Decision-Making

All three participant-groups underlined the importance of respecting choices made by the end-user for the wearables and the monitoring technologies inquired in this study (Fig. 1). Family caregivers said that the elder user can choose the watch if they wish to, or they can decide against it. In cases of indecision, some of the family caregivers expressed their hopes that the elder parent will be reasonable and would agree to use the technology, since it has a supporting function. For those with dementia who are deemed incompetent to make a legal decision, all three participant groups reported that proxy decisions could be made by the healthcare team and/or the family after explaining the purpose of the technology and its utility to the older person.

Professional caregiver 1: The most important thing for me in such matters is the consent of the monitored person. So, if I know there is a camera in my kitchen and living room, that is something different from when I find out afterward that someone has been watching me … Or if a nursing home is equipped like this [with sensors and cameras] in a whole building, for example, also in the hallways and the elevator, then there should be transparency. If someone is interested in the nursing home, they should know that … [that] it is a measure by the facility to reduce falls and the time residents spend lying down, just like that.

Fig. 1

Ethical deliberations in the use of new technologies to care for older persons

The notion of user control of the technology was evident for all three technologies (see Fig. 1). In the case of the robot Pepper, discussions revolved around the older user being able to set boundaries for what the robots can do and cannot do in order for the user to be safe. Likewise, for wearables, family caregiver and older person participant groups noted that users should decide whether and when to have the smartwatch’s feedback and where the cameras should be installed so that every facet of an individual life is not captured. Finally, related to the sensors at home, family caregivers stated that there is a greater risk of not being in control because, unlike wearables and robots, one cannot easily put sensors away and since video surveillance and ambient sensors run automatically throughout the day.

Older person 4: Yes. Otherwise, if he [Pepper] were to become independent, it would be disgusting if he taught himself. You just have to show him the boundaries, “You’re allowed to do that and there you have to …,” when he then says where it is okay …

Family caregiver 8: If you have video surveillance, you cannot turn it off, you have it, the sensors are always there, the clock runs 24 hours... so of course it is easy from that point of view, you can put one away [the robot] and the other [sensors] always runs. That is probably why the thresholds here (monitoring) are higher than on the other side.

Benefits of Using New Technologies for the Older End-userEnsuring Safety and Health

For each technology, the three study participant groups noted that there were certain benefits to the older user. Sensor technologies on the wearables, as well as those in the home, could send alerts in emergency situations, thereby ensuring the safety of the older person. The sensor technologies also collect data on their users, which might allow caregivers to detect risks of falls or equip the users with information to improve or manage their current health conditions, such as seizures. For instance, one older participant said: “Of course that [wearable] can be positive. I see it from the perspective, when I am no longer able to get help, the help is automated” (Older person 3). Related to health maintenance, the three participant groups felt that the reminder functions were also important for planning and self-management purposes by repeatedly supporting older persons with their medication, nutritional or daily fluid intake, and their physical activity needs (Older person 1: “Yes, I would find that very beneficial for older people because they often don’t drink enough”). This benefit for the safety and health management of the user did not come up for the robotic technology (Fig. 1).

Ameliorating Loneliness

Professional caregivers and older study participants saw the robot, Pepper, as a tool that could help older adults reduce loneliness, as it could support them in activities such as reading a book, having a conversation, or connecting with relatives who do not reside in the same place (Fig. 1). Pepper was also mentioned as a source of entertainment for older persons with dementia. For instance, one participant said: “You can use it as entertainment, so you can really do a lot of things. And we saw that too, that is, we also saw that [how it was used] for persons with dementia” (Older person 12). However, participants from the caregiver groups stressed the fear that engagement with robots could result in older persons self-isolating, by forming human–robot interpersonal relationships at the expense of others.

Family caregiver 9: I also see the disadvantage with these technologies, especially with robots, isolation. People go out less because they think, yes, this technical object is enough for me, which means that interpersonal relationships are lost or suffer as a result. That is what loneliness is.... Exactly.

Professional caregiver 5: Yes, I would find it strange as well. The relational aspect worries me or raises concerns, where people might suddenly feel they could form a relationship. And, it is not a real relationship. Or rather, that’s not quite right either; it is a relationship, but... a relationship at the push of a button that you can turn off. Maybe it would also prevent them from pursuing other relationships.

Benefits of New Technology for the CaregiversOptimize Care Resources

Professional caregivers and older persons underlined that, if a robot were able to complete some tasks generally performed by caregivers, this might effectively optimize available care resources. Specifically, Pepper can potentially improve caregiving by doing certain tasks for the caregivers, as nursing care staff would not be available to talk for the whole day. As one elder participant put it: “They [the residents) cannot have one nurse who would talk with them the whole day” (Older person 9). One participant also said that using personalized Pepper robots would have been beneficial since they could talk in her voice, a feature which have de-escalated the situation her mother was in where the participant felt unable to attend as a family caregiver. Thus, all three participant groups deemed robots as tools that could reduce caregiving stress (Fig. 1).

Professional Caregiver 23: We had a situation here [at work], … and they [carers of her mother with dementia] called and she [mother] was raging in the background … no one [other family member] was available and I could not leave …. I also understand the urgency of care [of the situation] … and in such a moment, I would be glad for help [to send a Pepper with my voice].

In addition, family caregivers and older persons felt that caregiving stress can be reduced and optimization of care secured if, for example, sensors were reliably used. Caregivers can determine what the needs of the older persons are, to ensure that they are safe by monitoring them remotely rather than always checking in-person (Fig. 1). Hence, camera and sensors in the nursing home context could help with the shortage of staff members. In a similar vein, the use of these monitoring technologies can help reassure family caregivers that their elder relative is well and that they need not make a visit to confirm that.

Older person 19: Well at the moment, I do not see a need for camera. If I were bedridden, things might look different. If it means the nurse does not have to check constantly and can instead see from the camera, “Ah, it’s very urgent, I need to rush,” then I think it would be a good idea. It might also relieve the person a bit.

However, this optimization of resources might reduce interactions between caregivers and care recipients. For example, with the use of ambient sensor technologies, caregivers can rely on these technologies to fulfil some roles that would ordinarily require them to go to the older person’s residence. Professional caregivers and older persons raising this concern were worried that with the cameras, more information is available for the nurses to decide whether a given situation is “worth” an actual visit, potentially resulting in reduced personal contact with the older adult.

Professional caregiver 9: Yes. For example, the caregivers can already judge for themselves with cameras whether it is an emergency or not, and maybe they come later or something. But with an emergency alarm, they don’t know if it’s really okay or if they need to come. … I find these two things (sensors in the house and cameras) a bit ethically problematic, even though they agree. Because maybe they need help, but the caregiver decides if they need help or not, or if it is urgent or not. I find that somehow... you do not know how urgent it is from the outside, I think.

Worries Associated with Technology Use for Older End-usersStigma

Stigma was reported as a worry by very few participants (from the older person and family caregiver groups) when using the wearables only (Fig. 1). The concern was that wearing the device might signal the presence of a care need or deficiency on the part of the user, particularly when the wearable was overtly noticeable. Referring to the use of smartwatches, and particularly to the idea that information or notifications from it may come at odd times, a family caregiver suggested that vibrations are discrete, ensuring that unnecessary attention is not attracted.

Older person 18: It [smartwatch] was just so clunky. One immediately sees [and thinks], ah yes, this is an old person who needs a watch like this now. But today I think the design has improved.

Family caregiver 5: Well, I think vibration is interesting because it is very discreet and not embarrassing when she’s [older person] in the city in a café or with her friends or something.

Risk of Physical Harm

Only in relation to the robot Pepper did the older adult participant group relay concerns regarding potential physical harm (Fig. 1). That is, using the robot could be dangerous if it gets out of control and physically harms the user. The scenarios in which this threat was described were dramatic. Hence, as relayed in the first theme, the participants felt that it was important that the user has control over the technology and can set boundaries for what the technology can and cannot do in order to be safe for older adults.

Older person 16: What do I do if the technology isn’t right and it comes and does something, not what I don’t want but what frightens me, what hurts me or something and I can’t stop it. … Yes, yes. Just when he comes and instead of saying “Hello,” with his little robot hands he takes one and tears the arm off, so just about …yes, yes, simply that something is no longer right in the electronics.

Over-Reliance on Technology

All three groups worried that the technology may be employed in ways that could result in relying on them too heavily. For instance, professional caregivers said that information collected from the wearable devices could be used in making an assessment about the health of the older patient, whereby the subjective health information given by the older patient is disregarded or not fully considered. Such circumstances could take away what is important for the older patient; that is, to be heard and trusted by their professional caregivers (Fig. 1). However, professional caregivers—specifically in the case of older persons with dementia—felt that the older users might not know how to react to the feedback given by the wearable, such as reminders to take medications. Thus, they raised the point that reminders may not work and falls may happen, cautioning against overdependence on such technologies.

Professional caregiver 18: Sometimes it might make things more difficult because I would know if something is not right from what they tell me … It might be harder to take their needs seriously if I have clear facts that contradict them.

Professional caregiver 17: Mostly, care involves supervision, especially for medication intake. It is often because people forget, or … or [medication is] taken at the wrong time. Even with reminders, it’s a trade-off—some people might benefit from it, thinking, “Oh yes, I forgot,” while others need someone standing right next to them, saying, “Take your pill now.” There are those who are so overwhelmed that they get distracted and forget. And there are those who just don’t understand what it is and throw it away.

Both older participants and family caregiver groups discussed the increasing physical dependencies Pepper may induce in older persons, since some activities of daily living may be done by the robot. An older person making this point noted: “Yes, get me a glass of water or … although it would be good if I got up every now and then and went to get it myself, … if I then have the Pepper, then I'll do it no more” (Older person 26). Underlining how undesirable the situation of a user made passive by their over-reliance on technology might be, a family caregiver stated: “Terrible! So no, then one is supported by technology for everything and then would not [need to] take care of oneself anymore?” (Family caregiver 4).

Constant Surveillance and Data Concerns

Continuous monitoring was reported by all participant groups as a key concern with the use of wearables and sensor technologies at home. At the same time, this concern did not arise regarding robotic technologies (Fig. 1). For the ambient sensor technologies, older participants felt that certain parts of a home are more private such that they might be less comfortable with the presence of sensors there: “ … So I mean camera, let’s say at the entrance, I would also think it’s something good. But camera on every corner, I don’t know if you’ll be a little worried, if you know [it’s there]” (Older person 5). As third parties who are subject to such continuous monitoring, the professional caregivers reported feeling mistrusted and assessed.

Professional caregiver 15: … Especially when you are really being checked to see if you’re really where you’re supposed to be at that time, right. I just have to say … No, very unpleasant … Even though I did not do anything wrong. It is like that sometimes.

A few participants said that data protection is not something that they think about, indicating that whosoever wants the data can have them. Others were sceptical of sharing data with insurance and banks: “Suddenly the health insurance company somehow notices, oh, they never move, then I increase the premium there a little or with someone else, they do something crazy, and then there too, so that’s the way it is” (Family caregiver 6).

General Worries about Technology Use in Elder CareFear of Replacing Human Care

The concern that less human care will be given to older persons as a result of the use of sensor cameras was evident from the above section on the optimization of care resources. However, we found that this fear of the replacement of human care was expressed more heavily in the case of the robot Pepper by the three participant groups (Fig. 1). They reported that having or seeing a Pepper feels like it is already replacing people a little bit, and that was not acceptable because the nursing profession is about building interpersonal relationships. Although there was openness to using Pepper for supportive purposes (i.e. helping with practical activities), it was underlined that it should not become a norm. A participant stated: “It would be a nightmare to have a nursing assistant sitting in an office and giving orders to five robots outside to provide care” (Professional caregiver 22).

Many older persons reported that they cannot imagine using robots for care because the human aspect would be lost, which to them was very important. One participant underlining the little human contact received in nursing care stated that he still values the human contact he gets from the people bringing food, as they get to know each other after a while and that is good.

Older person 22: I am … well, personally I’m just not a fan of any of this stuff [Pepper]. Firstly, this breaks the connection with a person [and it] simply doesn’t just interrupt [human care], but eliminates it. There is even less [human] contact.

Deception

Deception was a concern that also arose in the context of the robot Pepper, particularly when talking about personalizing Pepper such that it would have a voice of a loved one (Fig. 1). For instance, one older participant stated: “That would deceive me, I don’t want that. If it’s the son, then it’s the son, then I can react to that” (Older person 23).

Professional caregivers noted that they find it bothersome that Pepper “simulates something so human, which it is really not” (Professional caregiver 1). They further added that it may be terrible, and at times distressing, that the robot could mimic a person that the user may not know. The emphasis they placed on what is true was clear, and they were concerned with the potential for mistrust between the older resident and the professional caregiver. This line of argument was revealed by family caregivers and older persons as well. That is, participants noted that the robot should be itself, including its funny manner of speaking, and insisted that it should not copy a family member. It was also said that mimicking family members is in some ways scary, while one participant stressed that he would not want his older father to have the feeling that Pepper was his son.

Professional caregiver 6: So intuitively terrible. … So the client in question does not have advanced dementia, I think she would know that [Pepper is not a real person]. But now with someone who has more advanced dementia, that would be a bit of a, yes, fooling.

Family caregiver 10: No, I don’t think so. I don’t think so, and I feel now that it [Pepper] should be itself, it shouldn't be a family member. No. I think it’s funny when it talks, but I think Pepper should be Pepper and not somebody else, in my opinion. (Moderator: Ok, can you elaborate a bit more?) Yes, because, from my perspective, I don’t want to give it my personality, I don’t want my father to feel that it’s [me].