Three themes emerged, based on the most imperative facilitators and barriers identified. Themes, facilitators, and barriers are indicated in Table 6, including the acronym of our facilitators ACE.
Table 6 Themes, facilitators and barriers
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Theme 1: Staff training and support
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Theme 2:
Robot features
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Theme 3: Environmental Dynamics
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Facilitators (ACE)
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Appropriate training and support to staff
- Addressing staff’s concerns
- Self-motivated staff members
- Enjoyable and rewarding experiences
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Convenient and user-friendly features
- Enables independent and real-time communication
- Simple operation
- Advantages over other ICTs
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Resourceful Environments
- Supportive leadership
- Effective teamwork
- Established family-staff relationship
- Families autonomy
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Barriers
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Constraints in training
- Inadequate internal communication about the robot
- Limited in-person training
- Meeting diverse individual learning needs
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Non-customized design
- Heavy weight
- Low volume
- Small screen
- Challenges in charging
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Insufficient resources and structural supports
- Wi-Fi issues
- Challenges in human resources
- Lack of technical support
- Limited physical space
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4.1 Theme 1: Staff training and support
Staff described how training and support with different characteristics facilitate them from understanding and using the robots with different effects.
4.1.1 Facilitators: Appropriate training and support to staff (ACE)
Staff highlighted how quality training and support was conductive to supporting their understanding and use of robot.
4.1.1.1 Addressing staff’s concerns
“After your training, we understand it more.”
Staff highlighted the impact of training on their attitude towards the robot per se and its implementation upon initial introduction of the robot.
Emily (RN): “Before the training, I have not touched it [the robot] because I am not sure. I was hesitant.”
Pierre (RN): “You don’t want to mess it up or something.” (laugh)
Emily (RN): “But today, I feel better. More comfortable.”
Pierre (RN): “After your training, we understand it more.”
Emily (RN): “It [the training] stays more in your head with the symbols. Stays more in your brain.”(Focus Group, Public Hospital)
“Initially we had fear about the robot... there was a lot of fear. Like, am I going to be caught doing something that the family's not going to be happy with or? Is the family able to look on (through the robot) and then make complaints what they don't like? Those were some of the concerns that I think we addressed. I think your team has done a very good job of addressing our concerns on technology and privacy for both other residents and staff. I think staff education and the actual demonstration of how to use the robot helps. I think our staff has moved past that (concerns).” (Bridgette, Clinical Operations Supervisor, Garden View)
As staff started using the robot, provision of ongoing support was as important as the initial orientation.
“I remember the first couple of sessions, all staff were not sure [how to use the robot]. But the last [training] session I was involved in, I was doing my thing here, just listening in and you got people talking and involved. It (the training) was very informative, and people were really engaged into it…Over the time you have been here to show the staff how easy it is…just getting the staff really comfortable with it.” (Ashley, Patient Care Coordinator, Public Hospital)
4.1.1.2 Self-motivated staff members
“I look for ways to use the robot.”
“I learned from our staff champion, and it worked brilliantly.”
Staff champions who are proactive and self-motivated in using the robot were positive influences on the larger team. A staff champion at a private LTC home described how her implementation of the robot influenced her colleagues and helped the care team to start using robots.
“I look for ways to use the robot even outside of scheduled calls. When I put the laptop to be set up on the ground floor where entertainers are, residents and staff ask me, ‘What is that?’ And then I explained how people on the second floor cannot come downstairs can still attend the performance through this robot. Also, I brought the robot back and forth, which is important as it serves as a good visual reminder for other staff that this is something helpful for the residents. It can cause the other staff maybe to be motivated to engage as well. Staff can take it in by observing, and then from there, it might encourage their willingness to participate as well.”(Natasha, Life Enrichment Coordinator, Private LTC home)
A passionate staff champion could also disseminate knowledge about the robot by integrating this innovation into the new staff’s orientation and contributing to adoption of the robot by their new colleagues. Participants from the public hospital described how their staff champion Frank introduced the robot to the new members.
“Frank is really good. We have a new staff [member], I know he has talked about it (the robot) and showed her. He is a great team member. Very open to sharing things like that. We are very lucky to have Frank on the unit. He's very helpful.” (Ashley, Patient Care Coordinator, Public Hospital)
“I did two orientation days with Frank and he introduced me to the robot. He showed me how to make sure it was parked properly in the charger, how to set up the visitors pass, how it worked on the family members’ end, and so on.” (Jamie, Rehabilitation Assistant, Public Hospital)
It is also important to have staff members who are willing to learn from the staff champion (e.g., via peer influence). Julia mentioned how she initiated learning from Frank:
“I am one of those apprehensive people with technology. The robot was all new to me. I remembered when Sandra (a daughter of a resident) first started [using] the technology, Frank was going to give Sandra the orientation and show her how to move the robot within the room. So I said to Frank, ‘Hey, can I be present with you?’, and I learned from him. That's what we did, and it worked brilliantly.” (Julia, Social Worker, Public Hospital)
4.1.1.3 Enjoyable and rewarding experiences
“Once staff know that there is something for them to gain, they are more into it.”
In our observation, regular check-ins, and meetings, our research team noticed that the frontline staff and team leads from the five care sites were often overloaded. To incentivize them and lighten their workload, refreshments (usually bubble tea) and the latest newsletters were provided before each education session. Staff became more relaxed and attentive, with a curiosity to learn about the robot training. Natasha mentioned, “They (staff) really like the bubble tea and the training with that.” (Natasha, Life Enrichment Coordinator, Private LTC Homes)
Gamification was applied during robot demonstrations/trainings. Before each training, tools such as spinning wheels, trivia lists, and prizes (i.e., earphones, keychains, tote bags) for staff were prepared, as Figures 2a and 2b show. Each staff member was invited to spin the wheel after the introduction. When the wheel stopped at a number between 1 and 12, the staff member was asked a corresponding question from the trivia list. The staff member, or the player, who answered the question right was awarded a prize and cheered on by the entire care team and research team. Staff members who did not answer the question right were also rewarded with gifts from the research team during the session.
A team lead who observed her team members during the training explained how gamification worked well in engaging them:
“Your training is good. The spin wheel is great because your little prizes just get people engaged. Once people know that there is something [for them] to gain, even though it is little, they are more into it. Definitely.” (Ashley, Patient Care Coordinator, Public Hospital)
In addition to attending engaging training sessions, staff also reported positive experiences generated from using the robot and successfully enabling communication between residents and families. For instance, staff talked about how using the robot in supporting the resident-family connection made them feel their work is meaningful.
“I saw the delight in Sandra (a daughter of a resident)’s eyes when she figured out how to operate the robot [and virtually visit her father here]. At first, she had a bit of trouble, and it (the robot) went to the wrong way. Then Sandra operated it correctly, and she had it going right down the hallway, and you can see the delight in her eyes on the screen showed ‘Wow! This is actually working, and I can do it remotely from Europe!’ It was pretty cool. The robot made those meaningful moments of joy and happiness. That makes my day.“ (Julia, Social Worker, Public Hospital)
“The robots are very useful – they bring a positive influence to the residents' lives. The research brings lots of happiness to the residents. I appreciate your research.” (Amanda, Activity Assistant, Villa Cathay)
“If the family can use it properly and the resident is able to engage, I feel happy and content about helping the residents and being part of the project.” (Courtney, Clinical Operations Supervisor, Ocean View)
Staff also gained positive experiences by seeing the knowledge translation outputs developed by the research team that acknowledged their active usage of the robot. For example, a newsletter for the project was issued every month and disseminated among staff from all care sites. Staff felt rewarded by seeing themselves and their successful stories of using the robots featured in these newsletters (as Figure 3 shows).
“I am ok with the February newsletter because I am here (Alex pointed himself on the newsletter). Do you see me here? (laugh)” (Alex, Clinical Operations Educator, Ocean View)
Natasha, the Life Enrichment Coordinator from the private LTC home, shared: “From (my) experience, the staff got excited when they saw their own pictures. Also, I think those special events that you did, for example, for Mother's Day when you brought the flowers, that was really impactful for the staff. It caused a positive link between the robot and just feeling appreciated for being there to support.” She further suggested that future engagement could be “combined with maybe a special event: […] This way you can show some appreciation, but also refresh them (the staff) on the use of the robot.
Figure 3 Staff were excited to see themselves in the newsletter
4.1.2 Barriers: Constraints in training
Staff pointed out factors from the internal and external environment hindering their learning, as well as their diverse learning needs.
4.1.2.1 Inadequate internal communication about the robot
Staff described how poor knowledge dissemination about the robot and its implementation within the team resulted in limited robot usage.
“I think 80% of the staff members do not know how it (the robot) works. Usually it is just us [program assistants] that are in charge of this robot [who know it]. I think the nurses and care aides upstairs don’t know how to use it.” (Lora, Family Visitation Program Assistants, Non-Profit LTC)
Bridgette reported a similar situation: “We have our rotations, so it is not the same people every time you come. I know we have done some training with staff, but they may not be working that day. Definitely a matter of training.” (Bridgette, Clinical Operations Educator, Garden View)
Moreover, the focus group at the Ocean View, the public LTC home elucidated that reliance solely on self-motivated individuals (often staff champions) generates limited influence on the others in the team in using robots.
“Sarah (Clinical Educator) has been excellent, she goes and checks. When I am here, I go and check. But on the weekends and after-hours, we are not here. If our staff find it overwhelming, they will probably not know what to do.” (Courtney, Clinical Operations Supervisor, Ocean View)
4.1.2.2 Limited in-person training
The implementation of robots was started during the COVID-19 pandemic, when significant restrictions on in-person visitation were placed on LTC homes and hospitals [26]. As a result, the care team could only access the robot-related training and support online during that time period. One of our staff participants explained why in-person interaction is preferred over virtual connection:
“I find that in-person interactions are the most meaningful. Being in person is such a different relationship and feeling. You feel more connected. But because of the pandemic, you were not able to come and do in-person training or education.There were a lot of emails and phone calls back and forth when they were using robots. I think that was definitely one of the barriers – probably one of the biggest barriers.” (Julia, Social Worker, Public Hospital)
As the in-person visitation limitations lifted in 2022 and in-person training and support could be provided again, Ashley shared her view on those in-person training sessions that her care team received: “When you came in to do those information sessions, I saw from the last couple sessions, you got the team very engaged. They're very happy to see you. It (the in-person training session) helps.” (Ashely, Patient Care Coordinator, Public Hospital)
4.1.2.3 Meeting diverse individual learning needs
Staff spoke of their diverse learning needs, given variations in individual roles and routines. For instance, Jasmin in the focus group mentioned the need for printouts for her to learn about using robots in addition to some in-person trainings:
“You have been doing in-person trainings but we also like printouts…I know there is already something there. But there could be also a binder that I came across with information in it, like the signage there. So I guess the mixture of resources is good. You guys have already been helping us with that.”(Jasmin, Total Care Worker, Public Hospital)
Julia explained why some of our existing training materials were not tailored for frontline staff members: “Some of us, like physicians, we check our emails regularly and do Zoom meetings and connections. This is part of our daily work. For nurses and the TCWs (Total Care Workers) who provide direct care, they are not always on their email or attend Zoom meetings when they are here working throughout the day. So that (virtual communication) is not their norm. If you just send them emails, packages, or a video on how the robot works, you are not going to get the same buy-in or interest, because they don't necessarily feel involved. So for them, in-person orientation is better, making them feel invited and included.”( Julia, Social Worker, Public Hospital)
Interestingly, Lora expressed learning-related preferences that differed from the abovementioned formats: “It is better to have an overview, like an orientation about the robot. For example, how to create a password for the family members and how to teach them to use it. Guidelines on how to teach a family member on how to use their phones to control the robot would be great. A manual or both staff and family members would be enough. A YouTube video or[other] video would be better than a book as a guide.” (Lora, Program Assistant, Non-profit LTC home)
4.2 Robot features
Staff reported how features in the telepresence robots facilitate or hinder implementation, depending on the care team and the environment of the care sites.
4.2.1 Facilitators: convenience and user-friendly features (ACE)
- Enables independent and real-time communication
“It is a very valuable tool.”
Staff described key features that made the robot easy for them to use and to support their residents or residents’ social connections. Firstly, the most prominent strength was enabling independent, direct, and live videoconferencing between the residents and their families. Some participants described how little staff involvement was needed in the virtual visitation of families to residents.
“I think one of the biggest benefits to the robot is that staff members can just put it in a room, which gives a family member a window of time to call in. If everything is running properly, it (the robot) takes me only 30 seconds out of my day in the morning. I put the robot in the room and I can move on to my other tasks.” (Jamie, Rehabilitation Assistant, Public Hospital)
“I just need to send the link, put the robot in resident’s room and put back in the dock (after the videoconferencing). Other staff have similar positive experiences. They said it is easy.” (Frank Rehabilitation Assistant, Public Hospital)
Similar experiences were reported by staff from the public LTC home Garden View:
“I do see this [robot] as a very valuable tool – for families to have the ability to connect on their own without having someone setting it up for them (i.e., Skype or iPad that we had to set up). The families can do it whenever they want. All they have to do is to call us and ask us, ‘Can you send us the link as we have our loved one in the room?’” (Lisa, Clinical Operations Supervisor, Garden View)
Secondly, staff members also explained how the independence in the resident-family communication facilitated by the robot freed staff from being perceived as an “agent:”
“[The robot] is not hindering the workflow of staff. It is more compatible with our workflows because the family can connect directly to the resident without thinking [of] us as the middle people.” (Bridgette, Clinical Operations Supervisor, Garden View)
“It (the robot) makes a big difference. It lessens the workload. Because the families can directly call in [to] the residents.” (Alex, Clinical Operations Educator, Ocean View)
Lastly, for real-time communications, one of our participants recalled how the robot helped the visitor (a daughter) to address the resident (mother)’s mental well-being instantly during the virtual visitation.
“Whenever they called, the daughter reads her mother’s facial expressions depending on how she talked, for example if the daughter was too loud, or if she said something that confused her mom. The daughter could immediately see whether she needs to adjust her wording or to lower her volume based on her mom's live facial expression. Those little gestures could be captured by the robot and help her mother understand better and not feel frustrated.” (Natasha, Program Assistance, Private LTC)
Another story shared by staff indicated how the robot’s real-time communication function enabled family members to virtually accompany a resident during therapy:
“Therapists came to our residents for acupuncture. The family members wanted to see what they (therapists) are doing, to soothe them (the residents), and to translate between the residents speaking Cantonese and therapists speaking English. That is why we put the robot in the room and let them (families and therapists) communicate. For example, the residents can say where the pain is and which procedure makes them feel better, and the families translate between the residents and therapists, then the therapists could proceed more effectively. In that way, the session went well and became more effective.” (Lora, Program Assistant, Non-profit LTC home)
4.2.1.2 Simple operation
The second biggest facilitator that participants highlighted was the simple operation of the robot; this made it easier to set up calls for residents, teach residents’ families how to use it, and innovatively apply robot usage to novel situations. Consequently, most of the staff members found that having this new technology in their daily routine did not impact their workload, and instead even reduced their it.
“I just follow the steps, since it is easy to follow – click the link and send it. Very straightforward. I think it is so good, especially given the increasing demand for the health care professionals. The workload for us is very heavy. And this [robot] helps them (staff) to still give support to the family and patient, while not overworking or increasing workload. I think staff would benefit having a robot. It’s awesome.” (Francisca, Rehabilitation Assistant, Hospital)
In our focus group in the hospital, the multidisciplinary care team told us that:
“I like that it (the robot) is very user-friendly. Only four icons – easy enough to use.”
“Within 5 minutes you can set it (the robot) up with a family member … Workload-wise, it is not affecting us.”
“[Tablets] are charged more frequently. The robot could [be used] for 3 hours.”
“The QR code makes it much simpler for you to use [the robot than a tablet]. The other one (tablet) you have to wait and punch in the number…all that kind of stuff….it (the tablet) looked [a] little more complicated to me.”
Similar experiences were also reported by staff from the Non-profit LTC home:
“I just put the robot in the resident's room, scan the QR code, enter the duration [of the link], copy the link, and send it to the resident's family member. Then I can teach them how to use it (the robot) so it is quite easy for me.” (Lora, Program Assistant, Non-profit LTC home)
4.2.1.3 Advantages over other ICTs
In terms of easiness and difference in experience, the staff also compared the robot with other devices or software that they have been using.
“It is very easy. It is easier than, say, FaceTime, because [with the robot], you just need to email a link [to the families] and then they just connect. It is easy at both ends. You just need the other person's email. The robot does not show any information about where it (the email) came from because it's all private. It is comfortable to use it because it is so simple. It really, literally, is so simple.” (Ashley, Patient Care Coordinator, Hospital)
“I find the robot is more helpful [than a tablet]. Because otherwise we have to grab a tablet, and you have to log them (the families) on.” (Bridgette, Clinical Operations Supervisor, Ocean View)
4.2.2 Barriers: non-customized design
Staff reported some features in the robot failed to address their needs at work and older adults’ needs for communication, which discouraged staff from using robots.
4.2.2.1 Heavy weight
The robot weights 7.3kg, or 16 pounds [25] and two female staff members reported that for them, the robot is “too heavy to carry:” “There are only two robots in the facility, so the staff has to move them [with their hands] and place in the residents’ room.” (Amanda, Activity Assistant; Jane, Program Assistant, Non-profit LTC home). The research team assigned three more robots to the care home after the interview.
Other than manually carrying the robot, theoretically, staff have another option to move the robot, which is to drive the robot to the desired place, for example, the room of the next resident who is using the robot. However, in our regular check-in at the site, staff told us that it is generally time-consuming for the robot to be connected or re-connected to the desired Wi-Fi. Hence, it was faster to manually carry the robot to the destination given the busy schedule and heavy workload of staff.
4.2.2.2 Low volume
Staff also spoke of the too-low volume of the robot for residents with hearing challenges, which did not help to improve the residents’ experiences. For example, the private LTC home that Natasha worked at once hosted a performance by entertainers on the site’s first floor, but some residents with mobility challenges had to remain on the site’s second floor. Natasha described her experiences with the low volume of the robot after setting it up for residents who could not experience the performance from the first floor:
“I put the laptop next to the entertainers, and placed the robot next to residents. The volume [of the robot] is quite small or quite low, even though at its maximum. You can barely hear the music downstairs – it (the robot) was quiet.So I stopped doing that on the second floor because it was a little bit too quiet for residents to hear. I hope can still ‘attend’ the performance through this robot [in the future].”(Natasha, Life Enrichment Coordinator, Private LTC home)
Two participants also reported similar observations:
“Some of our residents are really old and cannot really hear from the robot, which is too quiet for them.” (Amanda, Activity Assistant, Non-profit LTC home)
“It would also help if the robot’s volume can be amplified based on the person's hearing needs.” (Courtney, Clinical Operations Supervisor, Ocean View, public LTC home)
4.2.2.3 Small screen
Staff expressed concerns that the size of the screen (9.7 inches) [21] could be too small for residents with visual impairments. For example, one staffer mentioned: “Some residents have really bad eyesight and do not use glasses. It would be beneficial to have the option to enlarge the screen.” (Amanda, Activity Assistant, Non-profit LTC home)
4.2.2.4 Challenges in charging
Charging the robot is a crucial barrier expressed by staff member Lisa, who suggested that challenges such as charging require more staff input. “The families are having difficulty driving the robot back to the dock. If [the robot was] not docked back, it was often not charged. When they want to use it the next time, it has no power. That was when we get the staff to help and assist.” (Lisa, Clinical Operations Supervisor, Garden View)
4.3 Theme 3: Environmental dynamics
4.3.1 Facilitators: Resourceful environment (ACE)
4.3.1.1 Supportive leadership
The leaders explained how implementing the robots supported the care teams’ care delivery, especially with respect to connecting residents and families directly and with respect to supporting the care team in achieving its goals:
“The main driving factor for me [to use the robot] is that it connects [the residents] with the family, despite them not being on-site, meanwhile without causing too much stress on the staff because it was already a very stressful time for everybody.” (Courtney, Clinical Operations Supervisor, Ocean View)
“It started within two weeks as I was watching staff deal with the robot with ease. I've seen quite a few instances where it was really benefiting the residents, especially Johnny. He has expressed that he does appreciate it when he has those [robot] calls.”(Alex, Clinical Operations Educator, Ocean View).
“I think it (the robot) is another great piece of equipment that can make life nicer while patients in here (the hospital) are separated from family. So, whatever we can do to make connections, continue with family members, friends, whatever it is, should be made available and widely used. I fully support it (the robot). It's good.” (Ashley, Patient Care Coordinator, Public hospital)
A staff member mentioned how care team leaders’ buy-in eases the integration of the robot into care plans supports the robot’s maintenance:
“When I initially started having the robot, some leaders were curious. They asked me, ‘What time are you going to do the call?’ Then they would try to make it to the call. One of the leaders was there when the call is being set up. Later, I asked another leader if she can let the care partners know [about the robot], she agreed and suggested placing it in the care plan. After that, I never had any more issues with robots being not charged.” (Natasha, Life Enrichment Coordinator, Private LTC home).
4.3.1.2 Effective teamwork
Besides leaders’ buy-in, staff also mentioned how good teamwork enabled seamless access to the robot for residents. For example, staff from the public hospital and the private LTC home showed how they helped each other to facilitate the residents’ connection with their families through the robot, regardless of their heavy workload:
“Last Friday I forgot to do it (put the robot in the resident’s room). The other staff scanned the robot, sent the email and put the robot inside resident’s room… We have a patient’s wife [who] usually calls between 4 and 7 o’clock. I put it there [at 4p] and other nurses just need to put it back to the dock at 7pm.” (Frank, Rehabilitation Assistant, Public Hospital)
“For anyone [who] wants to call in the evening or in the weekends, when Frank is not there, it is important that we have everyone on board. Overall, for the scheduled calls, the care aides know about the robot, how it works and where to find it, if they were asked to put in someone's room.”(Jamie, Rehabilitation Assistant, Public Hospital)
“I would usually always be there [for family calls] for the first 10 minutes, then I leave the room and they would continue their conversation. [After the call,] one of the staff would put it (the robot) back in its place.” (Natasha, Life Enrichment Coordinator, Private LTC home)
4.3.1.3 Established family-staff relationship
For a care home that has established a healthy relationship between family and staff, a robot is viewed to bridge the positive communication and maintained the mutual respect between staff and families. The three cases reported by Life Enrichment Coordinator Natasha (private LTC home) serve as examples:
“I was with a resident who was calling her family in their room, and a care partner wanted to check in on the resident. I would invite the staff to say hi to the resident’s family. The family is usually very grateful to the care partner for the care that they provide. All the time that has happened, the family directly thanks them (the staff) for all the care that they've been giving to their family, and they (the staff) really appreciate it. That connection through the robot is really nice, and usually it is not planned.”
“One of the residents, Alexandra, recently passed away suddenly because she had a fracture. During her recovery from the fracture, she had calls with her family [through the robot]. [After her passing,] her daughter reached out to me and told me it was a blood clot that got into Alexandra’s lung - that was why she passed away over the weekend. The daughter was really grateful that they had those robot calls, because up until Alexandra moved into our care home, the daughter has not been able to visit. If there was not a robot, they would have had a lot fewer face-to-face conversations. The daughter was really grateful to use the robot. She also told me over email that when she was speaking to some staff over the past couple of days, they told her Alexandra quite enjoyed the calls (over the robot).”
Further, the healthy family-staff relationship created an open environment and made families feel safe to speak about their timing and needs in virtual visitation with residents. Such relationship facilitated the staff’s application of the robot.
“The only challenge I heard about was if the daughter is calling [the resident] when the staff is giving care, then they (the family members) don't want to disrupt. Then the daughter was concerned about disrupting staff routine, so she told me it would be nice if she calls more spontaneously instead of scheduling calls. This is why another staff champion brought a robot over and put it in the resident’s room. The challenge was the daughter wanted more spontaneity and flexibility in the timing of her calls. That was solved by having the robot in the resident’s room.”
4.3.1.4 Families autonomy
Staff from three different care homes noted the importance of family autonomy to virtually visit the residents in terms of mobility, timing, and purpose. For example, Life Enrichment Coordinator Natasha (private LTC home) described how staff respected a family caregiver who would like to move around over the robot.
“We have a resident, Ted, whose daughter calls in, she probably would not want it (the robot) to be mounted, because she likes to drive to the doorway and see where he is and she drives it up to him. She just really thinks it (the robot) is a good fit for her and her dad.”
Similar anecdotes originated at other partner sites:
“I haven't had to do too much with the family members at all. They just call whenever they want. The only concern they brought forward is when they were calling and the robot was covered, and that was mostly in the beginning. I think once staff has become more comfortable - they are not putting the covers on. Very rarely do I have to do anything with the family.” (Courtney, Clinical Operations Supervisor, Ocean View)
“We have used the telerobot with somebody who was in the end-of-life situation where family members couldn't come in because of COVID. The daughter was ready to give birth, so she did not want to come into the hospital [to visit her father in person] because she was in a very vulnerable situation. So just to protect her and the family, we offered them the telerobot for them to be with their loved one as much as possible, although it be just virtually. I found it very interesting because the daughter was at home, and she was just doing her daily living stuff – cooking and cleaning, etcetera. But [through the robot] she could see her father in our hospital room here. I feel just the voices and the sounds of home might have been very comforting for her father that was here.” (Ashley, Patient Care Coordinator, Hospital)
4.3.2 Barriers: Insufficient resources and structural supports
4.3.2.1 Wi-Fi issues
One of the biggest barriers raised by staff across care sites is a weak and unstable Wi-Fi connection:
“I think the only challenge [in using the robot] I would say is the disconnection. We had many conversations interrupted due to our Internet.” (Bridgette, Clinical Operations Supervisor, Garden View)
“Sometimes you hear about storms or things like that, then there's no connectivity. If there's no Wi-Fi, you do not have the option. But as long as that [Wi-Fi] is running well, everything is good.” (Ashley, Patient Care Coordinator, Hospital)
“It is just when [the] Wi-Fi connection is not very good, the family will call the ward and tells us that the conversation keeps lagging. This is the only feedback that bothers positive reviews[about the robot].” (Frank, Rehabilitation Assistant, Public Hospital)
“When asked, ‘What barriers do you anticipate in implementing in other LTC homes?,’ the participant mentioned, ‘If the facility has bad Internet connection, staff and residents would be unable to usethe robot.’” (Amanda, Acitivity Assistant, Non-profit LTC)
The Wi-Fi issue was also highlighted in the focus group at the Public Hospital.
Evelyn (TCW): “[We need] strong [Internet] connection. Sometimes at the far end [of the hallway], the Internet is not working, not even on the telephone. There should be something [to] make the Wi-Fi connection stronger at both ends of the hallway. What do you call that?”
Pierre (RN): “Wi-Fi routers?”
Evelyn (TCW): “Yes, routers. I don’t know how many routers they have but sometimes through the far end even the telephone is not working, and the Wi-Fi is definitely not working."
Similar instances were referenced by the focus group conducted at Ocean View:
Courtney (Clinical Operations Educator): “The Wi-Fi connectivity is a resource that is needed for successful implementation [of robots]. It is not great in some locations; in one of the rooms, it’s really good and then in another one, it comes and goes. So, when family members are calling, that sometimes leads to frustration.”
Sarah (Clinical Educator): “I can echo what Courtney is saying in terms of the Wi-Fi connection. We are happy to support, but sometimes it can be frustrating to the resident if they had an appointment (i.e., scheduled call from families over the robot) booked but it [the robot] is not working out.”
4.3.2.2 Challenges in human resources
As mentioned earlier, our partner care sites sometimes experience staffing crises varying in extent, which leads to difficulties for staff to receive training about robots and to implement robots in their care delivery.
Insufficient staffing could also obstruct the team from using the robots in the long-term, as activities associated with maintenance, troubleshooting, and coordination of robots require staff’s attention. For example, when asked whether the care team would need ongoing technical support for the long-term implementation of robots, two participants from different LTC homes gave similar answers:
“Yes, absolutely, especially with connectivity and technical issues.” (Alex, Clinical Operations Educator, Ocean View)
“I think it (technical support) has to be ongoing.”(Bridgette, Clinical Operations Educator, Garden View)
In addition, a short-staffed care team could face difficulties in scheduling call-in with families due to robots being shared between residents at different rooms.
“One challenge that I did come across was the timing. I know some passes for family members [last] for 2 to 3 hours. A lot of time it (scheduled calling time) is on the calendar but sometimes it gets missed – we get calls [from families]…Otherwise, its good.” (Jasmin, TCW, Public Hospital)
A staffer reported an unexpected situation due to lack of coordination concerning a family call and concurrent care delivery for the same resident:
“We had an incident where staff is just walking in and the robot moves. The families was trying to set it up (call through the robot) like a business call but it almost caused a staff member to stumble. Because the staff has no idea. It (the robot) was controlled by the family.” (Bridgette, Clinical Operations Educator, Garden View)
4.3.2.3 Lack of technical support
Staff from different sites called for resources to support them as they are using the robot, in terms of troubleshooting and ongoing training for staff and families:
“Staff are more than happy to help if the support and resources are there and organized for them. When they (the robots) get knocked off, maybe we should have a central number to call instead of waiting for one of the people who are the main users to go and find out [about technical problems concerning the robot].” (Bridgette, Clinical Operations Educator, Garden View)
“[We need] more hands-on training for the staff so they are comfortable. I think a lot of times when it's not docked or when it's not charged or if there's any technical support needed, the staff [are] still not very familiar [with handling] the robot issues. We need more hands-on and more continued training.” (Lisa, Clinical Operations Supervisor, Garden View)
4.3.2.4 Limited physical space
Staff elucidated how a limited physical space discouraged them from using the robot. Two participant described unexpected situations, in which the robot was perceived as a safety hazard for residents and staff:
“It happened once that the family was trying to drive it (the robot) and the staff was coming in the way. So, it was also a safety concern and better to have it stationary.” (Bridgette, Clinical Operations Supervisor, Garden View)
“The [physical] environment is a little bit tight, especially with residents who use wheelchairs, so I try to make sure it (the robot) is in a corner where it is safe for the resident and also for staff so that it is not a tripping hazard.” (Sarah, Clinical Educator, Ocean View)
Other participants expressed their frustration about the incompatibility of placing a robot in a small area with the mobility needs and patterns of residents and staff, leading to an increased chance of a robot being knocked over:
“Depending on where the robot is placed, there’s always a possibility that it could be knocked out of his docking station by either the staff or the resident when they pass by because of the tight corners. Those [possibilities] are what we observed.”(Courtney, Clinical Operations Supervisor, Ocean View)
“I think the design of the robot is a bit tricky, given the shared spaces. If it was a private room, it would be less challenging because you would have a designated area [to place the robot]. But for shared rooms, the space is so small. It is bound to be knocked off.” (Bridgette, Clinical Operations Supervisor, Garden View)
Finally, some staff shared their observation on how shared rooms diminished users’ experiences with the robot, including their raised concern on privacy for residents and families.
“Privacy is a thing because of the shared rooms. You have to be mindful of your roommate, for example, when the roommate has loud TV on, or music. One of the concerns from one of the families was that they are trying to talk to their loved ones through the robot. They (the families) were having a difficult time because their loved ones had difficulty with hearing because of the background noise.” (Courtney, Clinical Operations Supervisor, Ocean View)