Abstract
Japan is facing a ‘care crisis’. There is an urgent need to ascertain the extent to which potential users are willing to use robotics-aided care before its roll-out as a formal policy. Based on our recent survey, we discuss home-care professionals’ real perceptions and their implications for the future development and implementation of home-care robots. While they showed some concerns about robotics-aided care, they perceived ‘physical support’, ‘communication’ and ‘monitoring’ functions positively. A small number of care professionals recommended assistive technologies listed in the insurance payment scheme. We conclude that both individual preferences and formal policy options are necessary for an effective implementation of robotics-aided care.
Introduction
All industrially advanced economies are facing the challenges of accommodating an ageing population to some extent, with many people wishing to lead an independent and active life in their private environment for as long as possible. Many recent studies show promising signs that technological solutions could support ‘ageing in place’ by creating an ambient assisted living system with in-home monitoring (Davey et al, 2004; Age UK, 2014). As the new coronavirus infectious disease (COVID-19) pandemic has highlighted, there is now a new focus on the introduction of telemedicine and the application of remote monitoring and robotics-aided care as countermeasures for the spread of the virus and the protection of older people and care professionals, particularly in nursing care facilities. Against this background, there have recently been debates and discussions in the media regarding human care and caring, and the question as to whether someone would ‘let a robot take care of your mother or family members’ (Jackson, 2019; Machin, 2020). Therefore, given the imminent roll-out of the robotics-aided care model as a public policy, there is an urgent need to ascertain the perceptions of care professionals. We certainly need to listen to the voices of users.
‘Care crisis’ in Japan
Wider application of assistive technologies is needed to help care professionals because workforce shortages and the burden of care work are serious issues currently facing the industry (‘care crisis’). As the proportion of older people in Japan grows rapidly (28.4 per cent as of 2019), the size of the older population is quickly becoming overwhelming, compared with similar countries. It is estimated by the government that there will be a shortage of 370,000 nurses and care professionals to accommodate this older demographic by 2025. Robotics-aided care is thus seen as not just promising, but almost inevitable. Considering the necessarily large-scale change required by assistive technology, integrating robots and information and communication technology (ICT) into care provision and daily life has been given serious thought in Japan. In April 2018, the Ministry of Health, Labour and Welfare established the Office for Nursing Care Robot Development and Promotion, and appointed special staff to take charge of it.
Attitudes towards robotics-aided care
In 2016, a robot-assisted walker was added for the first time to the list of reimbursable items under the Long-Term Care Insurance scheme. The list of items was expanded again in 2017 to include more assistive technologies. However, there remains a strong belief held by care professionals in Japan that care should be conveyed by humans rather than by robots (Beppu and Fukuda, 2008). Even in Japan, where people are familiar with the presence of robots and trials for communication robots are being conducted in home-care settings, care professionals may still have doubts regarding assistive technology.
Previous findings
In 2015, the Ministry of Internal Affairs and Communications in Japan commissioned a survey on ‘people’s perceptions towards new ICT services and technologies as a tool for solving social problems’, prompting responses from 2000 citizens aged 13 and over. The survey indicated high levels of willingness among older respondents to incorporate a robot into their care. Of respondents in their 50s (N = 400) and 60s and over (N = 400), 67.0 per cent and 68.6 per cent, respectively, said they would like to use or would consider using a robot when they become a cared-for person. Among cared-for persons, the percentage is even higher (68.3 per cent among those in their 50s; 69.5 per cent for those in their 60s).
Contrarily, surveys conducted in other jurisdictions highlight that many people are not prepared to accept such care. The results of a survey conducted in 2012 by the European Commission indicate that the care of children, older people and people with disabilities tops the list of areas where the use of robots should be banned (European Commission, 2012). Another recent survey conducted in Finland found that care professionals do not believe in the usefulness of home-care robots for the purpose of alleviating anxiety and loneliness (Rantan et al, 2018).
Our previous study results showed that the principal factor affecting the use of robotics-aided care by care professionals was ‘perceived benefit’ (Suwa et al, 2020); however, the questionnaire responses were insufficient for expounding the specific and necessary functions demanded by them. Therefore, some relevant questions have remained unanswered. For example, is robotics-aided care being welcomed by home-care professionals as an innovative instrument to support and promote home care, or is it considered unrealistic in home-care settings? Based on our recent survey, we discuss home-care professionals’ real perceptions and their implications for the future development and implementation of home-care robots.
Current study on perceptions of home-care robots
Participants
Considering the previous research, the team of researchers conducted a questionnaire in one Japanese prefecture to understand perceptions of home-care robots among home-care professionals in 2017. The self-administered questionnaire contained questions about how a home-care robot is perceived, how a robot may be useful and how willing the participant is to engage in research developing such robots (Suwa et al, 2020). A total of 444 valid responses were returned from home-care professionals.
Methods
An additional comment section was provided in the questionnaire to ensure that home-care professionals were able to express their views regarding robotics-aided care. According to Decorte et al (2019), open-ended comments may provide valuable additional information to the closed questions; however, most relevant studies have failed to examine this issue. Among the few studies addressing free comments in questionnaires, rhetorical (Decorte et al, 2019) and discourse analysis (Stokowski, 2013) have been employed for relatively long text comments. We conducted a quantitative analysis based on categorising respondents’ comments.
Two researchers (Naonori Kodate and Hiroo Ide) independently assessed the reported comments and classified attitudes towards home-care robots into three categories: positive, negative and mixed. The comments categorised into ‘mixed’ indicated both positive and negative feelings towards home-care robots (Vandemeulebroucke et al, 2018). For example, if respondents often expressed the usefulness of robots and anxiety over malfunction in the same comments, we classified the comment into ‘mixed’. For comments where the two researchers did not agree about the categorisation, these comments were assessed again by the third researcher (Atsuko Shimamura). Then, Naonori Kodate grouped the topics mentioned in the free text according to similarities in the meanings.
We calculated the percentage of negative comments for each topic. It must be noted that we assigned plural topics to cases where respondents suggested multiple meanings in a comment. We counted the number of comments and conducted a chi-square test and Kruskal-Wallis test for the top three topics by frequency order, controlled for gender and age category. We counted the types of devices that were recommended by home-care professionals or already introduced in home-care settings.
Results: voices from home-care professionals
Among a total of 444 home-care professionals, 351 were women (79.1 per cent), those in the 40s (n = 136, 30.6 per cent) and 50s age groups (n = 134, 30.2 per cent) represented the majority, and 175 (39.4 per cent) filled the additional comment section. After the assessment of the additional comments, there were 71 positive (40.5 per cent) and 108 negative (61.7 per cent) comments for the introduction of assistive technology. A total of 29 comments (16.5 per cent) were deemed to be neither negatively nor positively worded (mixed).
We categorised 324 comments into 14 topics (Table 1). The top three topics by frequency order were ‘malfunction’, ‘human versus machine’ and ‘physical support’. The respondents mostly expressed concerns about malfunction; among a total of 43 comments, 38 comments (88 per cent) had negative nuances. A total of 42 respondents referred to a fundamental difference between care delivered by human beings and robots (human versus machine), and 30 of those comments (71 per cent) were negative. A total of 28 respondents suggested that nuances will never be accurately picked up by robots, and expressed concerns about what would happen if the care robots have to make a decision urgently, disregarding subtle messages and nuances that influence human decisions. On the other hand, there are high expectations for ‘physical support’. The ‘communication’ and ‘monitoring’ functions are also perceived positively. For those topics, the percentages of negative comments were relatively low (44–58 per cent). Only six respondents were wary of ‘privacy’ concerns, and two were anxious about ‘job loss’. The characteristics did not statistically correlate with their attitudes towards home-care robots (all p-values were above 5 per cent).
The number and the percentage of comments mentioned in the additional comment section by the respondents
| Topics | n | Number of negative comments (%) |
|---|---|---|
| Malfunction | 43 | 38 (88%) |
| Human versus machine | 42 | 30 (71%) |
| Physical support | 34 | 15 (44%) |
| Communication | 31 | 18 (58%) |
| Monitoring | 30 | 12 (40%) |
| Nuances | 28 | 24 (86%) |
| Speedy implementation | 26 | 20 (77%) |
| Alert | 22 | 10 (45%) |
| Usability | 20 | 13 (65%) |
| Value for money | 17 | 9 (53%) |
| Aftercare | 16 | 16 (100%) |
| Dementia | 7 | 4 (57%) |
| Privacy | 6 | 3 (50%) |
| Job loss | 2 | 2 (100%) |
Notes: A total of 175 respondents provided their comments in the additional comment section of the survey. The number of topics categorised by the authors was 324 overall, as shown in the table.
A total of 16 home-care professionals (3.6 per cent) had prior experience recommending assistive technology for their patients: five home-care professionals previously recommended ‘an alerting device for noticing drug intake’; four professionals used ‘a monitoring device to watch older people out of the home or falling from the bed’; and three professionals had recommended a ‘robotic-assisted walker’. The other types of assistive technology mentioned were ‘an automatic defecation assisting device’ and ‘a communication robot’. One home-care professional recommended ‘an artificial muscle technology for caregivers’.
Discussion
In the current survey, more than a third of home-care professionals expressed attitudes against the use of home-care robots. The majority of the comments were classified as negative. In some cases, respondents expressed disapproval in a very explicit manner (for example, ‘I reject inhumane care’). In addition to respondents’ concerns about potential safety risks, moral and ethical aspects of introducing assistive technology have to be given a considerable amount of attention if or when such a novel model of care is rolled out (Jasanoff, 2016).
Japanese care professionals seem to have very ambivalent feelings regarding how they reconcile the quality of care and the idea of a ‘care crisis’. According to the answers to the current survey, potential loss of employment did not feature much as a consideration. Rather, the respondents believed that reduced human contact and interaction was a major disincentive against the adoption of assistive technology. Care professionals especially emphasised the value of warm and intimate interaction between cared-for persons and their carers. At the same time, a number of professionals showed interest in using home-care robots. In this regard, the current study elucidated that physical support, communication and monitoring were frequently mentioned in the free text comments. Those functions should be prioritised to develop and implement assistive technologies in care provision.
Answers to this survey about past experiences of using assistive technologies suggested that several professionals had attempted to implement monitoring and alerting devices, as well as assisted walkers. It is natural for care professionals to trial the listed devices because the payment was secured and the devices were safe to use. Close attention should be paid to the similarities between the devices listed in the insurance payment scheme and those that the home-care professionals tried to introduce independently, which suggests that the public institution is implementing restrictions on the professionals’ behaviour with regards to the use of assistive technologies. Reform of insurance policies to support demand for novel technologies will likely be needed to support the rapid implementation of home-care robots.
On the other hand, it can be said that those care professionals’ preferences may reflect short-term technological needs. Leslie et al (2019) discussed a ‘need-based approach’ and a ‘goal-oriented approach’. The latter approach could provide a long-term solution, which is a sustainable caring model, by enhancing system capacity and resilience, knowledge, skills, and social connections. In this regard, participation of care professionals in the development of assistive technologies in order to find shared goals among users and developers will be valuable for future care utilising assistive technologies. Although there continues to be a dearth of research evidence that demonstrates the effectiveness of home-care robots, as empirical studies begin to highlight the usefulness of assistive technologies (de Graaf et al, 2015; Obayashi et al, 2018; Brims and Oliver, 2019), there is a strong impetus for bringing these innovations to the next level of policy implementation.
Conclusion
In order to evaluate the effective introduction of robotics solutions in care for older people, interactions will need to be examined from the perspectives of both individual preferences and institutional choices. Individual caring practices reflect a range of activities and expectations, which are deeply situated in cultural, organisational and political contexts. In addition, the current COVID-19 pandemic has evoked interest in and discussion regarding care provision with care robots as possible countermeasures against the spread of infections, as well as the risks of social isolation. Therefore, home-care professionals’ perceptions may have been affected by the pandemic. However, there is no question that the need and demand for discussion, research and development as regards robotics-aided care are greater than they have ever been. As a way of overcoming many of the challenges facing the current long-term care policy in Japan, it is essential to establish co-design methods for researching and developing assistive technologies.
Conflict of interest
The authors declare that there is no conflict of interest.
Note
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