmability.

Table 1.

The main themes and sub-themes identified from the interviews.

Themes	Categories	Quotations
Perceived benefits	1. Embracing technology for non-contact care	“During COVID-19, Aria played a big role in emotionally supporting older adults. It is convenient to be able to monitor the client's activities and manage them over the phone without the need for physical contact.”
	2. Useful for caring and promoting well-being	“Older adults with dementia need to take dementia medications. We tell them to take medicine regularly over the phone, but it is not easy to remind them every day. When the care robot is used to tell the older adult when to take medicine every morning and evening, the older adult's awareness of taking medicine is increased by repeatedly listening to the care robot.”
		“Silbot has advantages in that it could increase class interest by talking and moving. The older adults can play games with the care robot, which may improve cognition and socialization.”
Perceived challenges	1. Limited capabilities of the technology	“When (I) first heard of Silbot, I thought that a robot could run all programs by itself. However, the Silbot seems to be used only as a tool led by the program's operator.”
		“They (older adults) keep forgetting to recharge it. When they said it (care robot) was not working or talking, most of the time, it was because they did not recharge it, or it was turned off, or the volume was very low, or they were trying to plug the charger into the wrong port, or not using the specific robot cable that fits.”
	2. Dealing with an increased workload	“The tasks include receiving the device when someone returns it, replacing it with another when the device breaks down, teaching and answering questions, reconnecting it again when Bluetooth is not working, and so on. They quit because there is too much work involved. When contingent staff constantly changes, and we must continuously train new ones.”
		“Because it is costly, I have to keep the robot well and check it, so it does not break down. Furthermore, I have to be aware of what types of programs are available, how each program operates, and how long it runs for.”
Improvements needed to enhance the quality of care	1. Needs for technical improvement	“Many things (functions) have to go through multiple paths (steps).
		Educating older adults on the route for each function is not easy.
		For example, if (someone) presses and holds number 1 or 2 on the cell phone, it automatically connects to your child's cell phone.
		Like that, it must be simple and easy to operate.”
	2. Strengthening the support system	“I need to improve my ability to handle Silbot, and to make the program more attractive. (Older adults) say it is hard when a program includes too many physical (doing) activities. They also complain that their head hurts when too much focus is required for cognitive (thinking) activities. So, I want to learn how to balance these two aspects.”
		“These services are free (to selected people) because we are paying for them. By increasing government support to lowering the burden, when a household with older adults (with dementia) apply for a service directly (not through a public center), this (care robot) will be more widely used.”

Results

The main themes were (1) perceived benefits, (2) perceived challenges, and (3) improvements needed to enhance the quality of care (Table 1).

Theme 1: perceived benefits

Embracing technology for non-contact care

Participants perceived non-contact care as an alternative way of continuing care during COVID-19 and that adopting technology in the workplace was inevitable. The types of socially assistive technology that the participants experienced varied, although all were AI-based technologies. The socially assistive technologies used by the participants included a humanoid robot (Silbot), a doll-shaped care robot (Hyodol), a cylindrical-shaped smart speaker (Aria), and a weekly interactive Care call service (Supplement 1). Participants reported that Silbot use was implemented before the outbreak of COVID-19; however, the other care services were adopted during COVID-19 due to the increasing trends of lonely death and worsening depression with social isolation among older adults. Participants noted the possibility of real-time monitoring as an advantage of using a care robot system.

Useful for caring and promoting well-being

Participants perceived that socially assistive technology and care robots are beneficial in promoting the well-being of older adults living alone and those with dementia. Particularly, they reported that older adults may feel more emotionally secure with a care robot (Hyodol) because it could be touched and held. Hyodol also verbalized words, such as “grandma” or “grandpa”, when its head or back is stroked. They stated that older adults enjoyed having Hyodol around because it induces the feeling of living with someone.

“I can tell the older adult liked the care robot by their tone of voice over the phone when I called and with the way they smiled while talking about Hyodol when I visited. Depression or isolation due to COVID-19 seems to have improved with Hyodol.”

Participants noted that older adults often forget their medication times. Thus, setting a reminder alarm was helpful. One participant explained that a humanoid robot, Silbot, has facial expressions and can dance and sing, and carry out different activities, such as puzzle matching and coloring in. She stated that when an operator presses a button to respond, such as “good job,” people were amazed by the responses.

Theme 2: perceived challenges

Limited capabilities of the technology

Participants perceived that socially assistive technology and care robots “cannot converse like humans” and are still lacking many capabilities to varying degrees, depending on the types of socially assistive technology. They stated that people may experience communication difficulties and frustration due to the limitations, such as speaking unilaterally without interacting, interacting but not sophisticated, and poor voice recognition. Moreover, a participant who operates Silbot said, “The program has many built-in features, but one major disadvantage is that an operator must lead and press the button for the Silbot to respond to people's activities.”

Participants opined that older adults tend to speak slowly and not as clearly. Thus, conversations were frequently interrupted because of the AI's poor voice recognition of people with dementia. Moreover, the participants reported that some people were annoyed with the mechanical sounds produced by the AI-based device and that some people had difficulties with charging the battery.

“Sometimes, the AI would ask another question if they (older adults) did not answer promptly or were still thinking about the answer. As a result, some said they felt disconnected and slightly offended because the conversation (dialogue) did not occur naturally.”

Participants pointed out that some people liked the care robot initially because it was like a talking doll. People were curious. However, some disliked the care robot because they were startled by the sudden sound of a doll calling them grandma or grandpa, scared of the doll speaking alone, fearful of being watched, or frustrated that the robot did not answer their questions.

Dealing with an increased workload

Participants perceived an increased workload when working with care robots. Participants said, “Even now, the workload is heavy” (due to COVID-19). A participant responsible for the care robot and other tasks said that if she makes a home visit for work related to a care robot, other tasks may be delayed. Regarding the use of care robots and smart speakers, participants said their main tasks were to explain how to use the device to users and their families, set up the device, monitor usage, and evaluate users’ satisfaction. Furthermore, participants said that they evaluated users’ cognitive level and depression before and after the use of the care robot and periodically evaluated any changes in their conditions. The participants emphasized that these tasks require more staffing and effort. Additionally, they stated that they had called or visited older adults to check their conditions and situations, when the care robot was not working, and when there was a sudden change, such as too little or too much use compared to the previous month. Moreover, participants said that when they received a “contact request” message from a care robot user, they would call the user. Many times, the “contact request” button was pressed accidentally (unintentionally). Participants were concerned about easily contaminated components, such as the hands and the clothing of a care robot.

“First, (I) turn on a cell phone and look at the app to check whether these (robots) are on and whether there are any contact request messages. Then (I) go to the homepage for Hyodol that shows statistical data about how much this person has been using the device.”

Theme 3: improvements needed to enhance the quality of care

Needs for technical improvement

Participants responded that the care robots should be easy to use, able to talk interactively to some extent, and have a screen that can draw older adults’ interest, but not complicated like a TV, and should be turned on automatically, able to respond slowly or quickly when conversating with older adults, and possess a voice recognition function. Furthermore, they expected a long-lasting battery life because the users tend to forget to recharge electronic items. For Silbot, participants hoped that the robot takes the lead when running the program rather than necessitating an operator to respond by pressing a button to say words. For the AI speaker, the participants suggested the inclusion of a more intimate expression and text, such as “It is time to take medicine,” by adding a screen. They stated that the care robot mostly talks unilaterally, and that the capability to talk interactively and provide a wider selection of songs would be useful. Furthermore, improving the contact message function was deemed desirable.

In addition, participants expressed that it would be helpful to have a built-in CPR manual, a roaming detector, and a video call function that connects directly with family and friends when asked by voice. Furthermore, some participants said that they gave feedback to the technicians for aspects that are to be improved with the care robot and socially assistive technology.

Strengthening the support system

The participants said that if more staff are available, closer monitoring would be possible and greater rapport would be established. Participants expect that the care robot services will increase significantly during the next few years. Thus, more people need to have the necessary qualifications, particularly professionals. More workers who know and are aware of older adults’ characteristics are needed to provide better care.

“Robots do not do everything. After all, people do. This (Silbot operation) is something that a human must operate, and the robot does what the human commands it to do. Even if robotics advances, we ultimately still need a human workforce to work with the robots. This should be remembered.”

Participants said that care robot services are costly, including the need to purchase the socially assistive technology devices, and access is limited only to selected people for a certain period (e.g., months or a year). They said that governmental support is needed to improve access to these technologies for those who need them for a longer period. Furthermore, the participants said that providing education to nursing students and nurses regarding care robots would make them more comfortable with using one in their practices. Participants preferred offline education and observing the care robot in person during a physical class. They underscored that competencies are required, such as abilities to use the care robot in practice, to communicate well with older adults, and collaborate with other professionals (caregiver providers). Moreover, the participants desired to have an opportunity to learn about the basic principles of AI and how to operate programs effectively, with consideration of the cognitive function of different older adults.

Discussion

Our findings demonstrate that the participants perceived that a care robot could help alleviate loneliness and assist with daily activities, especially for older adults living alone and those with dementia. Similarly, a study conducted in Belgium during the COVID-19 pandemic demonstrated that socially assistive robots were beneficial in alleviating feelings of loneliness and social isolation in older adults with mild cognitive impairment.¹⁴ Moreover, studies on the care robot, Hyodol, have shown positive effects on depression, and the quality of life.^{23 , 24} These results are consistent with our findings and support the usefulness of care robots and socially assistive technologies for enhancing the well-being of older adults. Furthermore, the participants in this study viewed AI-based smart speakers positively. Likewise, emerging evidence has demonstrated that voice-activated smart speakers have potential benefits in assisting older adults with activities and providing companionship.^{25 , 26} Altogether, these findings suggest that adopting socially assistive technologies, including care robots may be beneficial for promoting the well-being of older adults, especially those living alone and those with dementia. However, concerns relating to the use of care robots, initial anxiety or fear,²⁷ or privacy issues, exist.²⁸ In contrast, our participants had a positive attitude toward care robots. This may be because our participants prioritized the importance of non-contact care due to the COVID-19 pandemic. However, further studies to confirm our findings are necessary.

With regard to the technical aspects of socially assistive technology and care robots, this study demonstrated that the capabilities of the care robots are still limited. Care Call is an AI-based interactive call service. Aria is an AI-based voice command smart speaker that provides music, information, and emergency contact. Hyodol, a doll-shaped care robot, can verbalize words when stroked, work as a reminder alarms, and send contact requests. Silbot, a humanoid robot with facial expressions, can perform different activities to improve the user's cognition and socialization, and respond to the user, for example, “good job” (when an operator presses a button). The participants in this study suggested that bidirectional communication is one of the essential functions for a care robot. Studies have raised concerns about the conversational limitations of assistive devices, including poor voice recognition, poor or untimely responses (responding before the user finished speaking, or not responding to a question).^{29 , 30} Moreover, some people disliked the mechanical voice of AI Care Calls and some had difficulties communicating with socially assistive robots and other socially assistive technology devices. Thus, caregivers should pay more attention to those who have difficulties using socially assistive technology. Our findings suggest that care robots that are unable to verbally communicate may not be the best option for older adults living alone, especially when isolated during the COVID-19 pandemic. Our findings also highlight the importance of having good quality conversation functions built into the socially assistive technology devices.

Our study revealed that older adults may face difficulties with using care robots, including charging the battery. Therefore, an easy power charge system compatible with a cell (smart) phone that the older adults are familiar with or long-lasting batteries would be helpful. Thus, it is essential to improve the functions of the care robots to meet the needs of the users. Improvements should be made based on feedback from users and caregivers.

In regard to the workload, studies have suggested that nursing care workload may be reduced by using robots, such as for lifting or delivering logistics.³¹ In contrast, other studies have raised concerns regarding an increased workload when using care robots in older adult care.^{11 , 15 , 32} Similarly, caregivers in older adult facilities perceived an increased workload due to additional tasks when using the care robot.¹⁵ Our findings also revealed that nurses could face increased work burdens due to their expanded roles and tasks, such as explaining how to use the robots, monitoring their usage, visiting the users when needed, and evaluating their satisfaction with using care robots. Considering the exigencies of the COVID-19 pandemic, arranging enough staffing may not be easy due to several reasons including the shortage of nursing staff, uncertainties about how much additional human resources are needed, and how long services may need to be continued, even after COVID-19. Our study indicated that a proper staffing ratio is needed to provide quality care and maintain the continuity of care. To better understand the increased workload, further studies are needed. For example, studies to investigate the impact of nursing experiences with socially assistive robots or similar technology on workload, and the level of technical support from the care robot companies on the perceived increased workload, are warranted. Furthermore, a study reported that the potential infection risks of using social robots, such as Paro, may be managed by following strict hand hygiene and standard precaution protocols.^{33 , 34} Moreover, our participants were concerned about cleaning the doll-shaped care robot. This indicates that the surfaces of the care robots that are frequently touched must be made of materials that are easy to clean or disinfect, and that standard protocols should be developed and adhered to.

To improve socially assistive technology and care robots for use in nursing care, our participants recommended that socially assistive technology devices should be equipped with multiple functions and a screen. For example, an AI-based smart speaker with visual interfaces, and a video call function was suggested. A new model, Alexa echo Show, which has a visual screen has been developed and is already in the market. This implies that feedback is being considered and integrated into new socially assistive technology devices and models. Thus, by exploring and sharing people's experiences with socially assistive technology and care robots, existing models and devices may be enhanced to meet users’ satisfaction.

Most of the participants of this study were interested in learning more about socially assistive technology. With the fourth industrial revolution, artificial intelligence or robot technology in the health industry is advancing rapidly and being integrated into our daily lives.35, 36, 37 As socially assistive technology and robotics continue to develop and progress, it is essential to ensure that users, especially new users, have opportunities to be educated and updated, so that they are confident and competent with using socially assistive technology. Based on the participants’ responses, nurses need hands-on training in using the care robots, improved communication skills when conversing with older adults, cognition and well-being evaluations, and teamwork with other professionals. Additionally, skills related to remote monitoring are needed including how to respond to and handle emergencies. Moreover, nurses who utilize the Silbot need skills to modulate the use of the robot to the cognitive functions of older adults. Furthermore, nurses need to be sensitive to ethical and safety issues involved with technology utilization in care.^{38 , 39} Importantly, the support and time needed to feel comfortable and competent using care robots may differ between nurses, depending on the types of robots being utilized and the nurses’ experiences with technology and care robots. Thus, offering basic training as well as advanced skills development would be helpful. It is also necessary to develop guidelines and protocols for care related to socially assistive technology and disseminate these to caregivers in need. In Korea, socially assistive technology services are free to eligible people in the public community health centers within certain periods. However, the cost of wifi connection and other requirements to operate socially assistive technology devices could be obstacles for the users. To improve access to socially assistive technology services among older adults who are willing to use them, additional financial and caregiver support strategies from the government are essential.

This study has several limitations. First, the number of participants was small; however, the participants were recruited from various regions to represent a more diverse group of participants. Second, we focused on caregivers’ experiences. Thus, further studies to explore the perspectives of older adults are necessary to provide more comprehensive insights into care using socially assistive technologies.

Conclusion

This study explored the nurses’ perception and their work experiences with socially assistive technologies and care robots during COVID-19. Our study demonstrated that it would be beneficial to embrace care robots and socially assistive technologies as assistive tools for older adults who live at home and revealed that challenges related to the limited capabilities of the technologies have to be overcome to provide quality care. This study indicates that caregivers are burdened by their workload; therefore, it is vital to provide more staff to ensure the quality of care. Additionally, more governmental support is needed to enable more people to have easy access to socially assistive technologies. Furthermore, it is crucial to provide education to healthcare personnel on care robots and socially assistive technologies.

Funding

This research was supported by the Chung-Ang University research grant in 2022.

Declaration of Competing Interest

The authors declare that they have no conflict of interests.