READY? – Reflective dialog tool on issues relating to the use of robotic systems for nursing care

3.1 Reasoning and Methodological Approach of the Tool’s Development

The theoretical line of argument for the “READY?” assessment tool is based on Cecek-Kecmanovic & Janson ²⁸ who prefer the theory of communicative action according to Habermas ^{29 , 30} as a suitable framework for the integration of technologies into social and communicative processes. In this context, the “READY?” reflection tool can be seen as a way of promoting open dialog in nursing institutions. Within the “READY?” workshops, interest groups representing the relevant stakeholders of a care facility are given the opportunity to enter into an argumentative exchange and agree on a common understanding. Seefeldt et al. ³¹ provide a detailed description of this reasoning approach. The assessment tool is also empirically based. Several steps were taken to develop the instrument (see Figure 1).

Figure 1:

Steps for developing the assessment tool.

The focus group and workshop respondents were recruited via email distribution lists of the project partner German Caritas Association. For the expert interviews, people with relevant professional expertise were contacted by email. The surveys were conducted from September 2020 to September 2022. A positive ethics vote was obtained via the ethics committee of Osnabrück University.

The data was analyzed in MAXQDA 2020 ³² using the structuring qualitative content analysis according to Kuckartz and Rädiker. ³³ The deductive category framework was based on the categories of the literature-based heuristics. The subcategories were formed inductively. One workshop was held for each field of action to develop criteria for the use of robotics formulated as questions based on the empirical data and the literature reviews. The fields of action included: (1) Care for older adults (outpatient) and care for people with disabilities (outpatient), (2) care for older adults (inpatient) and care for people with disabilities (special forms of living) and (3) hospital. Participants in the workshops included people who had professional experience in this field of action or had a practical connection to it. Up to eight questions for each field of action were formulated per category. The six categories included: “Care”, “Privacy and legal issues”, “Technology and infrastructure”, “Ethical criteria”, “Institutional and social embeddedness” and “Economic criteria”.

1. Development of a Heuristic Based on Interdisciplinary Literature Reviews

   First, a set of criteria was developed regarding the reasoning of the use of robotics for nursing care. Based on the results of interdisciplinary literature analyses, a theoretically founded heuristic was created that contained criteria to justify the use of robotics at the level of care practice (micro level), the institutional level (meso level) and the level of societal effects (macro level). The heuristics included national and international literature analyses to incorporate perspectives from the state of evidence and discourse in the social and nursing sciences as well as nursing practice and the current state of technical development. Systematic literature searches were carried out using international databases to create synopses of user-centered and participatory design, an overview of projects relating to the development of robotic systems for nursing care ⁴ and the identification of ethical lines of argument.

2. Criteria Catalog to Assess the Use of Robotics in Nursing Care

   Focus groups and interviews were then conducted to enhance the heuristic. Twenty-five guided and problem-centered expert interviews ³⁴ with experts from nursing science (n = 15), technology development (n = 1), organizational development (n = 2), law (n = 1), health economics (n = 2), care (n = 2) and ethics (n = 2) were conducted. Additionally, ten interviews were carried out with experts from the joint projects of the “Robotic Systems for Nursing” funding line. Three focus groups were held with 15 participants from management positions in care institutions. Furthermore, twelve focus groups (n = 51) were conducted with representatives from care practice and care management in various fields of action, including hospitals, inpatient care for older adults, outpatient care for older adults and special forms of housing for people with disabilities. The shared objective of the focus groups and interviews was to understand the conditions under which the participants considered the use of robotic systems in nursing care work to be conceivable. A broad spectrum of possible application areas, such as interaction-related and task-related care, for different types of robots were discussed.

3. Transfer of the Criteria to the Assessment Tool for Robotics for Nursing Care

   In the next phase, the catalog of criteria was transferred into the “READY?” assessment tool. To this end, the conceptual, preliminary work for the tool and the accompanying workshop concept was further developed and empirically reviewed in ten guideline-based, problem-centered expert interviews with the potential target group of the evaluation tool. As part of the interviews, factors such as the preferred duration of the workshops, the composition of the group of participants and the response options were examined.

4. Consensus on the Assessment Tool

   Focus groups, workshops, and expert interviews were then conducted to reach a consensus on the assessment tool in the disciplinary discourse. Two workshops were held with representatives of welfare associations and employee representatives (n = 14). Additionally, four focus groups, each with seven participants, took place. These included representatives from professional care associations, relatives’ representatives, self-help associations and representatives of care practice and the fields of ethics, medicine, law, and economics from care institutions. A pretest with welfare organization representatives followed this to evaluate the formulation of the questions. For this purpose, cognitive interviews (n = 5) were conducted using the techniques of concurrent think-aloud and probing. ³⁵ Ten questions from the tool were reviewed and modified in each interview.

As part of a research workshop, the tool was tested with participants from joint projects of the “Robotic systems for nursing care” funding line. The questions of the assessment tool were then revised as part of a workshop within the BeBeRobot project. In a final step, the digital support system for the systematic processing of the “READY?” assessment tool was implemented.

3.2 Methodological Approach to Testing the Assessment Tool

The digital support system for the “READY?” assessment tool and the concept of the “READY?” workshop format were tested in practice. The testing took place in one institution each in the action fields of inpatient care for older adults, care for people with disabilities (special forms of living), hospitals, and outpatient care for older adults. Recruitment was carried out by the project staff of the German Caritas Association, who contacted care facilities and services via e-mail distribution lists. The data was collected from March to April 2023.

The number of participants ranged from four to twelve people per workshop. A total of 35 people took part (see Table 1). Church-affiliated institutions from south, west and north-west Germany took part. According to the concept, each workshop lasted 4 h and was located at the facilities and services. At the beginning, the project’s context and the workshop’s aim were explained during an introduction. In addition, various types of robots were introduced by means of an introductory presentation and with the inclusion of videos regarding the use of robotics. Four robotic systems from and beyond the funding line “Robotic Systems for Care” were presented: (1) Bed-mounted robot arm system from the AdaMeKoR project ^{36 .} It provides support by holding and stabilizing functions during transfers between bed and wheelchair or when handing objects. (2) The Jeeves robot, which can, e.g. carry out service activities such as the delivery of items. ³⁷ (3) The Giraff robot for initiating video calls, reminding to take medication, or calling for help in an emergency. ³⁸ (4) The PARO seal robot for interaction-based care and support of communicative activities. ³⁹ Additional videos of the funding line were retrieved from the BeBeRobot project website,^[1] whereby the selection of the videos presented varied depending on their applicability in the field of action.

This was followed by joint work on the questions of the “READY?” assessment tool. The participants discussed the questions and agreed on a common answer. At the end of the workshop, a focus group (45 min) ⁴⁰ and a supplementary standardized short survey (15 min) were conducted as part of the evaluation. A total of 32 people took part in the focus groups and surveys. During the focus group, questions were asked regarding the assessment of the discussion process and decision-making during the workshop. Additionally, questions about the presentation at the beginning and the added value of the evaluation tool were included.^[2] While some usability aspects were analyzed, the focus of the testing was on the workshop format and the discussion process, including the roles of the participants, response options and not on the software. A self-developed survey instrument was used for the supplementary questionnaire-based survey. The focus groups were recorded. A transcription office then transcribed the audio recordings. Post-scripts were also prepared in each case. The data was analyzed according to the structuring qualitative content analysis according to Kuckartz and Rädiker. ³³ We first created a deductive category framework using the focus group guideline. The subcategories were formed inductively (see Figure 2).

Figure 2:

Categories for the analysis of the focus groups.

The survey was analyzed using descriptive statistics using IBM SPSS statistical software. ⁴¹ Both the results of the focus groups and the survey were included in the presentation of the results of the testing. In line with a mixed-method approach ⁴² the evaluations of the focus groups and survey were combined with the aim of expanding knowledge.

4.1 Objectives

The “READY?” assessment tool consists of a digitally supported question catalog and a workshop concept. This is intended to support services and institutions in systematically reflecting on issues relating to the use of robotic systems in a discursive process. The tool is designed to be multi-perspective and incorporates the views of various stakeholder groups within the respective institution. Thus, the tool enables a systematic participatory integration of the views and concerns of caregivers, interest groups of people in need of care and their relatives as well as other professional groups of care institutions.

Using the tool, the facilities gain an overview of the aspects supporting or opposing the use of robotics. Depending on the institution’s focus, the tool enables a reflection on the use of robotics as a whole or a consideration of a specific robotic system. As a result, an overview shows which prerequisites would have to be created for the potential use of robotics in the respective institution. Overall, the “READY?” concept is designed as a reflection process for organizational development. The results can be used by the institution to initiate a further institutional examination of the topic and provide orientation as to which challenges need to be addressed regarding robotics.

4.2 Target Groups

The assessment tool is aimed at care services and facilities from three fields of action, consisting of (1) care for older adults (outpatient) and care for people with disabilities (outpatient), (2) care for older adults (inpatient) and care for people with disabilities (special forms of living) and (3) hospital. To take into account the sector-specific characteristics, the “READY?” assessment tool provides a specific list of questions for each of the three fields of action.

4.3 Workshop Participants

In order to keep the number of participants manageable, the “READY?” concept envisages a number of six to twelve participants per workshop (Table 2). The number of participants was determined based on the results of the ten interviews to verify the tool concept and transfer the criteria to the evaluation tool for robotics for nursing care (see Figure 1). The interviewees suggested a preferred number of participants ranging from four to 20 people. In the majority of cases, the number of 6–12 people was considered appropriate to ensure a goal-oriented discussion. The interviewees were also asked which groups of people should participate. Based on the interview results, different groups of people from the institution are included. The composition of participants varies depending on the field of activity.

4.4 Timeframe and Procedure

The “READY?” concept provides for a maximum of 4 h per workshop to work on the questions. The results of the expert interviews with representatives from institutions and services (n = 10) showed that the scope should be kept manageable due to the institution’s limited resources. The time recommendations of the interviewees ranged from 1.5 h to sessions spread over two days, each lasting 4 h. The iterative evaluation loops then limited the maximum time required to one session of 4 h.

The “READY?” evaluation tool is run through by the moderator together with the participants. First, the workshop concept and objectives are explained and the topic of the use of robotic systems for nursing care is introduced by means of short video excerpts. Various types of robots are presented to illustrate different possible applications for the use of robotics. Questions about institutional requirements for the use of robotics are then discussed together.

4.5 Categories of the Tool

The evaluation tool contains up to eight questions per field of action for each of the following categories: “Care”, “Ethical criteria”, “Institutional and social embeddedness”, “Economic criteria”, “Technology and infrastructure” and “Privacy and legal issues”.

In the “Care” category, questions on the requirements for the use of robotics are examined from a nursing science and nursing perspective. E.g., the effects of the use of robotics on work processes and the question of the extent to which the use of robotics is compatible with the understanding of good care in the institution are addressed. It is also addressed to what extent the needs and requirements of those in need of care and carers are taken into account when using robotics, whether the institution has insights into the nursing-relevant benefits of robotic systems and whether further training needs can be met.

The category of ethical aspects includes questions on ethical reflection, for example concerning the protection of privacy or the value of human relational work. For instance, the category also includes questions on the extent to which people can reject the use of robotics and whether it can be ensured that no dependency on robotic systems is established.

The category “Institutional and social embeddedness” addresses the requirements relating to the process of implementing robotics in the institution, and the question of the extent to which the use of robotics is justifiable from a societal perspective. It also addresses questions about the extent to which the advantages and disadvantages of using robotics can be communicated comprehensibly to everyone in the institution.

In the category “Economic criteria”, aspects relating to the cost-benefit analysis, acquisition and refinancing aspects as well as market economy criteria are addressed. The extent to which robotic systems can be tested before a purchase decision is made and the extent to which the use of robotics contributes to an expansion of the range of services is also discussed.

The “Technology and infrastructure” category focuses on structural and technical requirements, e.g. to what extent technical support is available, to what extent integration into the existing technical infrastructure is possible and to whether the conditions in the outpatient sector are suitable for the use of robotics.

The “Privacy and legal issues” category deals with aspects of data processing, the protection of personal rights, occupational health and safety, and liability issues.

The discussion is structured by the catalog of questions which is available online along with the assessment tool.^[3] The translated version of the set of questions is available.^[4]

4.6 Process of Discussion

The moderator goes through the questions of the “READY?” assessment tool together with the participants. The questions per category are displayed in the digital tool. To support the moderator, explanations of terms concerning the questions are available via a mouse-over effect, which help to clarify the questions for the participants. Three possible answers are provided for each question according to a “traffic light principle” (red, yellow, and green). The participants discuss the question concerning the institution and agree on a common result. This result is documented by the moderator in the tool.

If there is no need for further discussion, as the participants do not see any challenges in the institution regarding the respective question, the answer option “green” (“We have no need for discussion”) is selected. If the question can only be agreed to under certain conditions, the answer “yellow” (“Regarding the question, we provide the following note”) is available. These conditions can be entered into the tool concerning the questions, and are then automatically saved. The answer option “red” (“Concerning the question, the use of robotics is not possible”) indicates that the question is not approved and that the requirements for the use of robotics concerning the question cannot be met at present. A text field can be used to explain the reasons. In addition, an optional text field is available to explain the conditions under which use might be possible. The workshops aim to ensure an equitable exchange. If it is not possible to reach a conclusive answer to certain questions within the workshop’s timeframe, further discussion can take place after the workshop and additional expertise can be consulted if necessary. Additionally, the tool can be run through again at a later date by the institution in order to record changes in assessments over time.

The concept provides for an external moderator with knowledge of care practice, robotics, and new technologies. An external moderator is intended to ensure a high degree of neutrality. Furthermore, the moderator should be trained in dealing with possible resistance or conflicts within the institution and encourage the active participation of all participants.

4.7 Output of Results

At the end of the workshops, an output of results is provided. This includes a spider chart that shows the strengths and weaknesses of an institution regarding the implementation of robotics (Figure 3). The proportion of questions answered with “green” is weighted with one point. The proportion of questions answered with “yellow” is weighted with 0.5 points. In addition, the results output includes a presentation of the documented answers to the individual questions according to the traffic light system. This provides the institution with a clear overview that illustrates any need for action concerning the requirements for the use of robotics. The results overview thus contains operationalized results about the respective institutional requirements of the use of robotics in the institutions.

Figure 3:

Example spider chart as part of the workshop results output.

5.1 Results of the Focus Groups

5.2 Results of the Short Survey

Most respondents of the accompanying questionnaire survey (n = 32) stated that the time frame for the workshop was appropriate (see Figure 4). Only two participants somewhat disagreed. The majority of participants were also satisfied with the moderation. The aim and process of the workshop were clearly presented. Almost all respondents rated the number of participants as appropriate: 30 out of 32 people chose the response options “Somewhat agree” or “Agree”. However, eight people considered the composition of the participants to be (somewhat) unbalanced. In the free-text responses, it was noted that data protection expertise should be represented in the workshops.

Figure 4:

Results of the short survey following the testing of the tool (n = 32).

Concerning the design of the evaluation tool, 26 out of 32 respondents stated that the evaluation tool structured the discussion process (rather) well. The majority of respondents rated the assessment tool as appealing and easy to use. Regarding the list of questions, 13 of the 32 people stated that the questions were difficult to understand. The majority of respondents evaluated the questions as appropriate for reflecting on the use of robotics in the institution. Seven people (somewhat) disagreed. Most participants (28 of the 32 people) agreed or somewhat agreed that the workshop overall added significant benefit concerning the conditions under which the use of robotics could be considered.

One barrier to using the tool was a lack of previous experience and the lack of robotic systems available on the market. Several people noted in the free-text responses that some of the questions needed further clarifications, further summary or were redundant. One respondent mentioned that the discussion focused too much on managers and that greater openness would be desirable. The validity of the tool was also critically questioned by one participant.