Abstract
Introduction
Care robots are machines, operating partly or completely autonomously, that are intended to assist older people and their caregivers. Care robots are seen as one part of the solution to the aging population, allowing fewer professional caregivers to provide the necessary assistance and care. Despite the potential benefits, the dissemination of care robots, and welfare technology in general, is limited in Swedish elder care.
Purpose
To explore the challenges of introducing welfare technology, particularly care robots, in elder care.
Materials and methods
Twenty-one individual interviews with key actors at the societal level, analysed by thematic analysis.
Results
The challenges, from the societal actors’ perspectives, were related to; the beliefs in technology, attitudes, ethics, collaboration, and the need for knowledge and skills regarding care robots (individual and group challenges). Challenges of a national character were: national governance, infrastructure, laws and regulations, economics, and procurement (systemic and societal challenges). In addition, the necessary preconditions for successful introduction were revealed as: the utility of the technology, implementation, evaluation and safety, security, and integrity (preconditional challenges).
Conclusions
The introduction of care robots in elder care services seems to be more challenging than that of welfare technology in general, given the context and prevailing attitudes and preconceptions about robotics. Significant challenges need to be managed, at all levels of the society, before care robots can become an integral part of daily care and assist older people and their caregivers in activities and rehabilitation.
The challenges described by the societal actors‘, are partly similar to those of the end users’, in terms of attitudes, ethics, knowledge and skills, and collaboration. This consensus should provide a solid foundation for the conceptualization and introduction of care robots in elderly care.
The challenges follow the pattern of an ecosystem involving all sections of society, which are intertwined and require consideration before the expected benefits can be realised.
A user-centred approach is necessary to support the design, implementation, and usefulness of care robots and their suitability for meeting the real needs of older persons and professional caregivers.
IMPLICATION FOR REHABILITATION
Introduction
The European countries are undergoing significant demographic changes, with the increasing older population exceeding the capacity of welfare service provision. The aging population will dramatically increase the need of care providers. The old-age dependency ratio in the EU is projected to increase by more than 21% by 2070, resulting in the EU only having two working-age people for every person aged over 65 years, compared with the earlier old-age ratio of 3.3 [Citation1]. Politicians and decision makers, among others, believe that assistive technology might provide a solution whereby fewer employees could provide more extensive welfare services; however, such a profound technology transformation has not yet taken place in Swedish elder care.
Assistive technology is intended to improve individuals’ functioning and thereby promote their wellbeing [Citation2]. In Sweden and the other Nordic countries, it is more commonly known as welfare technology. There is no common definition of welfare technology, but its purpose is to maintain or increase the safety, activity, participation, and/or independence of individuals with disabilities or those who are at risk of disability [Citation3]. This paper focuses specifically on care robots as a form of welfare technology, referring to robotic assistance used in elder care contexts. Care robots can be defined as machines that operate partly or completely autonomously with the aim of supporting older persons, their families, and care professionals in providing physical, cognitive, or emotional support [Citation4,Citation5].
Care robots and welfare technology in elder care
Robotics has made remarkable progress in recent years, in many different fields of work [Citation6], such as medicine and healthcare. Care robots represent a field of robotics that has emerged over the past decade in response to demographic developments. Countries such as Japan have pursued the use of robots in elder care for a long time and a similar development is predicted for Europe [Citation7]. Care robots for elder care services are receiving growing attention, since their use has been shown to have a positive impact, not only for older persons, but also for their caregivers [Citation8]. It is proposed that care robots can potentially enhance the wellbeing of older persons [Citation9] and decrease the workload of caregivers [Citation9,Citation10]. Until now, the different types of care robots used in elder care have mainly provided assistance with daily tasks, monitoring of behaviours and health, and companionship [Citation10–12]; however, the use of care robots, and welfare technology in general, is still limited in Sweden. The most common welfare technologies used in elder care settings and ordinary accommodation are passive alarms (e.g., sensors and fall alarms), electronic planning tools/video, GPS alarms, and night surveillance cameras [Citation3,Citation13]. Examples of robotic welfare technology that is currently being used or tested in Sweden are JustoCatFootnote1 (a social robot for persons with dementia), BesticFootnote2 (an eating aid), PoseidonFootnote3 (a shower robot), HALFootnote4 (an exoskeleton to support physical capabilities), Servo GloveFootnote5 (a power-reinforcing glove), and EvondosFootnote6 (a medication administration robot) [Citation3].
Acceptance of care robots in elder care
The acceptance of care robots has so far been rather poor, despite the potential benefits they are meant to provide [Citation14]. The establishment of robots in care settings is apparently influenced by the attitudes of the end users—older persons and care providers. Care robot use in elder care is a delicate subject, due to ethical and social issues [Citation15], so their use has provoked both concerns and positive responses. Some studies of perceptions of care robots have tended to describe negative attitudes. A survey of the EU population showed that over 30% of the respondents considered the idea of robots in geriatric care to be very unpleasant [Citation16]. It was further suggested that older persons are more negative towards robotics than younger persons [Citation11]. Nevertheless, other studies suggest that the attitudes of older persons are more often positive than negative and that they are willing to have a robot assisting them in daily life [Citation17–20]. Factors affecting the acceptance of care robots are related to, for example, individual characteristics, cognitive ability, education, and culture [Citation21]. The care professionals’ attitudes and willingness to use innovative technology may also affect care robot use [Citation22]. Resistance to implementing welfare technology in general has been recognised among care professionals and relates to organisational, cultural, technological, and ethical issues [Citation23], but many care professionals also see the potential for care robots to be useful in many areas [Citation24].
The demographic changes have necessitated intertwined service and technology systems in many social spheres. The technology transformation in elder care has its origins in political discourse and policymaking [Citation25]. Several reports and directives have been published in the field (e.g., [Citation26,Citation27]) and state funding has been granted to enable municipalities to increase the rate of investment in welfare technology in municipal healthcare activities, including elder care [Citation28]. Despite these incentives, and the growing attention given to care robots and their potential benefits, the dissemination of care robots remains limited in Sweden; care robots are still in the development phase and only a limited number are commercially available. This study aims to explore the challenges of introducing welfare technology in elder care, with a specific focus on care robots. An ecological system approach [Citation29] is applied to explore the perspectives of stakeholders operating at a societal level.
Materials and methods
The present study is part of the ORIENT project under the Joint Programming Initiative “More Years, Better Lives”. The ORIENT project focuses on orientation to care robots and the continuous co-creative process of introduction to technology use. Partners from three European countries (Finland, Germany, and Sweden) participate in the project, but the present study focused on the Swedish context.
The study has a qualitative descriptive design [Citation30] with an inductive approach using interviews. The study took as its methodological point of departure an ecological system approach [Citation29], to explore the exo- and macro-level perspectives (referred to as the societal actors’ perspectives) towards introducing care robots.
Ethical considerations
Throughout the study, the ethical principles of the Swedish Research Council [Citation31] and the principles of the Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects [Citation32] were followed. Information concerning their participation, and the right to withdraw at any time was provided to all the informants between November 2018 and May 2019. Prior to the interviews, the informants signed an informed consent form.
Data collection
A purposeful sampling technique was used for recruitment [Citation33]. The informants were chosen as representatives of central organisations or being stakeholders operating at a societal level, who had some interest in, involvement with, or connection to the research topic (see ). The informants included representatives from public sector organisations (PSO); robotics companies (RC); interest organisations for care professionals (IOC); interest organisations for older persons (IOO); educational organisations (EO); political decision makers (PDM); research institutes (RI); insurance companies (IC); funding organisations (FO); and media organisations (MO). A total of 21 individual interviews, two or three in each respective field, were conducted between November 2018 and May 2019. At the beginning of the interviews the concept of care robot was discussed so that there would be no misunderstanding of what kind of technology the interview referred to. The interviews included a range of questions where the informants were asked to elaborate on general aspects of care robotics, including the potential and risks, responsibilities, attitudes, information, and knowledge. Thereafter, strategic-level questions were posed, involving management, product development and innovation, collaboration and networks, implementation processes, change and steering factors, hindering and supporting elements, and costs. Each interview lasted between 42 and 95 min; they were audio-recorded and transcribed.
Table 1. Demographics.
Data analysis
The data was analysed using inductive thematic analysis with a semantic approach, meaning that the analyst is not looking for anything beyond what the informants have said [Citation30]. The six phases consisted of familiarising with the data, generating initial codes, searching for themes, defining and naming the themes, and finally, producing the report. Initially, the transcripts for all 21 interviews were read and reread to detect the features associated with the challenges of introducing care robots in elder care. Data extracts, consisting of sentences and paragraphs, were marked and collated. Initial codes were systematically generated across the entire dataset. The codes were grouped into potential themes, which were identified within the surface meaning of the data. Finally, the relevance of the themes was checked in relation to the codes and the entire dataset (see ). The generated themes displayed different dimensions of the challenges and were organised into overall grand challenges.
Table 2. Example of the analysis process.
Results
Three overall grand challenges with a total of 14 themes constituted the societal actors’ perceptions of the challenges of introducing care robots in Swedish elder care. The descriptions of the challenges are based on the generated themes and codes (see ).
Table 3. Grand challenges: themes and codes displaying the challenges of introducing and embedding care robots in elder care, and the represented informant groups for the respective themes.
Individual and group challenges
The themes relating to the individual and group challenges represented the areas of concern that, according to the societal actors, need to be considered and managed when introducing care robots in the context of elder care. The five themes were: belief in technology use, attitudes, ethics, knowledge and skills, and collaboration.
Belief in technology use
The theme suggested that the expectations of what can be achieved with care robots must be realistic, considering both their capacities and the economic benefits that they can bring. The functions of care robots may easily be overestimated, with people attributing to the technology a greater capacity than is available at present. The development of robots is actually very complicated, and we are still far from having robots that are flexible and meet the—often demanding—requirements of the users. Furthermore, too much trust in technology may be risky, bearing in mind that we are dealing with older persons who may be frail and/or suffer from illnesses.
Attitudes
The word “robot” often arouses negative attitudes, since it is commonly perceived as referring to an industrial environment or a vicious mechanical creature in a Hollywood film, rather than a technical aid that makes people’s lives easier. The public’s acceptance of welfare technology and care robots is increasing, but resistance to technology use is still widespread. The theme suggested that negative attitudes seem to prevail among those who do not need any assistance in their daily lives. Other factors affecting the attitudes of older persons were, for example, not being accustomed to using technology at all and fear of the unfamiliar. The care professionals’ attitudes were perceived to be rooted in a traditional idea of how care should be carried out; that is, by human hands, not robots. Many care professionals may even have avoided a technical field of work, preferring to work with persons, but now need to adapt to new working routines involving the use of care robots—a change that may cause anxiety regarding the ability to handle the technology or the possibility of causing harm to someone. Suspicions of the motives for introducing welfare technology probably exist, usually concerning cutbacks of care professionals or money.
Ethics
Several ethical issues were identified by the informants. Careful assessments should be made regarding whether and in what situations it is appropriate to replace human care with care robots. The human encounter can never be replaced, but care robots may complement it. One concern was that the use of care robots could increase the alienation of older persons. The individuals’ needs and wishes should be carefully considered, since there is no “one size fits all” solution. A common view is that older persons must be allowed to speak for themselves, so neither decision makers, families, nor anyone else should decide what is best for the individual; nor should care professionals be forced into using the technology, but rather prepared for, and involved in, its introduction. Increased use of welfare technology and care robots in elder care service might affect the balance of power between care professionals and clients.
Ethical concerns are also related to individuals’ economic conditions. One prediction was that society may not be able to cover all the costs of digitalisation, which may, in a worst case scenario, cause inequality in the provision of care. Reasons for inequality, other than economic conditions, may be a lack of interest and/or capability among the end users.
Knowledge and skills
The transition to an increased use of welfare technology in care was predicted to create a demand for additional education and training for all groups of care professionals, such as assistant nurses, registered nurses, occupational therapists, and care managers. Such education may cover all aspects of technology, from basic computer knowledge to concrete working methods using virtual care visits or videoconferencing. Care professionals need to be prepared for their increased responsibilities and realise that they will be highly involved and expected to act as supporters for clients and their families. There may be an increased need for new types of professionals with specialist skills in pedagogy, logistics and people with combined technological and caring skills.
One concern was how the current educational institutions will cope with the increasing demand for digitalisation and welfare technology content in their programmes. The current teachers have little experience of the technology themselves, and sometimes no interest, so it is a challenge to bring in competence from elsewhere. To hire people with only technical skills would not be adequate, since the education must have its foundations in the appropriate environment of use—a care context.
Collaboration
There seemed, based on the results, to be a lack of collaboration and networking between, and sometimes within, municipalities concerning the exchange of experiences and dissemination of knowledge. One example is that several municipalities are testing similar types of welfare technology, but are not taking part in each other’s evaluations. In addition, private companies may regard their tests as business secrets and do not want to share their knowledge. Arenas for collaboration are necessary to facilitate the involvement of actors at all levels, including non-profit organisations, researchers, and so on.
Systemic and societal challenges
The themes illustrated the systemic and societal dimensions of the concerns that need to be taken into account when introducing care robots in elder care. The five themes were: infrastructure, national governance, laws and regulations, economics, and procurement.
Infrastructure
A major concern among the informants was the digital infrastructure in society and access to broadband and Wi-Fi, not least for elder care institutions, many of which lack internet and/or digital competence. High standards for how different systems communicate and interact with each other are required. The infrastructure discussions should involve the educational institutions, which need to prepare themselves to educate care professionals in welfare technology and digitalisation. Home environments, and logistics for services and goods supply, were other mentioned challenges.
National governance
The themes suggested that a national strategy for controlling the introduction of welfare technology and care robots seems to be missing in Sweden, and no-one appears to be taking the lead. Many authorities are involved, but there is no clear pattern in the coordination of their work. The development depends, to a large extent, on individuals’ interests and prioritisations. The fact that there are 290 independent municipalities and 21 county councils in Sweden makes it even more challenging to, for example, compile knowledge and results from tests and projects conducted in different parts of Sweden. Another concern was that the main focus of technology implementation is on eHealth in the county councils, and significantly less on elder care in the municipalities. The question was raised of whether two parallel digital infrastructures and systems should be constructed, for the municipalities and county councils respectively, or whether it would be possible to share welfare technology and costs between the organisations? Furthermore, the distribution of responsibilities between the different actors is challenging, particularly for the public sector and social services.
Laws and regulations
The legislation has not kept pace with technological developments and, sometimes, laws and regulations even work against it. Uncertainties exist with regard to whether the welfare technology and care robots are applicable, since there are conflicting laws and authorities stipulating different regulations for what can and cannot be done. The prevailing legislation was referred to as a “grey area”; for instance, when older persons do not have the ability to decide for themselves (due, perhaps, to cognitive impairment), how the decisions are made becomes a concern. There is a risk of excluding persons with cognitive impairment from the use of welfare technology, because of the legal issues involved. Another concern is about the liability involved when a machine takes over human tasks, such as, for example, administering medication in home care.
Economics
The theme suggested that the funding of care robots is a concern in several respects. Firstly, the technology is usually rather expensive, and questions arise regarding who should pay and for what. Problems exist in the organisations that have economic models based on receiving compensation for the hours of physical work performed, raising questions of how the work performed by welfare technology and care robots should be compensated. Secondly, budgets are generally not adapted for the purchasing of innovative technology, especially in the municipalities, where the budgets for technology procurement are too small. One argument is that municipal elder care services and home care are not treated the same as other healthcare services in the county councils, with municipal elder care traditionally being perceived as having lower status and, consequently, a lesser need for welfare technology than the county councils.
Procurement
How to acquire and procure the welfare technology, was pointed out as a major concern. Regarding care robots, there may also be ambiguity concerning whether they should be classed as medical equipment or welfare technology, and the municipalities rarely have procedures or competence for such procurement. The people making the decisions about the procurement of care robots in the various organisations often do not have relevant experience, knowledge or, perhaps, interest in technology; thus, it can be difficult for them to understand what is available on the market and how to choose suitable products. Procurement issues also involve licences, support, maintenance, and upgrading of the products, and the procurement process is therefore perceived as time-consuming and complicated. A further complication is that all regions and municipalities need to acquire the appropriate technological skills and keep them up to date in a rapidly-changing field. The procurement of innovative technology can cause problems for both the companies and the suppliers, who incur financial costs due to the extended processes involved.
Preconditional challenges
The themes depicted the necessary preconditions for the successful introduction, effective management, and competent beneficial use of care robots in elder care. The four themes were: the utility of technology; implementation; evaluation; and safety, security, and integrity.
The utility of technology
A common viewpoint was that care robots must meet the needs and requirements of the end users, which is presently not always the case. Products are developed that cannot be implemented because they are still at the prototype stage or simply do not match the needs of the users. These problems seem to have several causes, of which the most important concerns user involvement. According to the informants, it is vital that the potential users of the technology, such as older persons, families, and care professionals, participate in the development process, but this seem to be lacking for several reasons. Manufacturers and companies develop products without consulting the users, or they involve the users too late in the process, only when it is time to test the product. The care providers have, on the one hand, failed to express needs that welfare technology could help to solve and, on the other hand, the care professionals perceive themselves to have been left out of the discussions, especially when it comes to developing products for care professionals’ use. Additionally, it can be difficult for technology companies to obtain the care providers’ input, thereby making it difficult for them to develop useful products.
Another challenge to making welfare technology useful is the issue of changing work practices. The technology itself is only a small part of this; the main part is about changing the existing, often traditional, ways of working, often aggravated by the currently high workload in care organisations.
Implementation
Implementation of technology was perceived as a time-consuming and complex process. One concern was the “project problem”, meaning that, when a project ends, it all ends, rather than the project being firmly anchored in the organisation, so that the technology can be implemented after the project ends. Another challenge is how to launch the products on the market. Often, for a single product and small businesses, there is a shortage of capital, financing, and investment, and the unattainable market even seems to have reduced the inflow of innovation. A broader overall approach is required, with involvement from bigger actors.
Evaluation
There is a need for models to evaluate the impact of different kinds of technology. The existing standards are quite rough, and some aspects need to be further considered; for example, how the working environment is affected, end users’ experiences, and the organisational and financial effects. Rapid technological development can be a challenge because, by the time an evaluation has been conducted, the technology has already been updated. Another aspect of evaluation relates to the tax money invested in research for welfare technology and its consequent results. Financed research needs to reach the public.
Safety, security, and integrity
Safety and the elimination of risks were given high priority by the informants. Care robots must be safe to use, so that no one gets hurt, but technology can fail, just as humans can, and there must be backup in case that happens. One concern to address was that, with increasing technology use, the number of care professionals may eventually be reduced, making it more difficult to personalise the service offerings, if needed. The protection of privacy and integrity is also, always, of major importance. The more care robots are used, the more information is stored, and the more behaviours are mapped, necessitating careful consideration of what data should be stored (or not) and how it should be stored. Sometimes naivety and ignorance prevail regarding the sharing of digital data.
Discussion
The findings of the present study revealed several challenges, collated into three grand challenges that, according to societal actors, need to be tackled for the successful introduction of care robots.
Firstly, the individual and group challenges refer to belief in technology use, attitudes, ethics, knowledge and skills, and collaboration. These challenges were, to a great extent, similar to the concerns described by end users [Citation34,Citation35]. One challenge that needs to be addressed concerns the prevailing negative attitudes that still exist; for example, the word “robot” seems to be a somewhat problematic term, evoking images of malevolent mechanical creatures. This seems to be a particularly delicate issue in the context of elder care; while the use of robots may generally not be viewed entirely negatively by the public, the context of their use in elder care is of great concern [Citation16,Citation36]. The negative preconceptions seem to be based on the vagueness of knowledge about what care robots are and how they can assist in daily activities [Citation36–38]. Similar findings were described for both older persons and care professionals, revealing an evident lack of orientation towards care robotics [Citation35]. However, when studying the impact of specific care robot use, positive effects were revealed [Citation39–41] and older persons even described themselves as more keen to accept robots than their care professionals and families [Citation20,Citation42]; thus, concrete information about care robots and their applications, as well as the incentives to implement the technology, need to be publicly disseminated in order to change negative attitudes based on a lack of information. Because the word “robot” could be problematic in the context of care, and especially in relation to frail older persons, other concepts should be considered. Since the technology itself is not the main interest, but rather the potential benefits it can bring, care robots could instead be referred to as “assistive technology” or “health and welfare technology”. Too much tension exists between fundamental ethical values and the robot concept, which is unlikely to be overcome, at least not for many years. Such prejudice might slow down the development and implementation of useful assistive technology. A full understanding of robotics in nursing is needed to enable developers to provide suitable technological solutions [Citation43]; hence, arenas for collaboration and the dissemination of knowledge are in demand [Citation44]. To some extent, prejudice may, initially, affect the introduction of new welfare technology in general, since it implies deviation from classic caregiving principles.
The introduction of technological innovations in elder care also places new demands on care professionals. The requirements involve technology knowledge and skills and the development of working methods based on using the new technology. A major concern is how current educational institutions will cope with the need to increase the digitalisation and welfare technology content of their programmes. The literature has, for example, not yet truly addressed how care professionals should assist frail older persons in the selection and use of care robots, and there is a demand for the welfare technology content to be developed in conjunction with nursing practice [Citation45,Citation46]. The findings revealed an awareness that the new technology is only the first step and that the main challenge is to change ways of working.
Despite the strong incentives to implement technological solutions in healthcare, in order to overcome the challenge of an aging population and a lack of care professionals, there is an awareness of the ethical issues involved. Concerns that care robots will replace human care, or infringe on the individuals’ right to speak and decide for themselves, corresponded to those referred to in previous studies as ethical concerns [Citation15,Citation47]. Although the findings showed that the belief in technology use is strong, simultaneously there are concerns that the expectations of what care robots can assist with may be too high. There is also an understanding that care robots might not be suitable for all. Previous research suggest that care robots are tolerated as assistive tools, communication, rehabilitation and such, but are more questioned as companions or for relieving anxiety or loneliness [Citation19,Citation42].
Secondly, the systemic and societal challenges related primarily to the national level and included deficiencies in infrastructure, management, laws and regulations, economics, and procurement. The infrastructure issues concerned a possible lack of access to broadband and Wi-Fi, and the fact that some older persons living in institutions still lack access to the internet. At present, about 42% of Swedish persons aged 76 years and older live in “digital exclusion” for various reasons [Citation48], but this is likely to change in near future. National governance and a strategy for the introduction of welfare technology and care robots also seem to be missing, with many authorities being involved, but without anyone coordinating the work. These findings were somewhat surprising, since the Nordic countries are considered to possess a high level of digital competitiveness and comparably high levels of digital skill in their populations, therefore being well-suited to the development, testing, and launch of solutions within the field of digital healthcare and ambient assisted living technology [Citation49]; Sweden is even aiming to be the best country in the world by 2025 in its use of digitalisation and eHealth [Citation50]. These conditions should provide a solid foundation for introducing care robots and welfare technology; however, the technology introduction is perceived to be focussed on healthcare in county councils, rather than on elder care in municipalities. The findings indicated that elder care is somewhat excluded from the digitalisation of healthcare, even though most care activities are conducted in this context—despite the stated high willingness and motivation to enable older persons to self-manage their lives in their own homes and the fact that public investment in self-care solutions has been authorised [Citation49]. Thus, regardless of stated Nordic strongholds, the dissemination of welfare technology, and care robots specifically, is still limited in elder care services, and this is not unique to Swedish elder care. The majority of robotic developments do not reach the market and only a limited number of robots designed for older persons become commercially available [Citation20]; for instance, in a systematic review conducted by Bedaf et al. [Citation51], 107 robots for older persons were identified. Only six of them were commercially available, while the rest were either in a conceptual or development phase. In addition, care robots are not yet commonly used by care professionals [Citation52]. This slow development has been criticised by, for example, the assistant nurses’ union, which suggested that not enough effort is being made to implement welfare technology in elder care services. The technology can assist, not only older persons, but also care professionals [Citation13,Citation53], so it is predicted that robotics will alter the scope of practice in the caregiving professions [Citation54] and enhance the wellbeing of older persons [Citation9].
For the successful introduction of care robots, there are several additional challenges to overcome regarding laws and regulations. The legislation is perceived as a “grey area” that has not kept pace with technological developments. In this regard, the government has recognised the need for constitutional proposals that can facilitate the use of welfare technology; for example, regulations concerning the consent of persons with reduced decision-making ability [Citation27]. The economic concerns refer to the financing of the products, and the care organisations’ compensation models for services provided by care robots. The municipalities’ budgets do not seem to be adapted for purchasing welfare technology, in comparison with other healthcare services, which is surprising given the strong incentives for increasing the use of welfare technology in elder care services [Citation27]. The procurement of the technology is another challenge, due to lack of experience and expertise in technical procurement procedures.
Thirdly, the preconditional challenges refer to the conditions and processes necessary for the successful introduction and implementation of welfare technology and care robots. The implementation of innovations in elder care is perceived as a complex task. Implementation difficulties do not only apply to elder care services; some estimates have indicated that two thirds of organisations’ efforts to implement innovations in health services fail [Citation55]. The findings showed that a common approach is to initiate a project, but when the project ends, the technology remains unimplemented. Implementation requires careful reflection on whether the current solution is the best, and what needs to be done differently when using the innovation [Citation56]. Considering that the scope of welfare technology is broad, assessments are required to determine whether the various technology solutions have a realistic chance of being transferred into elder care practice [Citation57]. One essential precondition involves aspects of safety, security, and integrity, all considered to be of vital importance in healthcare, and perhaps even more so in the elder care context. Care robots have a wide variety of tasks and appearances and they could, in a worst-case-scenario, cause damages to objects or even persons. This concern may overshadow all other gains and benefits [Citation58].
The utility of the technology was perceived as one of the main preconditions for its successful introduction. The care robots must be regarded as beneficial, meaning that the advantages outweigh the disadvantages. The importance of recognition of the relative advantages of an innovation is well known in the implementation literature [Citation59]. By adopting a user-centred approach, from design to implementation, the care robots can better match the end user’s needs and requirements. For this it is imperative that the end users are involved in the development of products to ensure the products’ appropriateness [Citation60]. Older persons have been found to have high demands of the care robots’ functions in order to consider them useful [Citation61], which further reinforces the importance of their participation in the development process. Although older persons may currently find some care robots’ functions too limited, many are still positive about the idea of a robot providing sufficient support to prolong independent living [Citation20,Citation34]. The use of welfare technology and care robots greatly affects care professionals. They belong to the group of end users, but are additionally expected to instruct and support the older persons and their families in the use of the welfare technology; consequently, their involvement is of the utmost significance. More effort should be made involve care professionals in the whole process, not only in the final phase when implementing the welfare technology [Citation23,Citation53]. Care robots have great potential to support care professionals in their work by, for example, strengthening bodily functions and thereby preventing injuries, but their perspective seems to be neglected at this point in time [Citation13,Citation53].
Successful introduction should be founded on a flexible implementation plan, having its basis in trustworthy knowledge and previous evaluations. It is imperative that the healthcare providers and organisations share their experiences and learn from each other, but one challenge is the lack of evaluations of the various types of technologies, including high-quality studies [Citation57]. A systematic review [Citation62] revealed that there is a lack of coherence regarding evaluations of the implementation of welfare technology. Coherent models are requested that explore individual perspectives, as well as the economic and organisational dimensions [Citation62]. Information and communication technology, robots, and sensor technologies seem to be the most frequently explored areas of technology in terms of acceptance, effectiveness, and efficiency; however, studies of efficiency (cost analyses) are rare. Notably, formal care in ordinary accommodations seems to be an unexplored field, considering that most care takes place in people’s homes. Only 6.7% of all the included studies focussed on formal care at home and 8% on informal caregivers [Citation57].
Care robots represent a field that has been emerging over the last decade [Citation7], but the use of them is, for various reasons, still limited. The findings showed that the introduction of care robots can be viewed as a process of social embedding, implying an effort to build a support network and to promote environmental changes to facilitate the diffusion of innovation. Social embedding is characterised by activating and sustaining dialogue between the various actors and it is based on a cyclic view of innovation, emphasising fundamental questions that require continuous consideration. The key actors in such a system are the end users, the technology and service providers, and the societal actors (e.g., public authorities and interest groups) [Citation63]. The heterogeneous composition of the actor groups calls for special attention to be paid to communication and collaboration during the process; therefore, sufficient time needs to be allocated for the societal embedding of welfare technology, and care robots specifically.
Limitations
This study had the wide-ranging objective of capturing challenges relating to the introduction of care robots. In the present study, we did not explore the end user’s perspectives, instead focusing on the challenges as perceived by organisational and societal actors. The content of the identified grand challenges may not be all-encompassing; however, given that they concern an ecosystem in which all the parts are interconnected, the findings may be considered as providing an overall description of the challenges.
There are, of course limitations, to our study. One is that there were only two or three informants from each field; however, together they represented key actors from central organisations operating at a societal level, with a central interest in, involvement with, or connection to the topic. Together they were able to provide an overall understanding from a societal perspective; that is, the exo- and macro-level perspectives [Citation29]. To gain a deeper understanding, we suggest further research within each of the proposed challenges/themes. For that purpose, this study could serve as a map.
In addition, it was not possible to determine when the informants expressed their own personal opinions and when they spoke as professionals; however, personal viewpoints will always be reflected in what is said. It cannot be ruled out that the informants were only referring to care robots, and not welfare technology in general, even though the interview questions specifically referred to care robots; hence, both concepts were used in the present study.
The present study focussed on a Swedish context, but the findings should, in many respects, be transferrable to other countries, since an increasingly aging population and an inadequate workforce is not merely a Swedish challenge. Although the study focused on care robots, the findings are probably, in many respects, transferrable to the introduction of other types of assistive technology in elder care contexts.
Conclusions
Seen from a broader care service perspective, it is concluded that technical innovations in general, cannot be introduced into care services as “separate islands”. Introducing and implementing welfare technology in elder care services is probably even more challenging, given the reported prevailing attitudes, preconceptions, and the intertwined context. Not until the ecosystem as a whole is considered and managed can major changes in welfare technology use take place. The study provides an overall insight into the complexity of introducing and embedding welfare technology, in the context of elder care services. The results from the study can be used in identify significant challenges, when planning to introduce and implement welfare technology in elderly care. The presented challenges follow the pattern of an ecosystem, in which all the different parts are intertwined and need to be considered. Once the ecosystem and the challenges are addressed, respected and managed the opportunities for utilising the potential benefits offered by welfare technology will increase. By assisting older persons and their caregivers in daily tasks and rehabilitation, time can be freed up to be spent on activities that promote wellbeing and a meaningful life. Care professionals could be given the opportunity to invest their time and knowledge where they are needed most—in caring activities that cannot be replaced by technical solutions.
Disclosure statement
The authors report no conflicts of interest.
Additional information
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Notes
References
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