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Robotic Support of Nursing Care

State of the Technology and Future Predictions
Published:October 09, 2022DOI:https://doi.org/10.1016/j.mnl.2022.08.007

      Abstract

      It will be unimaginable to practice without the help of robots in the future. There will be downtime procedures for robots. Current robot technology is on the verge of becoming part of care processes but not yet a disrupting force. Leaders should not underestimate the potential for robotics to revolutionize care. In the future, beyond any of our careers, robotics could pose an existential threat to nursing, potentially reducing nurses to the role of technicians, with the pressures of efficiency and evolving priorities. But, we can prevent this.
      Key Points
      • Current robot technology is on the verge of becoming part of care processes.
      • Leaders should not underestimate the potential for robotics to revolutionize care.
      • We can add value to humans as future robotic systems evolve.
      It will be unimaginable to practice without the help of robots in the future. There will be downtime procedures for robots. Current robot technology is on the verge of becoming part of care processes but not yet a disrupting force. Leaders should not underestimate the potential for robotics to revolutionize care.
      • Tietze M.
      • McBride S.
      Robotics and the impact on nursing practice. Silver Spring, MD: American nurses Association; 2020.
      In the future, beyond any of our careers, robotics could pose an existential threat to nursing, potentially reducing nurses to the role of technicians, with the pressures of efficiency and evolving priorities. But, we can prevent this.
      Today’s most advanced health care robots will be tomorrow’s lower-performing robots. In the future, there will be levels of robots, including robots that require regulatory approval for their manipulation of the physical world, their algorithms, and how they interact with humans. Currently, a leader’s job is to ensure the ethical, biogenic (life-giving), human-centered evolution of nursing robot technology.
      Current and near-future robots can support tasks surrounding nursing, but they cannot replace fundamental aspects of nursing practice for two significant reasons. One, robot technology’s ability to delicately manipulate the physical environment is not well suited for dressing changes, intravenous starts, activities of daily living, placing tubes, or interacting with medical devices designed for human hands. Today’s robots function best in a stable environment performing repetitive tasks. Patient care areas, including homes, schools, parks, hospitals, nursing homes, and the community, are ever-changing. Current robots, such as Moxi, can deliver supplies and medications because hospital hallways and nursing stations remain in the same location. Near-future robots (5 years) will face functional barriers to entering patient care rooms or directly touching patients.
      We characterize the current stage of health care robot technology as akin to the early personal digital assistants (e.g., Palm Pilots) of the late 1990s. Those palm pilots were a vivid sign of times to come, but the technology did not feel like it improved efficiency; it was under-integrated. Yet, it was the first device to give us a clear insight into the future and popularity of handheld devices managing our lives.
      • Lake M.
      Pocket marvels: 40 years of handheld computers.
      Those early personal digital assistants did not clearly unlock human potential, and sticking with a paper planner and email on your desktop was the preferred choice for many. Then came the Blackberry and the iPhone, and most people put their analog planners down.
      There was good reason then, as there is now, to become an early adopter as robot technology evolves. Early adopters have the chance to influence the evolution of robots, digital transformation, and ethical, effective processes. Leaders can acclimate their teams to robots as work partners now, before a noticeable return on investment, by building the infrastructure in the environment needed to allow robots to be part of the work team. By waiting and becoming a late adopter, when the technology becomes value-added, you risk being behind in infrastructure and culture, and you have lost the ability to influence the field, where you will have a workforce that has not experienced robots since the early days of the robotic revolution. Using robots now reduces the risk that you and your team will feel disrupted when the inevitable disruption of robotics in health care becomes a reality.

      Near-Term Robot Functionality in the Nursing Process

      In the near term, within many of our careers, robots will use artificial intelligence (AI) and integration with the digital environment to support the nursing process.

      Assessment

      Robots have a strong potential for offering patients enhanced surveillance. By pulling data from the electronic health record from sensors, cameras, and microphones, a surveillance robot can provide an initial assessment to the professional staff. Cameras and AI are already in use to predict when a patient may be about to exit their bed or to assess gait steadiness. These technologies could be integrated into a robot.
      Early sepsis recognition is a nursing function. This function is increasingly augmented as more nurses use sepsis algorithms to identify sepsis earlier.
      • Schinkel M.
      • Paranjape K.
      • Nannan Panday R.S.
      • Skyttberg N.
      • Nanayakkara P.W.B.
      Clinical applications of artificial intelligence in sepsis: a narrative review.
      With integrated pumps and monitors, a robot will be able to direct the titration of medications to sedation or hemodynamic goal following an algorithm or provider order, adjusting the dose and assessing the patient’s response. Nurses cannot be in more than one location at a time, yet they are responsible for the simultaneous surveillance of their entire patient assignment (inpatients, home health, schools, communities). This has been a limitation of our ability, and all nurses have a nightmare of missing something or not being there when their patient needs them. The robot’s role in supporting surveillance will be their most life-preserving function. Because much of this technology exists or is in the final stages of development, robots supporting surveillance will happen in 5 to 10 years.

      Diagnosis

      Near-term robots will be able to stage wounds; identify suspected deep tissue injury; diagnose sepsis, acute pain, anxiety, excess fluid, fatigue, ineffective breathing pattern, and even loneliness; and search for the most current list of nursing diagnoses. When reviewing the list of nursing diagnoses, it is not easy to find one that could not be identified by a robot using today’s or near-term’s technology and AI.

      Planning/Outcomes

      In the future, a robot’s AI-fueled assessment and diagnosis will lead to a request for delivery of supplies, medication, and equipment that will arrive for the nurse, delivered by robots, so the nurse can carry out the parts of nursing care the robot is incapable of offering.

      Intervention

      Physical intervention is where the current and near-future robots will not be capable of meeting most human needs. Physical intervention is likely 15 to 20 years out. Interventions that will imminently be possible by robots are education, reorientation, encouragement, goal setting, distraction, medication administration, and supporting connection to family members or communities of support. Robots can also provide comfort.
      • Epley N.
      • Akalis S.
      • Waytz A.
      • Cacioppo J.T.
      Creating social connection through inferential reproduction: loneliness and perceived agency in gadgets, gods, and greyhounds.
      This comfort is not equal to human comfort, yet it is comfort. An analogy is having a cell phone with you when driving alone—not the same as being with another person—but still comforting.

      Evaluation

      Much of what was discussed under assessment stands true for evaluation. What is new about a world with robots is that there will be interventions that a nurse must complete, and the nurse will delegate aspects of the evaluation of the intervention’s outcomes to a robot. For instance, a robot will be able to monitor the effects of medication for the desired result through vital signs, interaction with the patient, and observation of the patient’s movements. As agents of evaluation after nursing intervention, robots will become a standard of care. Before cell phones, we drove without a way to communicate with family, friends, or roadside services and hoped for the best. Now, 25 years after cell phones became common, the idea of driving from city to city or even the market without a way to communicate feels almost reckless. Most of us would not let a family member take off without a cell phone. Twenty-five years later, if not sooner, we will not let our family members have an intervention without a robot filling a role in evaluating and monitoring that intervention’s effect.

      Workforce Response to Robot Helpers

      According to Alla and Pazos, the five foundational adoption factors are safety/reliability, capability/function, cost-effectiveness, clinical effectiveness, and usability/acceptability.
      • Alla S.
      • Pazos P.
      Healthcare robotics: Key factors that impact robot adoption in healthcare.
      The clinical workforce will care about all these factors. Acceptability has been a significant focus for innovators looking to create health care robots. A robot on an automotive assembly line can look industrial and weapon-like because, in that case, the robot is working on materials with human technicians. Robots working with clinicians and patients must feel biological and infused with human qualities, as though the robot has a soul.
      Robots’ acceptability to humans, patients, and staff must be prioritized. Suppose a robot meets the other adoption factors but is not acceptable because it feels intimidating, invasive, or unfriendly to people. In that case, it will be at risk of disuse or even sabotage.
      We found that acceptability played a critical role in our own experience with the robot Moxi from Diligent Robotics. Moxi’s name and a friendly look resemble a childhood toy holiday present. Moxi is decidedly nonthreatening. The robot’s wide eyes and deferential navigation of spaces feel amusement parklike. People like taking selfies with Moxi, and people say hi to Moxi. People speak of Moxi like an acquaintance they are happy to see.
      Moxi’s functionality is mainly point-to-point secure delivery, moving medications, supplies, and equipment from location to location. People put the item for delivery in Moxi’s belly drawer, and Moxi delivers the item moving on to its next assignment. Moxi is training to be able to self-load the drawer. Functionality and safety are initial questions people have about Moxi, as well. Moxi is respectful of people’s space as people approach, and it is obvious when watching Moxi that it can navigate obstacles. Moxi moves at a speed that is nonthreatening. As more care tasks are integrated with robot workflow, we have to be prepared to manage the risks and patients.

      Setting Robots Up for Success: Early Adoption of Robot Technology

      Accept robots where they are. Make initial steps into using robots while the technology is early. Markets will drive advancements in robot functionality. Work with industry partners and technology departments to create environments, power sources, battery replacement, and friendly robot appearances that maximize the robot’s ability to reduce downtime, improve the execution of the robot’s mission, and improve human acceptance. Moxi looks friendly, which helps Moxi’s acceptance.

      Clinical Settings for Robots

      Acute Care, Post-acute Care, Long-term Care

      Hunting and gathering tasks, which take so much nursing time, can be delegated to the robot using today’s technology. In the future, pharmacy robots will support medication administration. Future robots will be highly integrated into the technology environment and bring to the physical world functions driven by insights from the metaverse, electronic health record, AI algorithms, human behaviors, and human availability. As the virtual world develops in complexity and acceptance, the physical world will need robots to connect physical and virtual. While robots will engage with people (patients and clinicians) in social ways (education, answering questions, conversation), the essence of human caring in the licensed health care facility setting, and likely all environments, will remain a human function. Caring modalities, spiritual care, and healing energy require human consciousness.

      Schools

      School nurses provide health surveillance to a community of students, often covering more than one school where laws do not dictate a ratio of one nurse per school. There will be robots that support education while observing for signs of health needs during student-robot interactions. The technology for monitoring speech patterns exists today, and the need for a speech therapy intervention can be activated at the earliest sign of a speech pattern deficit. With existing technology, temperature, mood, vital signs, reminders, and support for calming modalities are conceivable. The school nurse’s office makes distinct the function of health care and education. Education robots with nursing features will interact with students for teaching and simultaneously be observed for good health. Students with individual needs related to epilepsy, allergies, and medications during the school day will be supported by robots that sense imminent seizures, the presence of allergens, and dispensing of medicines for student self-administration, when appropriate. Robots can catch early meningitis outbreaks on college campuses, educate substance use and sexual health, observe for signs of depression, and offer accessible resources. Robots can serve as chaperones to let someone know they have had too much to drink and slow down and find a friend. The robot can even be that friend staying with the student until they are no longer at risk for injury, aspiration, or victimization.

      Home Health

      In-home monitoring has been a growing modality for decades. Robots in the home will be an extension of in-home monitoring, providing patients and providers with helpful information on well-being. Robots are also important for supporting the social needs of people at risk for loneliness.
      • Montalvo F.
      Social robot companionship: Understanding loneliness to improve interventions.
      Robot vacuums are already sweeping floors. Robots that assist with other aspects of maintaining independence at home are on the near horizon.

      Caring Science and Robot Technology: Avoiding a World Without Nurses

      Imagine a world without persons who know what nurses know; who believe as nurses believe; who do what nurses do; who have the effect that nurses have upon the health of individuals, families, and nations; who enjoy the trust that nurses enjoy… Imagine a world without nurses (para. 6).
      Gretta Foundation
      Our mission and history.
      At the 2022 Association of California Nurse Leaders, Jean Watson said, “There’s nothing wrong with technology, but if we don’t have the mindset to sustain the human-to-human caring connection, we’ve lost our way and not fulfilled our reason for being here. We have to critique technology with our new mindset.”
      • Watson J.
      Keynote address [Unpublished].
      As robot technology improves on the long horizon, there will come a time when robotic machines will be able to handle delicate manipulations and respond to complex and changing circumstances. In that world, it is not hard to imagine a human robot technician monitoring the robot’s performance in the care of patients absent the human nurses. Yikes…it is dystopian to imagine, but imaginable. This is likely outside the time horizon of any of us; yet, it is us who will set off in one direction or another.
      Robots will be effective in the long run in delivering the health care of conventional science in a separatist worldview. Robots will not be effective at offering human consciousness as a resource for healing. Caring science and conventional science overlap in the acknowledgment that there are things we do not know and have not seen yet, so in that way, both sciences rest on the foundational mystery of the unknown. Caring science is nonlinear and interested in the bigger picture of life and creativity.
      • Watson J.
      Unitary Caring Science.
      Caring science is not seeking to fix a problem or add retail value. Instead, caring science seeks to fully express humanity, energy, creativity, kindness, and transpersonal relationships. Caring science relies on a belief in evolving caritas consciousness, new language, and unitary quantum world view.
      The lonelier and more disconnected we are, the more at risk of believing we have found an authentic connection with a robot; lonely individuals are more likely to anthropomorphize nonhuman objects, such as robots.
      • Epley N.
      • Akalis S.
      • Waytz A.
      • Cacioppo J.T.
      Creating social connection through inferential reproduction: loneliness and perceived agency in gadgets, gods, and greyhounds.
      The heart has a measurable magnetic field that robots do not have.
      HeartMath Institute
      Science of the heart.
      To prevent us from allowing nursing to be replaced with the conventional science part of nursing picked up by robotics, in general, we must shift our focus to include the clinical care caring science elements of nursing.
      We hope that robotics’ current state, near future, and distant future give nurses more coherence, presence, and awareness of self and others. Nurses will have fewer headwinds of tasks and fears of missing something that leads to that sense of being out of control and overwhelmed. We support robots that support nurses to be able to fully express themselves, their creativity, and their caring for other humans.

      What Nurse Leaders Can Do Today

      Recognize the Potential for Robot Technology

      Initial instincts may be that the broad application of robots and the lightening of nurses’ workloads are several years off and other technologies are the priority. But we should look to the horizon to set up future nurses and patients for the most supportive environment. Decisions made today about investments, building designs, and software systems should consider the broader context of the robot technology revolution. Robots will operate within the environmental context of the physical, data, AI, and metaverse environments.
      • Marr B.
      The amazing possibilities of healthcare in the metaverse. Forbes.
      Designing for interoperability will support future nurses.

      Adopt Robot Technology Early

      Early adopters of transformative robotic technologies will have a competitive edge as individuals, leaders, and organizations. Beyond return on investment, consider patient and employee engagement benefits from early acclimation to robots in the care space.

      Focus on Nurses’ and Patients’ Motivations

      Patients or staff facing robots will need the trust of both clinicians and patients. Introduce robots and future iterations with an emphasis on engaging experiences, nurse and patient preferences, and the perspective that robots are an emerging resource in our space that will succeed and have moments of failure. Patients meeting a robot may elicit joy, but we have to be prepared to address questions about privacy and risk. For nurses, new robot technology is based on its practicality. If the robot helps nurses help patients and each other, provides valuable insights, and is nonthreatening, it will be accepted.

      Promote the Caring Attributes of Nursing that Nonhumans Cannot Replace

      Loving-kindness, caritas consciousness, transpersonal relationships, and robot technology are not polar choices. The choices are independent. The option to embody care is as old as humanity. The choice to include robots is a matter of when. Nursing’s work to stay relevant as robot technology becomes more advanced starts by using the language of caring with today’s tech. By creating cultures of intention, presence, and human connection, we are improving today and tomorrow. We make inflections on the future of robots when we look for practice points where technology is between nurses and patients, and we make space for humanity there. The most vital clue to how we use the tech of tomorrow is how we use the tech of today. If we start to lose sight by caring for the technology rather than the person, we will slowly drift the shoreline of our profession. If we hold tight to our care for the human, with the technology as a tool, we can maintain a true north and add value to humans as future robotic systems evolve.

      References

        • Tietze M.
        • McBride S.
        Robotics and the impact on nursing practice. Silver Spring, MD: American nurses Association; 2020.
        (Available at:)
        • Lake M.
        Pocket marvels: 40 years of handheld computers.
        (Available at:)
        • Schinkel M.
        • Paranjape K.
        • Nannan Panday R.S.
        • Skyttberg N.
        • Nanayakkara P.W.B.
        Clinical applications of artificial intelligence in sepsis: a narrative review.
        Comput Biol Med. 2019; 115: 103488
        • Epley N.
        • Akalis S.
        • Waytz A.
        • Cacioppo J.T.
        Creating social connection through inferential reproduction: loneliness and perceived agency in gadgets, gods, and greyhounds.
        Psychol Sci. 2008; 19: 114-120
        • Alla S.
        • Pazos P.
        Healthcare robotics: Key factors that impact robot adoption in healthcare.
        IIE Annu Conf Proc. 2019; : 1121-1126
        • Montalvo F.
        Social robot companionship: Understanding loneliness to improve interventions.
        (Available at:)
        • Gretta Foundation
        Our mission and history.
        (Available at:)
        • Watson J.
        Keynote address [Unpublished].
        (Association for California Nurse Leaders Annual Meeting; February 7, 2022)2022
        • Watson J.
        Unitary Caring Science.
        University Press of Colorado, Boulder, CO2018
        • HeartMath Institute
        Science of the heart.
        (Available at:)
        • Marr B.
        The amazing possibilities of healthcare in the metaverse. Forbes.
        (Available at:)

      Biography

      Todd Griner, DNP, RN, NEA-BC is Executive Director, Critical Care Services at Cedars-Sinai Los Angeles, California, United States. E-mail: [email protected]