Introduction
According to the International Organisation for Standardisation [1], robotics is a discipline that encompasses the design, production, and utilisation of robots. Robotics is a multidisciplinary discipline that utilises knowledge from mathematics, physics and engineering fields, including mechanical, electrical, and computer engineering [2], to produce virtual or mechanical robots that assist in the occurrence of everyday activities [3] or that carry out tasks partly or fully independently [4]. A robot is defined as an automated device that can be programmed to move in two or more axes and exhibit a degree of autonomy to carry out specific tasks within its surroundings [1].
Healthcare robots are classified into three categories, namely, functional robots, service assistants and social colleagues [5]. Functional robots are most widely used in healthcare and include surgical robots, cleaning robots, and medication dispensing robots [6‐9]. Service assistants act as human assistants to perform complex tasks and can operate without constant supervision. Examples include robots used to carry out activities of daily living, logistics and telehealth robots [10, 11] and some robots that can carry out basic nursing roles such as vital sign measurement and fall detection [5].
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Social colleague robots, on the other hand, act as healthcare professionals providing healthcare services. They are used for entertainment purposes and to stimulate physical activities in older persons [12] and in the care of people with dementia [13] and to address the challenges of loneliness and isolation [14].
Service assistant robots can assist the nursing profession with manual and time-consuming tasks, thereby helping nurses focus on other essential aspects of priority patient care [15]. Researchers stated that 10% of nurses’ time is devoted to roles such as lifting described as nonprofessional roles that could be delegated [16, 17].
It has also been reported that only approximately 7.2% of nursing practice time was dedicated to direct patient care and that most nurses’ time was spent on unrelated activities such as telephone calls and other administrative tasks [18]. Direct patient care is a cornerstone of the nursing profession, reflecting the vital role nurses play in promoting patient health and well-being. In addition to providing compassionate care, nurses also take on important administrative responsibilities that contribute to the overall efficiency and quality of healthcare. As the healthcare environment evolves, nurses are stepping up to embrace expanded roles, adapting their skills and expertise to meet the growing and changing demands, and leading innovations in patient care and healthcare delivery [19, 20].
Furthermore, there are growing challenges in the provision of nursing care worldwide, such as an increase in the ageing population [21, 22], resulting in increased dependency on nursing care and an ageing nursing workforce, with many countries experiencing nursing shortages [15, 23‐25]. Consequently, nurses experience burnout [26], reduced job satisfaction and a high turnover rate [17]. These challenges to providing adequate nursing care suggest that it may be timely to explore alternative and creative ways of easing nurses in nonprofessional roles. One potential solution may lie in the more widespread adoption of robotics in nursing practice.
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Moreover, robots have the potential to positively transform nursing care and solve some nursing problems by assisting nurses in nonprofessional roles and allowing nurses to focus on more professional roles [17, 24]. Arguably, the use of assistive robotic devices in healthcare is designed to reduce the workload of nurses by performing logistical and laborious physical tasks [27].
With the growth in the use of robots in healthcare, it is important to consider the implications for the nursing profession and for nursing practice. A search of the literature revealed several published systematic reviews related to robotics in nursing in the past decade. Therefore, to illuminate the experiences of nurses regarding the use of robots in their practice, it was deemed timely to conduct an umbrella review to synthesise and provide a comprehensive summary of this evidence.
Methods
Aim
This umbrella review aimed to assess and synthesise systematically reviewed evidence on the utilisation of robots in nursing practice. The objective was to reveal what is already known about robotics in nursing practice and to make recommendations for further research [28]. The review questions were as follows:
1.
What are the documented nurses’ experiences of the use of robots in nursing practice?
2.
What are the perceived benefits of utilising robots in nursing practice?
3.
What are the perceived challenges of utilising robots in nursing practice?
Design
Using the methodology of the Joanna Briggs Institute [29], this umbrella review combines the findings of multiple reviews, including systematic, integrative, scoping and meta-ethnography, to provide a summary of the synthesised evidence, highlighting the consistencies, discrepancies and contradictions that exist related to this topic [30]. A protocol was developed for this umbrella review and registered on PROSPERO (Registration ID CRD42022361835).
Search methods
Nine databases, including PubMed, Embase, the Cochrane Register of Controlled Trials, the JBI Database of Systematic Reviews, CINAHL, Science Direct, IEEE Electronic Library Online, Web of Science and Medline, were thoroughly searched for relevant publications. The keywords included ‘robots + nursing’, ‘robotics + nursing’, ‘robots + nurses’, ‘robotics + nurses’, ‘AI machines + nursing’, ‘AI machines + nursing practice’, and ‘robotics + nursing practice’. The terms were combined using Boolean operators (AND, OR) to refine the search, and the filter ‘reviews’ was applied to narrow the results. Grey literature was not included in this review.
The population, exposure and outcome (PEO) framework was used to determine the key concepts, and the inclusion and exclusion criteria for this review are shown in Table 1 below. Included in this review were systematic reviews that report the perceived benefits and challenges of using robots in nursing and/or documented experiences of nurses in the use of robots in nursing practice, published in the English language and between the years 2012 and 2022 (Table 1). Excluded were protocols and reviews that reported studies that were not related to nursing practice and did not answer the review questions. Also excluded were reviews where the full article was not available in the English language. To incorporate recent developments and current evidence from the literature, an additional search adhering to the same criteria was conducted in October 2024. This search resulted in the inclusion of two additional systematic reviews [31, 32].
Table 1
Inclusion and exclusion criteria
Included | Excluded | |
|---|---|---|
Population | Reviews that reported the experiences of nurses, benefits and challenges of using robots in relation to nurses and nursing practice in all care settings including hospitals, homes, residential care | Reviews that reported on patient experiences of using robots. Excluded are also reviews related to use of robots in surgery, physiotherapy, rehabilitation, orthopaedics, nursing education etc. |
Exposure | Exposure to robots, robotic devices | Exposure to Artificial intelligence without the involvement of robots |
Outcome | Experiences of nurses with the use of robots including the perceived benefits and challenges | Other outcomes |
Types of review | All systematic reviews including scoping, integrative, bibliometric reviews, systematic reviews and meta-analyses. | Review protocols |
Language | Reviews published in English | Reviews in other languages |
Year of publication | Reviews published between the years 2012 and 2022 | Reviews published outside the required date range |
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Search outcome
A total of 1250 review articles were returned from the database searches. 108 duplicates were then removed using Mendeley reference management software. The screening and selection of papers were performed using RAYYAN review management software. Papers retrieved from the search were transferred to RAYYAN software for screening. Following this, 1142 publications underwent title and abstract screenings. 1105 of these were excluded. Each screening was done blindly and independently by each reviewer (AA and LK) as recommended by the JBI’s methodology for umbrella reviews [29]. Any conflicts were resolved by a third reviewer (AC). 37 reviews were eligible for full-text screening. Blind full-text review was again conducted by two independent reviewers (AA and LK), and conflicts were resolved by a third reviewer (AC). 24 full-text reviews were excluded because they did not meet the inclusion criteria. The remaining 13 reviews were included in this review (see Fig. 1- PRISMA flowchart of the selection process). The characteristics of the included reviews are summarised in Appendix 1.
Fig. 1
PRISMA flow chart of the selection process [33]
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Quality appraisal
The included reviews were critically appraised using Joanna Brigg’s Institute Critical Appraisal tool for umbrella reviews [29]. To assess the quality and methodological rigour of the included reviews, 11 questions were answered. Each question was rated as ‘Yes’, ‘No’ or ‘Unclear’. All the studies were included in the review because they met at least 70% of the pre-determined criteria in the JBI critical appraisal tool (Appendix II). A summary of the critical appraisal can be found in Appendix II and is discussed in the results section below.
Data extraction and synthesis
Data extraction was conducted using Joanna Brigg’s data extraction tool for umbrella reviews [30] by two reviewers for each paper. A spreadsheet, which was specifically developed to answer the review questions, was created to assist with the data extraction. The reviewers read the included papers several times to become familiar with the data and extract meaningful content. The findings of the reviews were examined for similarities and grouped into categories [34‐36]. These categories were key topics and concepts, as discussed in each review (Appendix III). The categories were grouped into synthesised findings in relation to the review questions. The synthesis is presented in tabular form, and a narrative report is provided in the results section below [30, 37]. This report is supported by direct quotations from the reviews. The findings and illustrations extracted from all the reviews are summarised in Appendix III.
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Results
Review characteristics and design
A total of 13 review papers were deemed eligible for inclusion in this review. These reviews were published between 2018 and 2024. Of the included studies, six were scoping reviews [31, 38‐42], three were integrative reviews [43‐45], three were systematic reviews [32, 46, 47] and one was a meta-ethnographic review [48]. See Table 2.
A total of 558 studies were included in the 13 reviews. These reviews included studies written from the perspectives of nurses, other healthcare professionals, formal and informal caregivers, older adults, people living with dementia and healthcare providers using a variety of methodologies, including quantitative, qualitative and mixed methods. The studies included in the reviews were from various geographical settings (including Europe, Asia, the Middle East, America, Canada, and Australia) and across various settings (long-term care homes, our own homes, hospital units, dementia care and controlled laboratory conditions).
Table 2
Review characteristics and design
Author (Year) | Type of review | Types of studies included | Number of studies included |
|---|---|---|---|
Buchanan et al. (2020) | Scoping | Qualitative, Quantitative, mixed methods, systematic reviews, scoping reviews, grey literature | 131 |
Gibelli et al. (2021) | Scoping | Traditional literature reviews, position papers, integrative review | 14 |
Huter et al. (2020) | Scoping | Qualitative, Quantitative, systematic reviews, Observational, Randomised Controlled Trials | 154 |
Maalouf et al. (2018) | Scoping | Not specified | 69 |
Papadopolous et al. (2018) | Scoping | Qualitative, Quantitative, and mixed methods | 19 |
Wong et al. (2024) | Scoping | Qualitative, Quantitative, and mixed methods | 33 |
Servaty et al. (2020) | Integrative | Qualitative, Quantitative, mixed methods, Case reports | 17 |
Kangasniemi et al. (2019) | Integrative | Qualitative, Quantitative | 25 |
Costo Martins et al. (2019) | Integrative | Case studies, prospective studies, literature reviews, Exploratory and descriptive studies | 17 |
David et al. (2022) | Systematic | Systematic reviews, Randomised Controlled Trials | 23 |
Tan et al. (2021) | Systematic | Observational, mixed methods, case studies | 33 |
Trainum et al. (2024) | Systematic | Qualitative, Quantitative, and mixed methods | 15 |
Scerri et al. (2021) | Meta-ethnography | Qualitative, mixed methods | 8 |
Quality of reviews
The results of the critical appraisals for the included reviews are presented in Appendix II. Four of the reviews [39, 44, 46, 47] met all the quality criteria. The remaining reviews were scored lower due to poor reporting of quality appraisal or lack of clarity in the review question. Eight of the reviews [31, 32, 38, 40‐42, 45, 48] did not state or were unclear about the criteria used for appraising the included studies or whether critical appraisal was independently conducted by two or more reviewers. In addition, four of the reviews [32, 41, 43, 45] were unclear about the assessment of the included studies for publication bias. Additionally, one of the reviews [38], did not state the review question clearly and explicitly. However, all the reviews were included in this umbrella review because they met at least 70% of the pre-determined criteria in the JBI critical appraisal tool.
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Summary of reviews
The findings of this umbrella review on the experiences of nurses in using robots and the perceived benefits and challenges of the use of robots in nursing practice are reported in a narrative summary supported by the table in Appendix III. The categories were grouped into three areas of synthesised findings to answer the research questions. The synthesised findings are ‘documented experiences of nurses using robots’, ‘perceived benefits of using robots in nursing practice’ and ‘perceived challenges of using robots in nursing practice’.
A detailed description of the synthesised findings and their respective categories is provided below. For each of the categories, examples from the reviews are quoted verbatim, and references to the corresponding findings are provided. The complete list of findings that correspond to the findings synthesised is presented in Appendix III.
Documented experiences of nurses using robots
This finding addresses nurses’ experiences with the use of robots in nursing practice. Only four of the 13 reviews [31, 42, 44, 48] reported on the actual documented experiences of nurses in the use of robots, while the remaining reviews reported on the perceived benefits and challenges of using robots in nursing practice. The reviews that reported the documented experiences of nurses also reported the perceived benefits and challenges of using robots in nursing practice.
In these four reviews, nurses were not the sole participants in the included studies. In some of the studies, the participants were reported as ‘professional caregivers’. The participants included registered nurses, nursing assistants, care workers, clinical coordinators, recreational therapists, activity coordinators, and facility managers, who mainly worked in long-term care, caring for older adults and people with dementia. In one of the included reviews [42], it was reported that in 11 of the studies, participants engaged with a robot, while in eight, participants did not interact with a robot. In such cases, their views were sought using questionnaires.
Nurses’ experiences with robots ranged from social companion robots to mobile, care, and service robots. Most of the robots were service assistants, as categorised in Table 3. The PARO robot, which is an animal-like robot, was named in four of the reviews [31, 42, 44, 48]. Other reviews identified a robotic bathtub, a robotic system that detected falls, a robot automated medication dispensing system and the Gesto nurse robot, which passed and retrieved surgical instruments according to hand gestures and commands [44]. Additionally, robots such as Justocat, Guide robot, Cafero, Kompai and Care O’bot were identified as robots that nurses interacted with in their practice [42]. Others include Stevie, Pepper, Mario, TUG, PaPeRo, Temi, Grace and Smart Walker [31]. A summary of the names and types of robots identified in the reviews are classified using Huang’s (2022) classification of robots in healthcare [5] in Table 3.
Table 3
Names and types of robots used by nurses in the reviews
Classification (Huang 2022) | Name of robot | Description | References |
|---|---|---|---|
Social Colleague | Paro | • Animal-like robot, form of a Canadian harp seal. • Responds to light, touch, movement and sound. • Most described robot in the reviews. | |
Social Colleague | JustoCat | Interactive robotic pet cat | |
Social Colleague | Cafero, Grace, Temi, Pepper | • Humanoid robot • Monitors vital signs • Telecommunication capabilities • Engages the user in games which provide cognitive stimulation | |
Service Assistant | Robotic system that detects falls, Smart walker | • Takes a continuous stream of images and processes them in real-time using machine learning algorithms • Used for mobility, gait detection and hazard avoidance | |
Service Assistant | Kompai, MARIO, PaPeRo, Stevie | • Humanoid robots • For mobility assistance • Telecommunication capabilities including raising an alarm in an emergency • social robot for companionship and support | [42] |
Service Assistant | Guide | • Humanoid robot • Measures vital signs • Interact through speech and via a large touchscreen. | |
Service Assistant | Gestonurse robot | • Humanoid robotic assistant • Pass and retrieve surgical instruments according to hand gestures and speech commands | [44] |
Service assistant | Care–O-bot, TUG | • Humanoid robotic assistant • Helps to fetch, carry and manipulate objects • Delivering linens, medications, and meals in the hospital settings | |
Functional | Automated dispensing system | • Packs solid medications in multidose bags, labelled with the patient’s names • Delivers them to the care units in a locked dispensing cart. | [44] |
Functional | Robotic bathtub | Operated automatically to bath residents | [44] |
Support/Therapeutic tool
Three of the four reviews that documented nurses’ experiences with the use of robots [42, 44, 48] revealed that nurses viewed robots as support/therapeutic tools used to assist them in practical tasks. Table 4 below outlines how robots were reportedly used in nursing practice.
Nurses felt that the four top tasks that the robot could perform were moving patients, cleaning, retrieving or moving objects, and bathing [44]. (p.11) (1a3).
Table 4
Robot use in nursing practice
Use in nursing practice | References |
|---|---|
Automated dispensing system | [44] |
Practical tasks– moving, retrieving, cleaning and bathing | |
Pacifiers | [48] |
Alternative to pets | [42] |
Tool for social connectedness and social interaction | |
Entertaining residents | [48] |
Data collection, surveillance and intelligent reminders | |
Recording and monitoring vital signs | |
Raising alarms in emergencies | [42] |
Nurses also described robots as being better than a soft toy and an alternative to actual pets (Table 4). A review [42]stated thus:
…a few professionals thought that animal-like robots could be a much better alternative to having actual pets in the healthcare setting [42] (p.14) (1a6).
In addition, the availability of robots 24 hours a day was viewed as a significant advantage.
...They especially viewed as a major advantage, the 24-hour availability that a robot could offer to patients and staff [42] (p.11) (1a7).
In other reviews [42, 48], nurses described robots as tools to initiate social connectedness and social interaction.
Robots were considered to have the potential to encourage social interaction between residents, to facilitate group activities, to be used as therapeutic tools [42](p.14) (1a9).
Interpersonal relationship
It was reported that most caregivers stated that robots helped reduce loneliness by initiating discussions, promoting social interaction and ultimately strengthening interpersonal relationships [42, 48], for example:
Formal caregivers felt that the presence of pet robots strengthened interpersonal relationships and contributed to seeing the person behind the condition [48] (p. 90) (1b5).
Conversely, nurses were concerned that some patients could miss out on social connections.
… They were also concerned about the more socially isolated older people and about the possibility that they would miss out on social connection if the caregiver was a robot rather than a human [42](p.13) (1b1).
Work environment
Nurses also commented about the work environment and the physical characteristics of the robots. They affirmed that robots made their job more interesting and that social companion robots can serve as an alternative to actual pets [42].
…but a few said PARO made their job interesting since it affected their residents in a positive way……a few professionals thought that animal-like robots could be a much better alternative to having actual pets in the healthcare setting [42] (p.14) (1c3 and 1c7).
In contrast, some healthcare providers including nurses expressed concerns that using robots added to their workload, including cleaning and charging the robots and addressing technical issues from using the robots [31].
HCPs expressed concerns that using robots increased their workloads such as teaching and assisting residents to use the robots, cleaning and charging the robots, and handling technical glitches… and that the use of robots might interrupt their established workflow [31] (p.10–11) (1c9).
Although the views expressed by nurses towards the use of robots in the workplace are generally positive [42, 48], it was reported that most staff expressed mixed feelings about sharing their workplace with a robot [42].
…it was reported that staff expressed mixed feelings about sharing their workspace with a robot [42] (p.15) (1c6).
Nurses were also concerned about the need for a robot that is easy to clean and conforms to infection control guidelines. Patient safety concerns were also an issue expressed by nurses [31, 42], described thus:
Infection control and safety were identified as major issues, and it was regarded as imperative for the robot to comply with current health and safety guidelines. In line with this perspective, they expressed a preference for a robot that is easy to clean, compliant with hygiene rules and does not pose any injury risk for patients or staff [42] (p.14) (1c8).
Beneficial but with limitations
A review [48] noted that robots could never replace human presence and stated that nurses experienced benefits but with limitations. They were cautious about the use of robots for some core nursing tasks. For example, one review [44]described it as follows:
…The 18 nurses felt that the four top tasks that the robot could perform were moving patients, cleaning, retrieving or moving objects, and bathing. However, they were wary of using the robot for administering medicine, assessing patients, performing bloodwork, and feeding patients [44] (p.11) (1d2).
Some of the limitations identified were the fear of breach of privacy, the reliability of the robots and ethical dilemmas [42, 48], as exemplified in the following quotes.
…for example, some participants expressed fears about privacy breaches resulting from the disclosure of information about the user [42] (p.14) (1d9).… Reliability was especially mentioned as an issue by health and social care workers who interacted with and often experienced problems with the technology [42](p.13) (1d8).
Another ethical issue identified by nurses is the concern that residents/patients are treated like children and that it is difficult to ascertain if an older person with dementia wants the pet robot or not.
… formal caregivers expressed ethical dilemmas that some residents were being treated like children when using pet robots and found it hard to understand whether residents with severe dementia wanted the pet robot or not [48] (p.92) (1d6).
Perceived benefits of using robots in nursing practice
The perceived benefits of using robots in nursing practice are discussed here, including categories such as the provision of care, time savings, the ability to build stronger relationships, data collection, a reduction in nurses’ workload, error reduction and safe and quality care (Table 5).
Provision of care
Robots were reported to be beneficial in assisting with the provision of practical care, and a range of these practical tasks are outlined in this review [42].
Health and social care workers identified many practical tasks that robots could help with, such as lifting, helping a user stand up from a sitting position, helping with dressing, picking up things, escorting, and giving directions [42] (p.14) (2a5).
Our findings also showed that robots assist nurses in meeting the hygiene and basic care needs of patients like toileting, lifting, turning and transferring the patients [32, 41, 44]. A review [41] explained thus:
In the LTC sector, there is evidence that robotic devices have been used to assist nurses in meeting residents’ hygiene and care needs (e.g., toileting, lifting/transferring, and meal delivery), demonstrating the potential for these tools to reduce nursing workload in this clinical setting… [41]. (p.5) (2a1).
Another perceived benefit is the use of robots for non-clinical, more tedious tasks and as physical assistance, for example, robotic walkers and autonomous transportation robots [32, 39, 40].
… there was a good predisposition for pairing assistive and social robots with nurses, especially in relation to the more tedious, nonclinical tasks, which respondents saw as easily achievable by robots [40](p.7) (2a3).
In another review [39], it was reported that a robotic patient lifter required less force when compared with a standard hoist.
A user study on a robotic patient lifter showed that the force needed to handle the lifter could be significantly reduced compared to a standard hoist… [39](p.12) (2a4).
Furthermore, our findings also showed that some robotic systems also serve as intelligent reminders for activities of daily living and can also navigate to patients’ rooms for monitoring purposes [38]. In some other instances, these robots were used to entertain patients thereby creating a more relaxing healthcare environment [48].
…pet robots were used in conjunction with other psychosocial interventions such as music therapy to entertain the residents by creating a joyful and relaxing environment and reducing stressful situations [48](p.90) (2a8).
Saves time
Due to the 24-hour availability, robots have been reported to relieve nurses from continuously checking on patients thereby saving nurses’ working times [38, 42, 44, 46].
Monitoring robots can be used to relieve nurses from having to continuously check on patients and record their vital signs [38] (p.4) (2b2).
Some reviews also revealed that robots can reduce the consultation time [39] and the operating time in robotic-assisted surgeries [44] as described thus:
…For example, robots have been reported to support surgical performance targets, by reducing the lengths of operations, providing greater accuracy, and decreasing patients’ risk than have traditional surgery that was performed by humans [44] (p. 12) (2b6).
Several research studies in [41] also revealed how socially assistive robots (SARs) freed up nurses’ time, thus allowing them more time to understand their patients’ preferences by spending more time with them.
Multiple articles predicted that by using robots to assist with some care activities, nurses may have more time to spend in getting to know their patients’ preferences… [41](p4) (2b3).
Stronger relationships
The review also discovered that robots were perceived to have an impact on nurse-patient interactions and therapeutic relationships [41]. The use of robots freed up nurses’ time and facilitated nurse-patient conversations thereby giving nurses the opportunity to gain a deeper understanding of their patients and establish rapport [41].
Multiple articles have predicted that by using robots to assist with care activities, nurses may have more time to learn about their patients’ preferences, respond to their needs and build stronger therapeutic relationships [41] (p.4) (2c2).In addition, several articles discussed how health professionals, including nurses, have used Socially Assistive Robots (SARs) to gain a deeper understanding of their patients [41](p.4) (2c6).
Data collection
Our findings also showed that robotic devices can be used to collect demographic and health-related information and are sometimes used in surveillance [38, 41].
A few articles reported that robotic devices and other AI health technologies (AIHTs) can be used to collect demographic and health-related information, including patient histories, allowing nurses more time for patient care [41] (p.5) (2d1).
Reduction of nurses’ workload
According to one of the reviews [32], nursing staff envisioned their ideal robot as one that could effectively assist in managing their heavy workload. Additionally, the reviews highlight the of robots to significantly reduce nurses’ workload [32, 41, 46]. This is achieved by assisting with the measurement, recording and monitoring of vital signs [32, 38, 39, 42, 44], alerting staff when patients are in danger [32, 42], helping with some nonclinical tasks [40], relieving nurses of physical strain [38] and making their work easier [44]. This was also perceived to result in nurses’ improved job satisfaction and an improvement in the quality of care provided [44].
Robotic devices were also used by nurses to collect vital signs and monitor patients, and the outcomes were reported or measured in relation to working time and workload [44] (p.10) (2e5).
Robots are also perceived to be useful in sending images and voice messages and providing audio and visual feedback thereby relieving nurses from continuously checking on patients, as in telepresence robots [38].
Humanoids are also capable of successfully performing this job; they can receive alarms, navigate to desired rooms in nursing homes, and send images and voice messages [38](p.4) (2e4).
There is also evidence in the literature that robots can relieve nurses of physical strain, for example, by pushing the hospital bed and could be a solution to the challenges of transferring hospital beds from one unit to the other [38].
…-a temporary solution to the bed-moving problem could be the use of powered robotic bed movers, which could enhance manoeuvrability in hospital environments [38](p.4) (2e10).
Error reduction
Robots are also reported to reduce medication errors especially when using the automated dispensing system [44]. The review explained that:
The implementation of an automated dispensing system reduced overall medication errors, saved nurses’ working time and made their work easier [44](p.9) (2f2).
In addition, as reported in one of the reviews [44], robots provided greater accuracy in robot-assisted surgeries.
… multimodal robotic scrub nurses, who assisted surgeons by passing and retrieving surgical instruments during simple procedures, they found that the robots recognized 95.96% of the 1000 instructions that were recorded. The robot also showed 100% accuracy when picking up instruments and 92.38% accuracy for placing instruments down accurately after use [44](p.11) (2f3).
Provision of safe and quality care
Our findings also suggested that one of the perceived benefits of using robots in nursing practice is the potential to improve the quality of patient care [44].
… minimizing nursing workloads, and the physical demands nurses face, with robots or automated devices can increase job satisfaction among nurses and can improve the quality of patient care [44](p.11) (2g1).
In other instances, robots are perceived to be useful in improving the accuracy and efficiency of the care provided [41]. In robot-assisted surgeries, it was reported that there is a decreased risk to patients than in traditional surgical approaches [44]. Buchanan et al. [41] described it thus:
It is reported that AIHTs have the potential to streamline workflow processes and improve the accuracy and efficiency of care provided in diverse clinical settings [41](p.5) (2g9).
Robots have also been reported to be useful as intelligent reminders for medications and activities of daily living and used to monitor patients by detecting and processing physiological parameters continuously [32, 38, 42].
…Nursing staff also desire a robot that could assist with monitoring patients and alerting staff when patients are in danger, physical therapy or mobility exercises and medication administration and reminders… [32]. (p.6) (2g2).
Another review [48] reported that robots were useful in the reduction of behavioural symptoms like wandering and agitation in older adults thereby reducing the risk of falls in this age group. Papadopoulos et al. [42] explained further that robots can be used as a therapeutic tool for social interaction among residents. It is explained thus:
Pet robots were found to be particularly useful in reducing agitation and restlessness and associated behavioural symptoms such as wandering (thereby reducing the risk of falls), repetitive behaviours… [48](pg.86) (2g5).Robots were considered to have the potential to encourage social interaction between residents, to facilitate group activities, to be used as therapeutic tools [42](p.14) (2g6).
The perceived benefits of using robots in nursing practice are summarised in Table 5.
Table 5
Perceived benefits of using robots in nursing practice
Benefits of using robots in nursing practice | Examples | References |
|---|---|---|
Provision of care | Assist nurses in the provision of patients’ hygiene needs Physical assistance Helps nurses with non-clinical tedious tasks Navigation to desired rooms Intelligent reminders Entertain patients | |
Saves time | 24- hour availability Prevents nurses from continuously checking on patients Gives nurses time to know patients’ preferences Reduction in the length of consultation Save nurses’ working time Reduce operating time | |
Stronger relationships | Build stronger therapeutic relationships Creates a joyful and relaxing environment Gaining a deeper understanding of the patients | |
Data collection | Collection of demographic / health-related information Surveillance | |
Reduction of nurses’ workload | Record/monitor vital signs Make nurses’ work easier Relieves nurses of physical strain Increase job satisfaction Raising alarm in emergencies | |
Error reduction | Reduce medication errors Provides greater accuracy in surgery | [44] |
Provision of safe and quality care | Improves quality of care Intelligent reminders to take medications Decrease patients’ risk in surgery Detection and processing of physiological parameters Reduce the risk of falls Tool for social interaction Improves the accuracy and efficiency of care provided Provision of audio and visual feedback |
Perceived challenges of utilising robots in nursing practice
According to this umbrella review, there were a number of challenges perceived by nurses in relation to the use of robots in nursing practice. The categories include cost/financial, medico-legal/ethical issues, patient safety and privacy issues. Others are issues related to social interaction, nurse-patient interaction, physical characteristics of the robot and the impact on the workforce (Table 6).
Cost/Financial
The financial, high acquisition and maintenance costs of robots are the most cited challenges of using robots in the literature [31, 32, 42, 43, 45, 48], explained thus:
Robotic users were worried about the high acquisition and maintenance costs of robotic devices, especially when there were more inexpensive alternatives [43](p.9) (3a4).Caregivers are concerned about the accessibility and affordability of robots and advocated for ‘distributed justice’. Care robots can be extremely expensive, but finances (whether those of the older adult or of the facility) should not prevent someone from accessing these devices [32] (p.7) (3a1).
Medico-legal/ethical issues
The ethical issues related to the use of robots included issues related to patient’s autonomy [32], deception and anthropomorphism [31], the reliability of the robots and the feeling of guilt among care workers for intentionally deceiving the residents [41, 42, 46, 47]. A review [42] described it as follows:
… Reliability was especially mentioned as an issue by health and social care workers who interacted with and often experienced problems with the technology [42] (p.13) (3b2).
Another drawback is the medico-legal issue of liability. Liability refers to the legal subject of who is to be held responsible for accidents or harm caused by robots or adverse events related to robot malfunctioning [40, 41, 46].
In any case, as far as we could gather from the reading of the papers, the main issue of medico-legal interest related to the robotisation of nursing care is represented by the relative legal ambiguity related to the identification of the legal responsibility (both from the civil and criminal points of view) of adverse events correlated with robot malfunctioning [40]. (p.10) (3b1).
As regards to patient’s autonomy from an ethical perspective, there was a debate about whether control of the robots should rest with the older adults or the nursing staff [32]. Additionally, concerns were raised about preserving the autonomy and dignity of the older adults in their interactions with the robots.
…Ethically, there was disagreement about who should control the robots—the older adults or the nursing staff.there are also concerns about maintaining autonomy and dignity of the older adult [32] (p.7) (3b13).
Our finding also suggested that there is a perception that patients can be harmed due to a malfunctioning robot and that sometimes there must be a balance between the principles of beneficence and non-maleficence in the interest of the patient [41, 43].
…For instance, some of the most common sources of danger that could be exposed to person carrier robots are unstructured environments that are extrinsic to the device; and mode transition that is intrinsic to the device. This principle of non-maleficence is usually paired with the principle of beneficence, i.e. promoting what is in the best interest of the user [43](pg.7) (3b10).
Patient safety
Patient safety is also a significant concern. In one of the reviews [31], health care providers did not trust robots to work independently. It was also stated that patients may be injured due to a failure in robotic technology [41]. The importance of ensuring adherence to current health and safety regulations when utilising robots was emphasised [42].
Infection control and safety were identified as major issues and it was regarded imperative for the robot to comply with current health and safety guidelines (p.14) [42] (3c3).
Another review [45] identified an increased risk for patients undergoing robotic-assisted surgeries. This was described thus:
Long robotic surgeries are associated to increased risks for patients, and the extended time during the surgery increases the risk of the patient for position-related complications… [45](p.4) (3c2).
Privacy issues
Patient privacy is a major concern in the use of robots. It is believed that patients’ privacy could be jeopardized resulting from disclosure of patients’ data [31, 40‐43].
…for example, some participants expressed fears about privacy breaches resulting from the disclosure of information about the user [42] (p.14) (3d2).
Furthermore, there is the risk of invasion of privacy by surveillance [32, 43] and unwanted intrusion into people’s lives, for example, companion robots [46] (Table 6), which could provide a sensation of being observed or watched.
…As robots could make continuous video and sound recordings of the users, older people voiced robotic applications as a form of forceful intrusion and ‘Big Brother’ surveillance of every snippet of their lives [46](p.8) (3d5).
On the other hand, healthcare providers are also impacted by the privacy concerns. In one of the reviews, healthcare providers felt that the robots were observing and tracking their activities [31].
Some health care providers expressed the feeling that the robots were monitoring their work [31] (p.10) (3d7).
Social interaction
The reviews further explained that in long-term care settings, social robots could mimic authentic social engagement and mislead older people into believing that they are engaged in real social interactions [31, 46]. Described as follows:
Social robots deployed in long-term care settings are seen as counterfeiting authentic social engagement with older people and misleading them to falsely believe that they are engaged in genuine social interaction. The unintended consequence of the deployment of social robots in long-term care is the encouragement of anthropomorphism [46] (p.10) (3b5).
It was also revealed that social isolation, compromised human interaction and fear of decreased social contact are major drawbacks to the use of robots [40, 46]
Social connectedness and compromised human interaction emerged as a major ethical issue faced in the deployment of robotics and autonomous systems in long-term care [46](pg.9) (3e6).
This review explained further that reduced social connections with people and the replacement of human touch by robots can also result in social isolation and limited social relationships [46].
Reduced social interactions with humans and the replacement of human touch by robots could result in social isolation and reduce the opportunities to form social affiliations with others… [46](pg.9) (3e5).
Nurse-patient relationship
One of the limitations of the use of robots is its effect on the nurse-patient therapeutic relationship. If nurses utilise robotic devices to monitor patients for compliance with medical regimens, this could embarrass the patients or make them angry thereby weakening the therapeutic relationship [41].
…If nurses use robotic devices to monitor adherence to treatment, one article suggested that this has the potential to cause embarrassment or anger among patients, weakening the therapeutic relationship and creating tension… [41](p.5) (3f1).
Another concern is the impact of the use of robots on the patient experience of caring in the healthcare setting. A review [41] highlighted the concerns about the inability of nurses to engage in caring interactions with the patients. This review stated that:
Authors writing from this perspective suggest that AIHTs may negatively impact the patient and caregiver experience of caring and are apprehensive about the potential effect of this technology on nurses’ ability to engage in caring interactions with patients… [41](p.6) (3f5).
In other words, delegating patient care to robots may result in a loss of the holistic aspects of care. In one of the reviews [32], staff advised that bathing a patient is more than a hygiene routine; it provides an opportunity for staff to interact with patients, build relationships and monitor health changes.
There also concerns about robots replacing important bonding time that occurs during meals…( [32] (p.6) (3e6).
Physical characteristics
Other challenges identified in the reviews were the physical characteristics of the robots, such as their size and tendency to become dirty easily [31, 43, 48]. There were also reports of distressing sounds from the robots [43].
… Other technological limitations were attributed to the size of the robot, as it was considered too bulky to hold, and the fur could easily become dirty [43, 48] (p.92) (3g2 and 3g6).…Of particular concern was the auditory feedback made by PARO that was perceived by some caregivers as distressing for residents [48](p.92) (3g8).
These physical features could affect the adaptability of the robots to the intended healthcare environment, for example, the robot can be too bulky or too large [43]. In some long term care homes, the robots are bulky to manoeuvre through the narrow hallways [31].
The robotic device not being adapted to the intended environment (e.g., it was too large, or the movement pattern did not fit in the setting) and the technology failing in certain locations were seen as barriers as well [43](pg.9) (3g3).
Impact on the workforce
The fear that robots would replace staff and decrease the number of caregiver jobs was also evident [31, 32, 38, 43]:
The main challenges are social isolation, less freedom, too much dependence on the robotic helpers, emotional attachment to nonhuman caregivers, and a decrease in the number of caregiver jobs [38] (p.7) (3h1).
This reinforces the fear and projection that the demand for human healthcare providers will reduce if robots are employed on a large scale [46].
It is projected that the demand for human carers will shrink substantially should both routine nursing care tasks and therapeutic tasks be delegated on a large-scale basis to robotics and autonomous systems [46](p.9) (3h3).
Ironically, some health care providers raised concerns that integrating robots could disrupt their established workflows and add to their workload [31, 32]. As a result, they prefer robots that are user-friendly, easy to clean, and require minimal maintenance [32]. Wong et al. [31] described it thus:
HCPs expressed concerns that using robots increased their workloads such as teaching and assisting residents to use the robots, cleaning and charging the robots, and handling technical glitches… and that the use of robots might interrupt their established workflow [31] (p.10–11) (3h4).
Table 6
Perceived challenges of using robots in nursing practice
Perceived challenges | Issues | References |
|---|---|---|
Cost/financial | High acquisition and maintenance cost High cost of robotic technology | |
Patient safety | Fear that patients could be harmed Increased risk in surgery Fear of negative effects on health | |
Medico-legal | Liability | |
Ethical | Reliability Deception Risk of surveillance Guilt of intentional deceit Patient stigmatisation Autonomy and dignity Objectification and infantilisation of older adults | |
Privacy | Forceful intrusion Invasion of privacy Risk of surveillance Tracking activities of healthcare providers | |
Social interactions | Emotional attachment to a nonhuman caregiver Fear of decreased social contact Deception and anthropomorphism Objectification and infantilisation Dehumanisation of care | |
Nurse-Patient relationship | Weakening of the nurse-patient therapeutic relationship Personal human interaction replaced by robots Erasure of human touch Lost connection with patient | |
Physical characteristics | Bulky Tendency to get dirty easily Sound issues Infection control | |
Impact on the workforce | Decrease in the number of jobs Fear that robots could replace staff Demand for human carers will shrink Workflow interruption | |
Increased workload | Concerns about attending trainings Cleaning and charging the robots Addressing technical glitches |
Discussion
To the best of our knowledge, this is the first umbrella review that synthesises the evidence on the experiences of nurses in the use of robots as well as the perceived benefits and challenges of using robots in nursing practice. This umbrella review identified 13 systematic reviews comprising 558 primary studies that were summarised, analysed and synthesised to highlight the evidence on the use of robots in nursing practice. The synthesised evidence was presented in three themes to answer the review questions. The experiential evidence of nurses using robots in practice was documented in four reviews, while the remaining reviews are concerned with perceptions or opinions about the benefits and challenges of using robots in nursing practice and not experiences. It is important to highlight that reviews that reported the documented experiences of nurses also stated the perceived benefits and challenges of using robots in nursing practice.
None of the included studies were conducted exclusively with nurses. Instead, the included studies involved mixed groups of healthcare professionals including formal and informal caregivers. This presents significant implications for the nursing profession. For instance, without studies conducted exclusively with nurses, policymakers may lack the necessary data to create guidelines that address the specific needs and concerns of the nursing workforce. This could lead to suboptimal implementation strategies that fail to maximise the potential benefits of robotic technologies in nursing. According to Metz et al. [49], the development of policies and implementation strategies for robotic technologies in healthcare settings should be informed by robust evidence. Therefore, to ensure that robotic technologies are effectively and ethically integrated into nursing practice, future research must prioritize studies focused on nurses’ experiences.
In addition, our findings suggested that the documented experience of nurses who have used robots in practice is sparse. This dearth of studies involving nurses’ experiences may be because the use of robots in nursing practice is in its infancy, and the majority of assistive robotic systems are either in developmental or testing phases [27]. Despite this, there is evidence that nurses reported that robots can support them in practical tasks, for example, lifting and moving patients. This finding is consistent with descriptions of robot activities in practice where robots assist with activities of daily living [3] such as cleaning, feeding and personal activities such as bathing and ambulation [15].
It has been suggested that robots have the potential to transform nursing care [24]; however, the evidence from this review suggests that nurses with experience using robots in practice had mixed feelings about sharing the workplace with robots [42]. Additionally, in this review, although mainly positive about the use of robots, there was evidence of nurses’ concerns about the performance of robots in delivering safe nursing care. There were particular concerns in relation to patient safety, infection control and medication safety. For example, it was reported that although a particular robotic system collected and delivered medications to patients, nurses still checked and verified delivery for safety reasons [27]. The implication of this is that the reliability of the robot in delivering this core nursing procedure was in question, and nurses retained responsibility for medication safety. There was similar evidence where caregivers, although not performing the actual task, needed to be present to supervise the robot [50].
The delivery of nursing care can be challenging due to global nursing shortages, and the literature suggests that robots support nurses in care delivery in these circumstances [15, 24]. This review found strong evidence of the perception that robots can assist nurses in meeting the hygiene requirements and care needs of their patients in diverse settings and that they are particularly useful in monitoring patients due to their 24-hour availability, thereby saving nurses’ working time and reducing their workload. Furthermore, it was also reported that the use of robots in nursing practice could improve overall job satisfaction by allowing nurses to focus on professional roles, leading to reduced turnover intentions [17].
It was also suggested that nurses and other human caregivers could be replaced by robots for the performance of certain activities [50]. However, participants in the studies reviewed stressed that robots could never replace human presence [48] and touch. Human touch is essential to nursing practice because it provides patients with comfort, reassurance, and a sense of empathy. Touch has been found to have physiological and psychological benefits, including reducing anxiety, promoting relaxation, and improving general well-being [51]. The nurses’ personal presence and tactile contact with patients ensure a therapeutic relationship based on trust and empathy. This review revealed that the use of robots could reduce the opportunity for human touch and the emotional connection that accompanies it. This may impact patient experiences and satisfaction. Although robots cannot replace the unique human touch provided by nurses, they can continue to play complementary roles in nursing practice.
Although the majority of the studies in this review did not document experiential evidence from nurses who used robots in practice, there was evidence of nurses’ perspectives in relation to the benefits and challenges of robots in practice. Social colleague robots, in particular, were perceived to be beneficial by some nurses and other caregivers in helping to strengthen therapeutic relationships by calming and reassuring patients, initiating discussions and promoting social interaction [42, 48]. Robots such as those in the Mario project [14] have been used to conquer the challenges of loneliness and isolation in people living with dementia. However, this review revealed that nurses were concerned that older people would miss out on social interactions if the caregiver was a robot instead of a human [42].
In this review, the perceived challenges of using robots in nursing practice mainly focused on cost, medico-legal and ethical issues. Although robots have many benefits, as evidenced in this review, the initial investment and maintenance costs must be considered. This could vary from one robotic system to another depending on what they are used for and where they are employed in the healthcare setting. For example, cost was identified as one of the barriers to the implementation of telepresence robots [52]. A thorough cost-benefit analysis would be necessary to make robots more affordable. On the other hand, one could argue that robots can be programmed and easier to train and can perform a variety of unusual and repetitive tasks than humans. They can also be exposed to dangerous activities that can cause occupational hazards for human beings [53].
The challenges identified also include issues of liability and reliability associated with the use of robots in practice. This implies that when errors occur or the robot malfunctions, it is necessary to identify who is to be held responsible. Are healthcare providers, manufacturers, programmers or users? Robots, like every other technological device, are prone to technical hitches, with a risk of adverse events occurring as a result [54, 55]. This poses a problem of accountability, especially when the robot’s actions may cause harm to patients or healthcare providers [54, 56]. Addressing these medico-legal, ethical and regulatory issues requires the collaborative efforts of healthcare professionals, robot designers, policymakers and medical ethicists to establish policies, protocols, guidelines and legal structures that will prioritise patient safety and the overall health of patients and healthcare providers before implementing and adopting robots [54, 57].
Our review also identified perceptions of potential risks such as the risk of invasion of privacy, risk of surveillance and unwanted intrusion into the lives of patients when using robots in nursing practice. The monitoring of patients, the measurement and recording of vital signs and the storage of sensitive and vital patient information are benefits of using robots; however, these benefits could infringe on the patient’s privacy and dignity. It was emphasised by [58]that the client’s privacy must be protected at all times. Therefore, adequate measures must be taken to secure patients’ data and prevent unauthorised disclosure of patient information.
Overall, our review revealed that there are some positive experiences with and perspectives on the use of robots in nursing practice, but there are also perceived challenges that are concerning for professional nursing practice. Additionally, this umbrella review revealed that nurses’ experience with robots in nursing practice is under-researched. More research is needed to explore nurses’ experiences using robots in practice.
Recommendation for nursing practice and research
The available evidence suggests that while robots have the potential to support nursing practice by reducing workload, there are also perceived challenges and concerns. It is important to further explore the experiences of nurses working with robots to better understand their main concerns regarding professional practice, quality of care, and patient safety.
As frontline implementers of an emerging technology that will impact nursing practice, nurses should be fully informed and actively involved in planning and decision-making in relation to the introduction of robots. The use of robots will inevitably affect nursing practices in terms of the nursing workflow and workload, job satisfaction, therapeutic nurse-patient interactions and the delivery of quality nursing care.
It is therefore important that nurses actively participate in the planning, design, testing, implementation and evaluation of the safety and dependability of robotic systems by collaborating with other stakeholders to explore strategies that will encourage effective and smooth integration of robots into nursing practice. Nurses must also ensure that ethical issues such as patient confidentiality and privacy and the potential impact of the use of robots on the nurse-patient relationship are addressed.
Finally, there is a need for the government to formulate and enforce policies, regulations and guidelines that will serve as a roadmap for the use and implementation of robotics in healthcare.
Strengths and limitations
To the best of our knowledge, this is the first umbrella review that synthesised evidence on the experiences and perceptions of nurses regarding the use of robots. The review questions were formulated and stated explicitly to include all relevant research syntheses in accordance with the published protocol. Systematic search techniques in numerous electronic databases were employed, the review was conducted according to the JBI guidelines, the methodological quality of the included reviews was assessed, and data extraction was performed using the JBI standardised tools.
This umbrella review is not without its limitations. One notable limitation is that it does not serve as a primary source of evidence; instead, its findings rely on the quality of the included reviews and the studies within them. While a quality appraisal was conducted as part of this review, it only partially mitigates this issue.
Second, all the included reviews were published in English, potentially excluding relevant reviews in other languages. Additionally, the reference lists of the included reviews were not searched, which may have led to the omission of some relevant studies.
Lastly, although one of the objectives was to explore documented nurses’ experiences with the use of robots, none of the included reviews specifically focused on nurses. These limitations should be considered when interpreting the findings of this review.
Conclusion
This umbrella review provides a comprehensive synthesis of the existing evidence on the utilisation of robots in nursing practice by identifying the documented experiences of nurses and the perceived benefits and challenges of the use of robots in nursing practice. There is evidence that there is a perception that robots can support nurses in their work, reducing nurses’ workload and saving their time for more critical aspects of patient care. However, this is a perception and more experiential evidence from nurses who work with robots in practice to support it is needed. There are perceived challenges that are of concern to nurses, particularly in relation to reliability, ethical dilemmas and patient safety.
According to the findings of this review, there is a dearth of studies on the actual experiences of nurses in the use of robots in practice. Therefore, further research is needed to focus on nurses to address this knowledge gap. There is also a need to explore the areas of education, training, policies and regulations on the use of robots in nursing practice to guide nurses in their professional practice and to address concerns about patient safety, professional practice and any legal and ethical challenges in the implementation of robotics in nursing.
Acknowledgements
Not Applicable.
Declarations
Competing interests
The authors declare no competing interests.
Protocol registration
The protocol of this umbrella review was registered on PROSPERO before the commencement of the review (Registration ID CRD42022361835).
Ethics approval and consent to participate
Not Applicable.
Consent for publication
Not Applicable.
Competing interests
The authors declare that they have no competing interests.
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