Exploring Taiwanese Nursing Homes as Product Ecologies for Assistive Robots Wan-Ling Chang, and Selma Šabanović, Member, IEEE Abstract Nursing homes and long-term care institutions often need technological assistance because of the high ratio of low-functioning residents coupled with a shortage of caregivers. To explore the potential uses of emerging robotic technologies in nursing homes, we apply Forlizzi s concept of the product ecology and a user-centered design approach involving field observations and focus groups to understand what kind of robot design would be suitable for the nursing home context. Our results show that instead of robots replacing human labor, nursing home staff prefer robot assistants who fit into their work process. We also learned the most appropriate functions for robots in nursing homes were helping with minor tasks and encouraging social interaction among residents. Our study was performed in two nursing homes in Taiwan. I. INTRODUCTION As aging society has become a critical issue for many developed countries, there is an emerging trend of developing assistive robotic applications for older adults. These assistive robots are generally developed for two contexts: assisting older adults living independently at home and supporting caregiving in nursing institutions. The majority of studies focuses on exploring robotic technology to enable aging in place, often using user-center design approaches, such as Care-O-Bot [1]. While aging in place is preferable for society as well as individuals, the reality is that more than one third of older adults experience living in the nursing home during their lifespan, particularly as they get older and experience decreased physical and cognitive functioning [2]. Nursing homes and long-term care institutions often need technological assistance because of the high ratio of low-functioning residents coupled with a shortage of caregivers. Therefore, the study of robotic technologies in nursing homes requires equal attention to independent living. Compared to research on robotic technology for older adults in independent living contexts, there are relatively few studies investigating robotic applications in nursing home environments. The Nursebot project intended to build a mobile robot that could assist people in their daily activities in an elder community [3]. The interactive robots performed the tasks of reminding people about daily events or guiding them through their environments. Additionally, in 2013, the Japanese government provided financial support for developing low-cost nursing home robots for specific care tasks in order to reduce the burden of nursing home workers [4]. The robots were meant to assist older adults in W. Chang is a doctoral student at the School of Informatics and Computing, Indiana University, Bloomington, IN 47401 USA (e-mail: wanlchan@ Indiana.edu). S. Šabanović is an Assistant Professor in the School of Informatics and Computing, Indiana University, Bloomington, IN 47401 USA (e-mail: selmas@ Indiana.edu). performing daily activities, including lifting or moving non-ambulant elderly people, assisting elder people walking, and tracking dementia patients. Initial studies have emphasized technological and functional development of assistive robots, but not many focus on the experiences of older adults and their caregivers in the nursing home environment, which are crucial to designing an appropriate nursing home robot. In this paper, we present a study that focuses on the users and their daily practices in situated contexts of use to explore the potential uses of emerging robotic technologies in nursing homes. We apply Forlizzi s [5] concept of the product ecology and a user-centered design approach involving field observation and focus groups to understand what kind of robot design would be suitable in the nursing home context. Forlizzi s [6] work shows that examining the product ecologies of older adults can provide a comprehensive understanding of the physical and social environments of older adults living at home, and guide the design of appropriate assistive robots for domestic contexts. Our results show that, instead of robots replacing human labor, nursing home staff prefer robot assistants who fit into their work process. The most appropriate functions for robots in nursing homes were helping with minor tasks and encouraging social interaction among residents. Taiwan is a country with a rapidly aging population, which causes a large demand for nursing home services. For this reason, Taiwan is an apt field site for probing the future use of robotic technology in nursing homes. Extending the product ecology framework and user-centered design approach to our research aims, we performed a rapid ethnographic study [7] to examine the institutional context of the nursing home and its relation to technology and robots. II. RELATED WORKS A. Product Ecology Framework Based on the concepts of cultural ecology in anthropology and information ecology, Forlizzi et al. [6] developed the idea of ecology of aging to investigate the interrelationships between product design and the experience of aging. They proposed a senior-centered model to order to understand the connections between products, people, and environments. The components in the ecology system are interconnected, dynamic and evolving based on situations the older adults face, and will adapt to changes among the components. An appropriate assistive technology should connect well to the other components, including other products, people, and the environments, of the older adults ecology system.
Forlizzi extended the ecology of the targeted users to the framework of product ecology [5], a product-centered framework that includes single users as well as other groups of people interacting with the product. Similarly to the ecology of aging, the product ecology also takes into account the people and surrounding physical and social environments as well as the dynamics, the interdependence, and the relationships among those factors. This framework can help us structure and select design research methods. There are five components in exploring product ecology: product, system of products, person/people, roles, and environmental and social context. In this study, we explored an emerging rather than an existing product, so we focused on the product, system of products, person/people and environmental and social context, and the interrelationships among them as units of study and use these dimensions in analyzing our results. B. User-centered design in HRI User Centered Design in HRI puts the emphasis the on users perspectives instead of technology development in the early stage of robot design [8]. Task analysis is one of the most common approaches to understanding the needs of users. Decomposing the operation and task process by interviewing the operators or end users creates access to users knowledge [9]. Except task analysis, surveys and focus groups are also practical ways to understand users needs [9, 10]. Michaud et al. [10] used multiple approaches to access users perspectives of the robotic system, including field trials of existing robotic systems, focus groups of health care professionals and potential clients, and working prototype evaluation by end users. We adopted some of these user-centered methodologies. Besides applying focus groups and discussing existing and potential robotic technologies with nursing home staff, we conducted field observations of the daily activities of senior residents and staff, the social and physical contexts of eldercare, and situated technology use. groups. Our interviews and focus group involved on staff and family of the residents in the nursing home. Most of the residents had cognitive impairments that made it difficult for them to communicate, so we were not able to include them in interviews or focus groups, but consulted the staff regarding residents daily experiences as well as their reactions to and interaction with different types of technology. We also observed their daily activities in the field sites. A. Field observation and informal interviews We adopted an ethnographic approach in exploring the nursing home context, including observation, participation in activities, and informal interviews with inhabitants. Taking field notes and photos, we documented the daily routines and social interactions among residents and between the residents and staff. We also photographed all the devices and appliances used in the nursing homes to learn about technology that had already been adopted. In addition to field observation, the researcher also interviewed the staff that worked with those devices to understand the basic details and scenario of technology use. We collected information and data about the elderly care policy, laws regulating the nursing institution, the reasons why residents relocate to the nursing facility, the general concerns of eldercare in the nursing home, and the societal impact on the nursing home management in our interviews and official document reviews. III. STUDY DESIGN We conducted a short week-long field study in two nursing institutions in a rural area of Taiwan. Both institutions had bedridden residents and people with mobile disabilities. One nursing home also provided care for people with cognitive impairments, such as dementia and mental retardation. The number of residents in the nursing homes was approximately 150 and 90, respectively. The majority of the residents were older adults and most of the residents had some level of dementia. The organizational structures of both institutions were flat, with frequent and open communication between staff and management. Besides a small number of managers, accountants, and social workers, the staff was mostly comprised by nurses and caregivers. The nurses were all Taiwanese and most had experience in other medical institutions, such as hospitals. Most caregivers were immigrants from Indonesia, Vietnam, and the Philippines. Our research particularly focused on understanding the context, the relations of humans and technology, technology adoption, and people s perceptions of technology. In order to catch the picture of the social and physical contexts and the people in the nursing home, we applied multiple methods, including field observation, informal interviews, and focus Figure 1. The presented robots: (A)Roomba (B)TUG (C)RIBA (D)Hair-washing Robot (E)PaPeRo (F)PARO. B. Focus Group In order to get insights into technology adoption and the institutional context, we conducted two types of focus group study, both of which explored the potential uses of robotic technology in the nursing home. 1) Technology in the daily routine of nursing home For this series of focus groups, we conducted two meetings with different combinations of participants. One focus group included two institution managers and a nurse supervisor, and the other one had three nurse participants. The topics covered details of daily routines and social activities, the interaction of older residents and staff or outsiders, the nursing home workers and residents experience with technology, challenges of nursing work, the new technology introduction process, the eldercare
technologies they are interested in, and the robotic technology which participants thought could be applied in the nursing home environment. 2) Robotic Technology for the Elderly This type of focus group aimed to find out how people in nursing homes perceive digital technology and how technology can be applied to assist them. Two caregivers, two staff members, and one resident s family member participated. Besides asking about technology in the nursing home, we asked the participants to evaluate six robots (Fig.1) related to eldercare, which included robots for domestic cleaning, nursing care, and hospital use, by presenting a video. In the end, we brainstormed about possible applications of robot technology in the nursing home. IV. RESULT Field study and focus groups produced qualitative data about the nursing home and user perspectives on nursing home technology. The first stage of data analysis mainly focused on four main questions: (1) What are the societal and organizational contexts of the nursing institutions? (2) What technology is used in the nursing home? (3) How are new technologies adopted? (4) How do people perceive robots designed for aging life? (5) What kind of robot is appropriate for the nursing home? A. The Nursing Home Context 1) Eldercare systems in Taiwan Among eldercare organization in Taiwan, nursing homes have the highest certification criteria and are staffed with professional nurses to operate the medical equipment and treatments. The services of nursing home are much more highly priced than those in other eldercare organizations. However, nursing homes attract people who look for better quality of caregiving and nursing, especially for bed-ridden residents. In addition, eldercare institutions in Taiwan tend to be small scale and localized. The eldercare institutions usually have residents with diverse conditions and have to be flexible and perform multiple functions in dealing with diverse service requests. Due to economic limitations, the local nursing homes tend to spend money on the necessary facilities rather than new and fancy interactive technology. Unlike many countries (e.g., United States), the national health insurance system in Taiwan does not provide an allowance for long-term care expenses of older adults with physical or cognitive impairment. So the economic issues are always a big concern for the families who need institutional caregiving services for their senior family members. Families generally prefer to choose eldercare institutions in the neighborhood where they live. The price of institutional eldercare service depends on the general incomes of the people in the geographic area and is usually equal or higher than the legal minimum wage of an individual. In our study, we also found that developments in Japan are a role model for Taiwanese eldercare system development as well as the main knowledge resource for eldercare institution owners. Because of the similarity of cultures and conditions between Taiwan and Japan, many workshop discussions referred to Japanese eldercare system models and eldercare policymaking. There is a strong connection between the Japanese and Taiwanese eldercare practices, so one might expect that assistive robotics will be making their way into Taiwan in the near future following Japan. 2) Institutional contexts The residents take showers every other day, and 75 and 45 people need to be showered in every morning in the two institutions. All of them need different levels of assistance in the process, so the caregiver labors are all devoted to the shower routine in the morning time. The residents who are not taking showers will take part in the Karaoke activities or watch TV in the lobbies. The lunchtime and dinnertime are stressful times for both residents and caregivers. The majority of the residents can t eat by themselves, and the caregivers have to take turns feeding them in a very short time. In the afternoon, besides napping time, the residents usually stay in the public area where the TV consistently plays news or TV shows. However, the residents are usually not social or communicative. Social workers or eldercare staff lead some activities (e.g., painting, exercising) in the afternoon for residents with better mental status. There are also monthly religious activities (e.g., church and temple visit) and supermarket shopping on weekends. In some traditional holidays, institutions have corresponding activities (e.g., making mooncakes in Mid-Autumn Festival) and include all the residents and the staff in the event. Those activities are what the residents look forward to most. Most of the rooms in the institutions have three to four residents. In order to increase the efficiency of services and management and socialization among the residents, the residents are assigned to rooms based on their physical and cognitive condition and gender. Female residents tend to be more social than males, but there is generally little conversations among the residents. The residents look forward to talk to people from outside to get new information instead of sharing their daily routines. The staff mentioned that many residents enjoyed daily greeting and physical interaction (e.g., hugging) with the staff, but because of the language barrier between cognitively impaired residents and foreign caregivers, these social needs are hard to fulfill. The general eldercare environment reflects that both the nursing homes and residents families have strong economic concerns over additional investments of improving the care services. Developing assistive robots which are economically acceptable will be important in the nursing homes. Besides, the physical and social contexts and daily activities of the nursing homes we studied (e.g., the morning showering time) can help us think about the potential needs in these contexts and must be considered in designing assistive technology to fit into daily institutional practices. B. Technology in Nursing Home We reviewed the technology already adopted in the nursing home to get ideas about the appropriate functions and presentation of robots. We discuss the applied technology in five categories below. 1) Medical Technology Most residents in the nursing home have chronic illnesses, especially the bedridden residents, who require
specific medical treatment and technical products. The majority of medical technologies used in the nursing homes are to support the physiological function of the bedridden, such as vacuum sucker, and oxygen supplier system; other medical equipment is used for monitoring health status (e.g., sphygmomanometer, blood glucose meter) and treatment (e.g., wound toolkit, steam inhaler). The automated drug dispenser is the most frequently used device, though not directly for medical treatments. As most residents have multiple chronic illnesses, it helps both staff and residents manage their drug intake. After packing medicines into small packages, nurses need to mark or tag the information of the residents and the date and timing of medicine intake on each bag to avoid mistakes in giving medicines to the residents and maintains the medicine-taking records based on the information of untaken medicine bags. 2) Service and environmental Technology Many of the technological devices in the buildings were used to provide daily services, including the calling bell, tools for preparing food and cleaning, therapy equipment, air conditioning and light controller. Those technologies substantially influence the residents life quality but they do not have much chance to interact with them directly. 3) Entertainment Technology There were multiple TVs in the building and they were usually on. In one nursing home, they had Karaoke activities every morning. They also had Wii-like interactive video games and other entertainment tools for physical group activities. Except for the TV, most of the entertainment products required caregivers assistance. The lack of human labors in supporting the entertainment activities lead to that TV becomes the major entertaining technology for most of the residents. Besides the public entertainment devices, part of the residents had their personal entertainment products, such as radio, brought by their family. 4) Indirect Technology Some of the technologies the nursing home workers use do not directly relate to the residents daily routines. For example, the fire alarm and broadcast system will be in use when there is a fire. The security monitoring system is used to record certain events (e.g., falling accidents) for assessment and service improvement. The computer and copy machine are only for the required paperwork in the nursing home. Barcode scanners are for supply stock control. Those technologies are rarely used, or are operated by a small number of staff. The majority of people in the institution have no interaction with them. 5) Digital Technology Most of the medical records were recorded on paper, so there were only limited computers located in the field sites. The computers were only used for the general medical records of the institution (e.g., the total number of residents who had fevers or went to the hospital) or official record of annual government assessment. Most of the documents were kept by the nurses, and they preferred working with paper and pens. For personal technology use, the majority of the workers, including foreign caregivers, in the institutions had cellphones, but very few had smart phones. Most of the residents did not know how to use cellphones and some of them could not make a phone call with a landline phone by themselves. Both residents and staff in the institution have low interest in keeping up with the latest digital technology. In our observation, not many modern technologies are used in the nursing homes, especially digital technology. Half of the installations and devices in the nursing home are low-tech and common in regular public buildings and people s house in Taiwan. The residents and the staff feel freer to interact with non-digital technology in their daily practices, which should be considered in the assistive robot design. C. Technology Adoption in Nursing Home In our study, we found that the managers of the nursing homes informed themselves about new nursing technologies only from oversea nursing home visits organized by the long-term care association and medical equipment sales. The nursing home managers mentioned that they had limited information resources for technologies used for eldercare and the busy daily routines kept them from searching out new information on assistive technology. PARO, a therapy robot resembling a baby harp seal, is the only robotic technology that had been mentioned by participants in the discussion of the assistive robotic technology they knew. The limited budget of nursing homes also restricted the adoption of latest assistive technologies. The information regarding eldercare or rehabilitation was usually provided by salespeople who were promoting their products. Most of the time, the technology introduced to the nursing homes were devices which had similar functions to those currently used and provided better functions. Those devices were usually proposed by nurses who worked in other nursing institutions or hospitals and had seen those technologies there. D. Perception of Current Elderly Robotic Technology Comments from the participants who saw the six robot videos (Fig. 1) in the focus group tended to be negative. Some nurses worried that the Roomba might cause falls of the elder residents, which might then cause rapid health decline. The TUG was criticized for its size, which would not fit into the narrow hallways of nursing homes. The hair-washing robot might be suitable for the hospital or home delivery service, but was too huge and did not fit into the residents showering routines. They were skeptical that the social interaction brought by PARO in Japan can be duplicated within their residents, and PARO would be easily dropped and broken because of the weak upper lambs of many residents. The most critical comments are about RIBA. The caregivers expressed concern about the diverse situations of moving the residents and the safety of robot carrying. The mentioned RIBA can be applied in the case of stable residents, but most of the residents are active while moving them. The discussion of the robotic technology reflected the participants negative attitude regarding the coldness and lack of humane care in using robots in place of human caregivers. The security of interaction with the robots was a major concern for the staff in the nursing home. The nurses and the managers mentioned that falling is lethal for older adults. Many residents have severely diminished functions and passed away shortly after a fall. In all the workshops, security
was mentioned as a critical criterion in evaluating current robotic technology and developing future assistive robots. In general, most of the workers in the nursing home questioned the practicality of the robot in the nursing home as well as coldness impressions of robotic technology. For them, the robots shall be secure to avoid causing falling accidents to the senior residents and flexible to fit into the nursing home environments and people s daily activities. E. Potential Robotic Applications The ideas of potential robotic application in nursing home environments across three focus groups are very different, but they can be grouped into the following three directions. 1) Assistive role in caring works The caregivers and nurses perform many tasks requiring heavy labor. Most of the available technologies are not easy to use and fit into their workflow. It usually takes longer time and more effort to work with new assistive products. They look forward to having flexible and easy to use robotic technology, which can easily adapt to their work with complex and varied situations. 2) Assistance in Minor Tasks Besides busy daily routines, the nursing home workers also need to manage various minor requests from the residents. Most of the residents are stable and stay in one place. They wait for the workers to serve what they need, such as bring a cup of water, tissues, or peeled fruit. Those minor requests are not only their physical needs, but also reflect the desire to be cared for. The nurses and caregivers need assistance in performing these minor chores and giving instant feedback to residents requests to make them feel cared for. For example, they hope to have a service robot to carry things the residents ask for. When the residents want fruit, they can prepare it in the kitchen and ask the robot to send it to the person who needs it. Some tasks in the caregivers daily routines are minor and time consuming. For example, they have daily activity schedule in multiple locations; many residents need help in moving wheelchairs. It takes a long time to get all the people ready. If those easy and minor tasks can be done with technology, both of the residents and workers can spend more time in the activities than waiting. 3) Entertainment and social interaction encouragement Life in the nursing home is usually boring. It is always a big challenge for the nursing staff. Most entertainment they try to introduce requires many workers to participate and assist. The workers play an important role in generating the interaction among the residents. Many residents look forward to talking to their family and people outside the nursing home instead of having a conversation with the other residents who have the same daily experience and nothing to share with others. The participants in the focus group suggest the technology used to extend the life experience and communicate with family and outsiders will help in emotional and psychological status of the residents and also promote social interaction among them. For example, the residents will be glad to have a robot which can take them for a walk in the park nearby the institutions. V. DISCUSSION Applying the product ecology framework, we will now attempt to translate our results into design implications and analyze them with the following dimensions. A. Product The results of interviews and focus groups showed a negative attitude toward the image of cold and inhuman robotic technology among the workers in nursing homes, especial nurses, caregivers, and social workers who had frequently direct interaction with the older adults. It was easier for the workers to accept robots as assistants that help them have more time to provide major care services that require human affection. The discussion reflected the needs of robotic technology to provide a certain level of human-like caring functions in order to increase the residents feeling of being attended to. For example, in talking about the minor task helping robots, the participants suggested that the robot should greet people while delivering things to them, or the robot s body should be made of soft or confortable materials in order to provide pleasant experiences in physical interactions with residents. The study participants also did not trust the development of robotic technology in completing complex and refined human tasks. Opposite to many complicated robot design ideas for the elderly, the workers in the institutions looked forward to having the robots doing some minor tasks for them. While concentrating on the actual work practices in the nursing home, the expressed needs of the users were not as complicated as what researchers have expected. The caregivers and nurses had heavy working duties, but a huge part of their work was dealing with minor requests from different individual residents. Fulfilling the requests was relatively time consuming but important for providing the feeling of care for the residents. The perception of the assistive roles of robots and the distrust of the robot s capability shaped the potential robotic applications they imagined being used in their working places. B. System of products The system of products displays the inter-relationships and interdependence of the different products in the ecology system. In the studied nursing home, we found not only the elder residents but also nurses preferred non-digital and traditional technology. While focusing on the context of future robot use in nursing homes, we found that the workers in the nursing home were more confortable with traditional ways in their daily life. It s not necessary for them to use new technology that might contribute to the efficacy of their work. For the participants, the potential robotic technology is not a replacement of current products functions, but provides additional functions, which the products already in the nursing homes do not provide. C. Person or People Sometimes, there are more than one person connecting to the technology or product, and their ideas, attitudes, and dispositions toward it are critical in exploring the product ecology system. As mentioned in the product section, people in our study had negative impressions of the coldness
of robotic technology and low confidence in the complexity of tasks the robots can deal with. They had concerns of adopting new assistive technology because they had negative experience of being impeded or slowed down in their busy daily routines while they had to learn and adapt new technologies. At the same time, they expected new technologies to fit into their daily work properly. In line with Mutlu s work [11], the reflection from the workers showed that, in designing robotic or assistive technology for the organizational contexts, it is important to take the worker s daily routines into consideration and reduce the effort needed to adopt the technology. Besides the participants comments and ideas of simple-task robotic technology, we found there are many work routines that could be assisted with appropriate robot design. For example, showering is labor- and timeconsuming work. The staff in the institution mentioned that it will be good to have technological assistance but it s hard for them to image what kind of technology will fit into their working flow without slowing down their work practices. Feeding the residents is also part of the work the caregivers may need help with, but the complexity of the working flow and concerns of lacking human contact stop the participants from thinking about the possibility of the robotic assistance in the process. The participants have little confidence on the robot design and robot capability. From their reflections, the needs of the assistive robotic technology challenges the existing robotic design field. D. Environmental and social context The older adults in the institutions usually move with walkers or wheelchairs and most of them can t quickly control the wheelchair and response to the environmental stimulates. The narrow hallways can t allow the huge side robots move along with the older residents on their wheelchairs or with their walkers. That s the reason why the nursing home workers critiqued TUG as an impractical and unsuitable design in existing nursing home. It reflects the necessity of considering the size of robot design based on the nursing physical setting. Because of the nature of the eldercare services, all the workers in the institution highly emphasized the security issues of introduced technology. Falls have a strong impact on older adults quality of life as well as the work of the institutions and caregivers. Robots should detect the seniors actions and behaviors in the environments to avoid making them fall down by mistake. Participants emphasized alleviating security concerns was more important to them than having a helpful robot. We also found societal and organizational factors might influence the development and adoption of robots in Taiwanese nursing institutions. Based on current Taiwanese eldercare environment, the institutions usually have limited budgets of introducing new technology and the family of the residents also has economic concerns of putting extra money in the eldercare. Low cost and simply functioning assistive technology will be a better choice for the localized eldercare institution. Because of the diversity of service requests made by various types of residents, the technology should support the flexibility of the institution working practices. All of those should be considered while developing robots for the Taiwanese nursing institutions. VI. CONCLUSION Our study of the two nursing homes showed the relationships of products and inhabitants in the product ecological system in the eldercare institutions. The findings posed the need to be aware of the organizational context, the daily routines of the inhabitants, and reflections of the users on robotic designs. This study was conducted at two nursing homes in rural Taiwan. 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