Long-term care (LTC) settings around the globe have been disproportionately affected by the COVID-19 pandemic, with LTC homes in Canada being first locked down in March 2020. In light of new public health measures and visitation restrictions, staff shortages and burnout (1), limited social connection, and increased isolation (2), there is a great demand to explore the needs of older adults and staff in LTC and strategies to support them. Meanwhile, the unprecedentedly high number of public health orders, uncertainty, and intense staff shortages have created physical and psychological challenges and barriers for conducting research in healthcare settings (3). Some researchers cannot be physically present on sites, putting into question the applicability of the pre-existing research designs. During this challenging period, alternatives and recommendations of research design, tools, and technology for conducting research emerged to support the research process (4).
Challenges of research during COVID bring opportunities
“Nothing for us, without us,” having residents’ and staff voices in research for long-term care is crucial to fully understand their experiences and complex conditions. Safety concerns and public health orders have restricted researchers from entering the LTC sites for data collection, the collaboration of implementation with the site, and the engagement of staff and residents. Many researchers are forced to change from face-to-face data collection to other virtual alternatives (5). The transition from in-person to virtual setting might lengthen project timelines from what was originally planned, e.g., recruitment and questionnaire development (6). Furthermore, observing participants’ non-verbal cues, e.g., facial expressions, minor gestures, and actions, is challenging without in-person interviews for researchers (4,7). Poor internet connection can also lead to pauses in interviews and poor audio and visual delivery (4). For situations where in-person data collection is allowed, the use of masks has an impact on building a rapport and trusting relationship between researchers and participants during an interview. Wearing masks is sub-optimal for participants with hearing impairment (8). In addition, researchers may face organizational barriers as some LTC homes lack financial resources for purchasing technologies, have limited Internet access, and have staff shortages that impede the technological implementation (9).
The involvement of patient and family research partners in research planning, implementation and evaluation is the foundation of Patient-Oriented Research (POR) and has been challenging during the COVID-19 pandemic. According to Canada’s Strategy for Patient-Oriented Research (SPOR) of the Canadian Institutes of Health Research (CIHR) (10), the perspectives of patient partners should be integrated into every step of the research project, including collecting data. However, under the socially distanced pandemic environment, patient partners from marginalized and vulnerable groups experience further exclusion, disadvantages, and struggles in health, economic and social conditions - for example, limited travel and challenging access to healthcare and technology (11). There is a strong need to bridge the potential gaps in accessibility and use of technology and maintain close connection and collaboration with patient and family partners during the research progress (11).
Despite numerous safety concerns and barriers, challenges bring opportunities. Creative and new strategies with technologies for conducting research and overcoming difficulties evolve during the pandemic. For example, phone calls, photovoice, video teleconferencing, text-based mediums, digital diaries, and Zoom calls have been used in interviews and focus groups (4,5,11). These tools have their strengths and drawbacks. For example, using phones does not require learning new technologies or the Internet. However, interviewers cannot observe participants’ non-verbal cues. Moreover, research showed that researchers take more time to build trust and rapport with interviewees via phones compared to face-to-face channels (11). Teleconferencing and Zoom calls allow video conversations and observations, but there will be a need for technical and Internet support, with staff on-site required to setup calls and potentially aid with any technical issues encountered. Furthermore, participants who are fast at typing may dominate the discussion for text-based focus groups (11). These strategies and innovations are opportunities to facilitate and adapt research in the context of the pandemic.
Telepresence robots
Telepresence robots are mobile communication devices that can enable virtual video and audio communication. They have various functions with their cameras, microphones, and loudspeakers, e.g., mobility of 360 degrees, height alterations, recording, and video and audio functions (12). Examples of telepresence robots are Beam, Giraff, and Double 3 (Fig. 1). People use telepresence robots in the business, educational, and research fields (13). Recently, research has been conducted using telepresence robots in healthcare settings for social connections (12,13). Researchers have found that telepresence robots enable the feeling of the person's presence from anywhere in the world via the robot (14–19). Moreover, telepresence robots are easy to use for residents (14,18–21). Residents do not need to learn how to control the robots as they are remotely controlled by the person calling in through the robots (15,22).
Using telepresence robots in research during the COVID-19 Pandemic
Recently, our research team has started a study exploring enablers and barriers to implementing telepresence robots in LTC to facilitate the social connection between residents and family members. After being connected to the internet, telepresence robots allow people to call in and remotely control virtual visits to residents in LTC. We learned more about telepresence robots during the research process and found that their features may be a suitable tool for virtually conducting research in our research lab during the pandemic.
We used telepresence robots to conduct interviews and workshops in three other research projects since July 2021. Table 1 describes the details of each research project and how telepresence robots were used in them.
Table 1
Descriptions of research projects & use of telepresence robots
Happy2Eat
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This Participatory Action Research (PAR) project explores practical strategies to improve the dining experience of LTC residents with dementia. As data was generated through conversations with residents, families, staff, and leaders, the telepresence robots were used to visit the site and have in situ discussions with LTC residents.
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Overcoming Loneliness
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This project focused on learning more about residents’ experiences of loneliness in LTC homes as impacted by the COVID-19 pandemic and developing strategies to overcome challenges. Data was collected through one-on-one interviews with residents, by using the telepresence robots for private conversations in their rooms.
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WhatMatters
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WhatMatters is a digital care plan mobile app being developed in collaboration with the stakeholders in co-design workshops. The telepresence robots were used in the workshops virtually as part of the design process.
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The research team conducting interviews via telepresence robots includes researchers, graduate students, patient and family partners. Before each session, we asked staff to place the robot in the resident's room. After that, the staff can leave the room without assisting the interview process. With the specific link for the scheduled interview sent by our technical team member, the interviewer could “call in” the telepresence robot using laptops, smartphones, or tablets. The interviewers’ faces would appear on the robot's screen once they called in virtually. The interviewers could see the resident in the room (Fig. 2). As telepresence robots have a broader view (see Fig. 2) compared to other video teleconferencing interfaces such as Skype and Zoom, the visual access allows observation of the resident interacting with the environment in real time. With residents' consent, the interviews were recorded via the system of the robots.
Purpose
Our research lab focuses on participatory research and patient-oriented research, where we engage patient and family partners in the whole research process as research team members. Currently, telepresence robots have not been used in conducting interviews in participatory research from a recent literature review on participatory research approaches during the COVID-19 pandemic (11). Telepresence robots are innovative tools for participatory research. In our reflection, we experienced challenges, failures, and successes through collaborations between team members and staff partners at the study sites. The purpose of this paper is to report the challenges, benefits, and implications of the innovative way to conduct research via telepresence robots. These experiences help expand new possibilities in using emerging technology in facilitating research in LTC remotely during the pandemic. These methods of performing remote research would be instrumental in the future, for times when visiting a health care or LTC site may not be safe or accessible. Based on our lessons learned, we wish to stimulate further discussions on the use of telepresence robots in research and to promote the commitment to involvement with patient and family partners in research.