The data revealed three aspects of CRO: (1) What CRO is, (2) Who needs CRO and by Whom it should be given and (3) How CRO should be conducted.
These three overall themes are described in categories based on the codes that emerged in the data (Table 3). The interview extracts, provided in the categories, are marked with the country of origin: Germany (Ger), Finland (Fin) and Sweden (Swe), as well as group of origin: older adults (OA), relatives (R), professional caregivers (PC) and care service managers (CSM).
The What Aspect of CRO
The theme explores the fundamental dimensions of CRO of grasping What care robotics is, the definition, how care robots can be used, possible benefits of using them and an understanding of the context in which care robot use can be beneficial. In exploring and accepting something new, it is fundamental to have a basic understanding of what that something is or could be. In situations when this understanding is lacking, it is problematic to know what to ask, and to contextualise possible use in everyday life. In contrast, when a basic idea of this exists, it is possible to discuss other aspects and considerations of the area, and to experience increased orientation.
The theme framing What CRO is consists of four categories: basic knowledge needs, processing of care robot information, ethical issues and funding considerations.
Basic knowledge Needs
The state of a lack of knowledge and experience in the field is evident, according to the informants, and it explains an initial existing scepticism towards care robots. When knowledge within the field is lacking, it is problematic to know what to ask for or where to look for the information:
[…] probably when it becomes more topical and closer to myself that now you need to get one, I would probably know how to ask for the information. But since I don’t think I need it now, I don’t even know what to ask for and what kind of information I would need. (Fin: OA)
Initially, the term welfare technology, care robots specifically, needs to be defined to reduce fears and prejudice and to overcome unjustified scepticism. This is exemplified in a changing attitude when being more informed:
So, my opinion already changed compared to the first statement about what I think about using robots [in this interview]. After seeing the film and the documents here, I don’t think I could have imagined it and suddenly now I could, yes, I could imagine it. So, it’s a question of informing people. (Ger: OA)
The need for basic knowledge in CRO refer to information intended to increase the knowledge, understanding and conceptualisation of care robot use in daily life. To fill the knowledge gaps, answers are required for various questions about care robots, such as what kind of care robots are available, which features do they have and what chores can they perform. These questions are related to how care robots could support professional caregivers as well as older adults and their relatives, currently, and future expectations and possible areas of use. ‘You should emphasise the benefits […] through the benefits, people will understand. If you just say we’re doing this, there will be resistance, but if you start from the benefits’ (Fin: R).
Not only general information is requested, but also more specific positive examples regarding benefits with care robots related to individuals’ specific needs. These examples should be connected to various disabilities, illnesses or other situations, where care robots can be supportive: ‘[…] even if you are interested in technical development and so […] if you are in a difficult situation, then you focus very much on your own little part in this and it is that specific information you want’ (Swe: R).
The contrary aspect is also discussed, when care robot use might not be suitable: ‘I have a hard time to see it [care robots] used in dementia care […] this is a big concern I have, because they need so much care, conversation and body language’ (Swe: CSM). In addition, older adults are concerned about practical issues related to how to manage and approach a care robot, and lack of space in the housing.
The need for basic knowledge in CRO should be seen in the light of potential users having different starting points in level of knowledge, understanding and reasoning, partly depending on having caring needs in daily life or not: ‘At first I have to experience it (the robot) before I am getting ill and can probably no longer make my own decisions’ (Ger: OA).
Processing Care Robot Information
The category describes the management of information about care robots. It is not just about passively receiving information. When the information is known, it is also necessary to conceptualise it in different scenarios in one’s own process of understanding and imagine one’s benefits from it. It is about processing the information and turning it into practical know-what and know-how, about managing the technology—care robots. From a managerial and professional perspective, it is also a process of putting the knowledge in an authentic context for practical application; for example, the needs of environmental factors, service structures, technology demands and training and changed work routines. Another prevailing perspective is that the use of care robots must be guided by the specific needs of the potential users: ‘There’s always the question, whether it’s robotics or any other kind of technology […] what problem this solves, and on the other hand, what problem does it not solve’ (Fin: CSM). There are also aspects related to legal and safety issues involved in the process, like what happens if mistakes or damages occur, caused by the care robot, as well as concerns about data security and integrity issues.
Overcoming prejudices and a common suspicion that the driving purpose is only a financial incentive with welfare technology in general could be challenging:
We must not forget about information and explanations both to older adults and relatives, regarding the purpose […] I think that is very important, because I think that they instantly believe that the purpose of new innovations is to save staff and make cutbacks, perhaps deteriorate things. (Swe: CSM)
To avoid such suspicions, a distinct communication is needed about reasons and intentions with the use of care robots. When these suspicions are resolved, an open-minded attitude beneficial for CRO can be experienced.
The significance of ethical orientation in the field of CRO has been highlighted. A main ethical issue is the importance of using care robots carefully and competently founded on ethical values. For meeting these requirements, there is an apparently explicit request for ethical guidelines, legislations and needed professional competences. This also appears as a request for reliable service, support and technology functions using care robots. In this category, an aspiration for competent and agile communication is highlighted, to clarify, understand and trust that the intention with using care robots is not to replace human caregivers, but ensure that care robots are complementary to professional caregivers. This suspicion is addressed in the following quote:
If a certain robot was to be introduced in one care unit and we [professional caregivers] were supposed to focus on the social part, one might think that we would get more time for that [the social part] but then the effect would be that they will remove staff, probably […] I would not want them to replace staff, but they will do that. (Swe: PC)
Given that the issue of compulsory use of care robots has arisen, it is worth acknowledging that this is an issue having at least two implications. On the one hand, it could be compulsory in certain situations, which might be offered from public care, referring to staff shortage and funding issues: ‘Here’s how care is done, this is a help we offer you […] if it is cameras or a timer for the stove, there are a lot of such things […] it’s nothing strange’ (Swe: OA). On the other hand, the need for sensitivity in introducing care robots is emphasised, implying that care robots shouldn’t be forced on people: ‘In the end, the user decides how far he or she wants to get involved with technology or whether he or she chooses the classic way of human care’ (Ger: OA).
The aspect of funding considerations calls for awareness and discussions about the welfare system. If there are financial benefits in using care robots, these might be the first choice when offering tax-funded care to older adults needing support in daily life: ‘As a starting point, it’s the municipalities’ business to pay for it, if the robot is absolutely necessary’ (Fin: OA). In these cases, it may not be optional, since the economy in the welfare system is limited. Tax-funded care robots bring up discussions about which care needs can be considered as the basic level for funding by the welfare system, and when does it become the individuals’ responsibility. If the care robots are not offered by the welfare system, an alternative might be to purchase your own care robot, if preferable, instead of having the support of professional or informal caregivers: ‘[…] if you have a lot of money, you buy your own robot’ (Fin: OA). However, this alternative raises questions about possible inequities based on different economic conditions:
Is this a merchandise, or is this our common right, will this mean that those who have the opportunity . . . intellectually, economically in terms of resources […] they can choose this, but all the others who do not have that, how to handle them… we are getting a very divided society. (Swe: OA)
Another alternative could be care robots funded by health care insurance: ‘I could imagine that the health insurance company would be happy to make it available free of charge, because it would keep labour costs as cheap as possible. That’s probably how it’s going to happen’ (Ger: CSM). A political philosophy aspect was revealed, given voice in the quotation: ‘Of course it’s always the one who benefits the most that should be the biggest payer. In many cases, we’re talking about society […]’ (Fin: R). A suggested alternative was care robots/welfare technology ‘libraries’ for periodic needs of this kind of technology.
The Who/Whom Aspect of CRO
The theme covers the groups of the recipients of CRO and the stakeholders and other actors conducting activities to increase CRO. The main target group of CRO includes those with needs who are expected to receive the support of care robots in daily life; in this case, primarily older adults with caring needs, but also relatives and professional caregivers. The group of professional caregivers and care service managers express the need for increased knowledge of care robot possibilities in their caring practice, but also for having a primary responsibility in CRO to the two former previously groups: older adults and relatives. A variety of stakeholders is suggested to provide the necessary orientation to the potential users of care robots, including people in one’s immediate surroundings, professionals and institutions and organisations on the societal level.
The next theme framing the Who/Whom aspect in CRO consists of two categories: target groups of CRO and stakeholders in CRO provision.
Target Groups of CRO
People with caring needs appear to be the primary target group of CRO and secondary is their relatives, often acting as informal caregivers. The primary group addressed the assumption that one is best susceptible to CRO when having the actual need for it. The professional caregivers are mentioned as an important target group, given their responsibility for providing care robot information. Positive attitudes among the professional caregivers are considered crucial for the introduction and use of care robots to succeed. Different categories of professional caregivers are expected to provide CRO; however, they are often not considered to possess the sufficient competence and recourses in this given responsibility, neither by their own nor the other potential users’ point of view: ‘[…] in a nursing home there should be health care professionals who have the knowledge . . . but I don’t know if they do, but that is how it should be’ (Swe: R). An increased level of knowledge would be necessary for all professional caregivers. As an extension of the discussion, a need for a new specialist profession in the area is addressed.
Care service managers are considered to be an important target group as leaders of the process of change, in terms of providing information and development of skills and working procedures. They also need to deal with upcoming problems and difficulties in the implementation of care robots, including motivating and supporting all involved parties: ‘What is most difficult, I think, experience wise, is to keep the motivation up and running with our professional caregivers, because you very easily fall back to what has been before’ (Swe: CSM).
In addition to the potential users, the more general societal need for increased CRO is highlighted. Improved CRO may change attitudes, especially when considering one’s own caring needs situation and the possibilities for staying independent in the private home:
So now we’re going to take this as our starting point. The Care-O-bot in any case, I would let it immediately into my apartment, if it would be necessary. If I could postpone a move into an assisted living for several more years.
I would definitely prefer that (care robot), before I have to go to a nursing home. (Ger: OA)
Stakeholders in CRO Provision
A common understanding is that too little is known on the subject of a good foundation for CRO. From the perspective of older adults, it seems adequate that the information should come from professional caregivers. When care needs arise, involved professionals should suggest appropriate care including CRO: ‘Yes, but everyone has a contact with the health service, if you are ill then you have that contact, then that contact should be the one who gives the information’ (Swe: R). However, older adults and relatives suggest that this is not accomplished because of a lack of knowledge in the area among most professional caregivers, as well as time constraints.
Other identified important sources in a more general discourse are family, friends and peers, who in daily conversation might discuss care robots and offer practical support. The information is considered to become more credible if the persons themselves have experience of using the product/robot:
Maybe it’s the peer aid, peer support, peer information on every level, so that users could tell future users, or the older adults who have been helped by care robots, could tell about their hopefully good experiences, and […] reduce distrust and fear. (Fin: R)
CRO provided by technical experts in collaboration with professional caregivers is suggested as an optimal strategy for CRO:
So, I could even imagine that a new profession would emerge, for example medical engineering, technology and nursing. Combining these together in one occupation and perhaps initially financed by industry. With the health insurance companies, of course, because they must finance it afterwards […]. (Ger: OA)
Seen from a general perspective, several stakeholders are mentioned in relation to provision of CRO. Official sources (governmental, regional and local authorities) are considered to have an official task for providing CRO in the national field of welfare technology information. Research and educational institutions are other stakeholders, regarded as a reliable CRO source. The manufacturers and suppliers of welfare technology and care robots also have an important role in CRO. However, the risk of bias in their trustworthiness is discussed: ‘I don’t immediately trust anything that I get from a salesperson. Of course, they just want to sell the product […]’ (Fin: CSM).
Concerning the general information from media and society as a whole, there are many possible channels; some mentioned the Internet and social media. Television, newspapers and advertising are also considered to be important actors in CRO. Other information channels, such as information in shops, pharmacies, fairs and independent advice centres for robots, are suggested:
Make it exciting, that it is pleasurable and that I see it on different social media, I see it in stores, I see it in movies, celebrities have a small robot. I think it is difficult to just introduce it in elder care, instead we have to make sure that this technology is visible and used by others also [not just older adults]. (Swe: OA)
On a more formal level, CRO can be given as community information in different places and situations. In particular, centres for older adults’ services, different care settings, theme-days arranged by seniors, centres for relatives and retirement organisations are mentioned:
So, I always think it would be nice if there’s some kind of external person who doesn’t want to sell me this robot and just tell me how great the device could be, but that you really get honest information about advantages and disadvantages. […] (Ger: R)
Field trips and information through human interaction are highlighted as important CRO arenas. In Germany, which has a different welfare system in comparison to Finland and Sweden, health care insurance companies also play an important role in providing information as a part of the general CRO.
How CRO Should be Conducted
CRO can be conducted in different knowledge improvement activities, from targeted information to more general governmental societal campaigns. As concerns the time aspect of CRO, it is discussed that the most beneficial learning/orientation is experienced when someone has actual needs that can be solved by welfare technology in the form of care robots. On the other hand, other time aspects indicate that CRO should be provided in advance, even to young people in schools.
The theme framing the How aspect of CRO consists of two categories: CRO activities and time aspects of CRO.
So far, CRO activities are occurring sparingly according to the potential users: ‘. . . you have to search for yourself . . . the channels that exist . . . if you are curious and interested . . .’ (Swe: R). However, it is suggested that CRO activities, on an individual or group level, imply giving an introduction and information presented in a positive manner. The information must be simple and adapted to the receivers, regardless of target group: ‘. . . for us older adults, when technology is taught, it should be taught in such a way that people really get it . . .’ (Fin: OA). It must be clear, descriptive and motivate the incentive of care robot use. For example, to overcome the initial assumptions that it is only about saving money. Another important aspect is that the activities should have understandable examples offering the CRO receivers related to cases of care robot implications and care robot efforts. If possible, it is anticipated that the learning and improved CRO will have increased results by using the didactics of ‘learning by doing’ and hands-on possibilities. Positive orientation activities are also described as being more effective in safe and permissive environments with joint learning attempts, also having long duration in test periods. The CRO should preferably be conducted in the environment and settings where the care robot will be used, while continuous CRO and training are desired, particularly among professional caregivers, partly due to high staff turnover.
Time Aspect of CRO
Another aspect how CRO should be conducted is when, in time, it is beneficial and most effective. One issue about this was raised in expectation that information should best be given when a person has needs and when it is relevant to a changed life or work situation that perhaps could be solved by care robots. Only then is it possible to put oneself into the situation and ask the right questions. On the other hand, there is an incentive to offer CRO, on a more general level as common information for peoples’ awareness of the possibilities for care robots. Improvements in the general CRO would have positive effects on the day when the individual or a relative and a professional have the needs or are facing care robot implementation. Seen from the perspective of older adults, it is discussed that they should be oriented before they become too old and frail to make their own decisions: ‘Technology needs to be introduced earlier in life, before people become affected by old age and illness’ (Ger: OA). However, many lack interest since they believe that care robot use is far ahead in the future and does not concern them yet. Thus, effective CRO seems to occur when it is motivated by an individual’s curiosity or interest in the issue.
Another time aspect of CRO is that it is a generational issue. The young people of today will be better prepared and probably not consider care robots to be something odd. It is suggested that to get used to the technology, it should be introduced and discussed at an early stage in school: ‘I think that even the next generations, those that have integrated technology, robotics and artificial intelligence in their professional lives, want robots for their care in future, too’ (Ger: CSM). However, the time aspect of CRO might also have a dimension of an expiration date, due to the rapid technology development. The use of care robots in elder care is also predicted to be a natural part of the care:
[…] I think, later, it will be like, one care unit realises […] we don’t have staff, we have to introduce it [care robots]. Then I think the technology exists, then there are probably . . . intelligent homes that can explain to someone who might be demented . . . explain that now we will do this and that. (Swe: PC)