Towards Ethical Guidelines of Using Telepresence Robots in Residential Care

This is a sel -a chi ed e sion o an o iginal a icle. This e sion may di e om he o iginal in pagina ion and ypog aphic de ails. Au ho (s): Ti le: Yea : Ve sion: Copy igh : Righ s: Righ s u l: Please ci e he o iginal e sion: CC BY 4.0 h ps://c ea i ecommons.o g/licenses/by/4.0/ Towa ds E hical Guidelines o Using Telep esence Robo s in Residen ial Ca e © The Au ho (s) 2019 Accep ed e sion (Final d a ) Niemelä, Ma ke a; Van Ae scho , Lina; Tammela, An i; Aal onen, Iina; Lammi, Hanna Niemelä, M., Van Ae scho , L., Tammela, A., Aal onen, I., & Lammi, H. (2021). Towa ds E hical Guidelines o Using Telep esence Robo s in Residen ial Ca e. In e na ional Jou nal o Social Robo ics, 13(3), 431-439. h ps://doi.o g/10.1007/s12369-019-00529-8 2021 Vol.:(0123456789) 1 3 In e na ional Jou nal o Social Robo ics h ps://doi.o g/10.1007/s12369-019-00529-8 Towa ds E hical Guidelines o Using Telep esence Robo s inResiden ial Ca e Ma ke aNiemelä1 · Lina anAe scho 2· An iTammela1· IinaAal onen1· HannaLammi1 Accep ed: 5 Feb ua y 2019 © The Au ho (s) 2019 Abs ac Robo ic elep esence is a po en ial echnology o help alle ia ing he loneliness o elde ly people. The impac s o long- e m use o elep esence obo s in esiden ial ca e a e no well known. We we e in e es ed in how using a elep esence obo in luences he esiden , amily membe s and ca e wo ke s a a acili y, and wha challenges and solu ions he e a e o wide adop ion o such obo s in esiden ial ca e. Wi h a elep esence obo Double, we a anged a se ies o h ee ials in wo sepa a e esiden ial ca e acili ies: one 12-week ial in a p i a e acili y and wo successi e 6-week ials in a public acili y. In each ial, we ins alled he elep esence obo in a oom o a long- e m ca e home esiden o communica ing wi h he / his amily membe s. Based on he esul s, elep esence obo s do inc ease p esence and possibly engagemen o amily mem- be s in esiden ial ca e, bu p i acy is a cen al conce n. The mobili y o a elep esence obo is ha d o u ilize in esiden ial ca e, and o be able o do so, e hical conside a ion and guidelines a e needed. We p o ide a d a o such e hical guidelines. Keywo ds Elde ly· Residen ial ca e· Telep esence obo · Social ela ionships· P i acy· E hical guidelines 1 In oduc ion Loneliness and dep ession a e se ious conce ns o elde ly people li ing in ca e acili ies [1, 2]. Communica ion and con ac s wi h amily and iends a e among he mos impo an aspec s in suppo ing he well-being o people. The e o e, o inc ease hei quali y o li e, elde ly people in esiden ial ca e should be o e ed mo e possibili ies o pa icipa ion, social ac i i ies and main aining social ela- ions— his app oach can be called pe son-cen e ed ca e [3]. Telep esence is a po en ial echnology o alle ia e loneli- ness by allowing iends and amily membe s o be i ually p esen o he elde ly pe son (e.g. [4]). Telep esence obo s (e.g., Beam, VGo, Gi a and Double), also known as i ual p esence o emo e p esence obo s, a e emo e-con olled obo ic de ices which enable a pe son no jus o be i u- ally p esen , in e ac and socially pa icipa e om a emo e loca ion, bu also physically mo e in he obo ’s local en i- onmen , so allowing he emo e use o ake mo e con ol o e he /his p esence.1 Fo elde ly pe sons, obo ic elep esence p o ides bene i s compa ed o non-mobile ideo connec ion [7]: because o he emo e con ol o he obo , he elde ly use can in e ac wi h i in a na u al manne , wi h li le addi ional lea ning. The emo e use ha ing he con ol o he obo can mo e lexibly adap o he physical equi emen s o he elde ly pe son, o ins ance, by mo ing close o he /him. A elep- esence obo is adjus able o many kind o uses, o bo h mobile and less mobile elde ly use s, who may also wan o * Ma ke a Niemelä ma ke [email p o ec ed] Lina an Ae scho Ae sc[email p o ec ed]; lina. [email p o ec ed] An i Tammela [email p o ec ed] Iina Aal onen [email p o ec ed] Hanna Lammi [email p o ec ed] 1 VTT Technical Resea ch Cen e o Finland L d, Tampe e, Finland 2 Uni e si y o Jy äskylä, Jy äskylä, Finland 1 Some ad anced obo ic sys ems such as Telenoid o Geminoid also p o ide obo -media ed social p esence o a emo e pe son o a local use in e ac ing wi h he obo . These sys ems a e a he desc ibed as eleope a ed and oid obo s han elep esence obo s [5, 6]. Telenoid and Geminoid allow ”anonymous in e ac ion” as he local use may no know who is ope a ing he obo ; his ou o he scope o ou s udy. In e na ional Jou nal o Social Robo ics 1 3 d i e he obo hemsel es. The obo can inc ease he eel- ings o sa e y and connec ion as he elde ly use knows ha o he s can easily “s op by” i ually. In addi ion o he bene i s, many empi ical s udies ha e poin ed ou also po en ial d awbacks (see nex chap e ). Howe e , ewe s udies ha e been conduc ed in he con ex o esiden ial ca e, and especially he pe spec i e o ca e wo ke s is no well unde s ood. In his pape , we u he elabo a e wha kind o social bene i s, conce ns and impac s a e ela ed o he use o a elep esence obo in esiden ial ca e, om he pe spec i es o (1) a esiden in a acili y and he amily and (2) he ca e wo ke s in ol ed in aking ca e o he esiden . The da a has been collec ed in h ee ield ials o a elep esence obo in wo esiden ial ca e acili ies ( he esul s o he i s ial ha e been ea lie epo ed in [8]. In pa icula , we analyze he e hical (p i acy) challenges ha ela e o mobile elep esence a a wa d, and as a esul , we p esen a d a o e hical guidelines o using elep esence obo s in esiden ial ca e. 2 Backg ound 2.1 Assis ed Li ing: In Be ween Home andIns i u ional Ca e Assis ed li ing is a combina ion o housing and basic nu s- ing ca e. I holds a p omise o ageing in place as he acili y se ices adap acco ding o he esiden s’ changing needs. This ype o ca e is also called esiden ial ca e [9]. The esi- dences a e o en a anged o di e en uni s (e.g. sepa a e wa ds o in ensi e ca e wi h de e mined daily ou ines) bu inside people li e in hei own small apa men s o ooms wi h a ki chene e and a ba h oom. Unlike long- e m ca e ins i u ions, assis ed li ing p o ides he esiden a home- like en i onmen o os e au onomy, p i acy and eedom o choice [10, p. 216]. People in esiden ial ca e can mo e easily make indi idual choices ega ding he se ices hey use, he daily ou ines and he ways o li ing [11]. This sup- po s he indi idual well-being o he esiden s. Ye , dep ession is common among olde people. Pe sons in esiden ial ca e a e also a isk [12]. Despi e he aim o p o iding a home-like en i onmen and con inua ion o he li es yle o hei choice, many eel dec eased p i acy, and he common a eas like dining ooms o li ing ooms a e no el as home-like [13]. Quali y o li e may su e also because mo ing in o a ca e acili y is a signi ican change in he li es o olde people. The ea lie social su ounding changes comple ely and he old ou ines and habi s a e b o- ken [14]. People may lose hei e e yday social con ac s, and eel socially isola ed [3, p. 64]. Fu he mo e, in Finland he municipal au ho i ies decide on a pe son’s en i lemen o a place in esiden ial ca e and o en e e people o he ca e uni s acco ding o he speci ic ca e needs and a ailable places [15], no acco ding o hei wishes o p e e ences. Thus, i is essen ial o suppo he social con ac s and con inui y o he social ela ionships be ween he esiden s in assis ed li ing and hei amilies and iends. Social engage- men in he sense o making social and emo ional connec- ions wi h people and he communi y [16] has a posi i e e ec on bo h physical heal h and social well-being o olde people [17]. 2.2 Telep esence Robo s o Elde ly inHome andinResiden ial Ca e Telep esence obo s ha e been es ed in di e en se ings o hei po en ial o suppo social ela ionships o elde ly people. Bo h lab and in-home sho ials ha e epo ed mos ly posi i e pe cep ions o mobile elep esence sys ems e.g., [18, 19]. In addi ion, long- e m s udies o a elep es- ence obo suppo ing independen li ing ha e shown posi- i e in luences [4, 20]. In pa icula , olde people and hei amilies ha e liked he possibili y o seeing he emo e pe - son. The e a e many o he bene i s, such as educed a el ime o emo e use s and he appeal o he obo i sel . The conce ns aised in he home con ex ha e included he call e ique e (how o end/ e use call), he elde ly pe son’s (lack- ing) con ol o e accep ing/ e using calls, he lack o ace- o- ace con ac , and mis/o e use o he sys em. In esiden ial ca e se ing, simila esul s ha e been achie ed. The es ed obo s ha e gained posi i e esponses om elde ly esiden s, hei amilies, and heal hca e p o es- sionals. In one s udy, a mul i unc ional assis i e elep es- ence obo was placed in he nu sing home o 1mon h, and bo h he elde ly use s and p o essional ca egi e s ound he obo use ul o educing loneliness and inc easing con ac wi h amily and iends [21]. Telep esence p o ided posi- i e emo ional e ec bo h sides: seeing he aces o amily membe s main ains he esiden ’s connec ion wi h hem, and he amily eels enjoymen and eassu ance o seeing he esiden is doing well. Ca e acili y as a use en i onmen o a elep esence obo b ings also new issues a s ake [22]. Repo a s udy in which a Gi a obo was used 6–8weeks in a nu sing home by i e elde ly pa icipan s, who su e ed om mild o mode a e demen ia, and hei amily membe s. In addi- ion o he gene al posi i e esponse and social e ec s, he amily could ge mo e in ol ed in he li e o he acili y by being able o alk o s a . The abili y o mo e a ound wi h he obo was epo ed bene icial o he amily membe s, as hey could obse e places and ollow he esiden in he acili y, al hough he p i acy issue was in conce n. The elep esence obo was p e e ed o exis ing ideo call applica ions because o he g ea e le el o con ol he amily has in e ms o connec ing, mo ing, and posi ioning In e na ional Jou nal o Social Robo ics 1 3 he came a. The s a liked seeing he esiden s enjoying he communica ion wi h he amily. The pa icipan s exp essed also conce ns abou whe he he esiden s would eac by con usion o ea o he obo , o would he amily membe s wi ness esiden s’ dis up- i e beha io . The s a el unskilled and ha hey had no ime o lea n o use he obo . I has been poin ed also elsewhe e ha he easiness o use o he obo , so ha i equi es minimum assis ance om he acili y s a , is essen ial [23]. The main bene i s and conce ns ela ed o elep esence obo s in esiden ial ca e a e collec ed in he Table1 (pa - ially published ea lie in [8]). Telep esence obo s appea o be a bene icial echnology o olde people in esiden ial ca e and hei amilies. The conce ns ela ed especially o p i acy and con ol mus be aken in o accoun . The bene i s and conce ns o ca e wo ke s and a elep esence obo ’s possible in luences o hei wo k a e less clea , and ca e wo ke s may ind he obo as an ex a wo kload. Howe e , o elep esence obo s o become common, hei pe spec i e and accep ance a e c i ical. 3 S udy Se ing The empi ical s udy was ca ied ou as h ee sepa a e ield ials, in which a elep esence obo Double (h ps ://www. doubl e obo ics.com) was placed in he ooms o h ee long- e m esiden s in wo esiden ial ca e homes (Table2). The esiden s li ed a wa ds o in ensi e ca e, wi h 15–16 beds o long- e m esiden s. In each ial, he pa icipan s we e a esiden as a p ima y (local) use , one o mo e o he /his amily membe s as seconda y ( emo e) use s, he pe sonal nu se o he esiden , and o he ca e wo ke s a he wa d. The esiden pa icipan s we e selec ed and in i ed o pa icipa e by he ca e pe sonnel who had he knowledge abou he pa - icipan s’ heal h condi ions and capabili y o pa icipa e. The ials las ed be ween 6–12weeks. The elep esence obo sys em ins alled in he p ima y use s’ ooms included he elep esence obo and i s cha ging s a ion, and a “call eques bu on”: by p essing a sepa a e big bu on he esiden could send an SMS eques o he mobile phone o he amily membe o ask he /him o open Table 1 Bene i s and conce ns when using a elep esence obo in esiden ial ca e Bene i s Conce ns Residen (s) Reduced social isola ion, inc eased connec ion be ween he esiden and amily membe s [4, 19–22] Especially being able o see he amily membe ’s ace is impo - an o he esiden [4, 18, 21, 22] Robo mo e in e ac i e and appealing o communica ion han phone [20] The esiden may eac nega i ely (be con used, igh ened) [22] Lack o physical ace- o- ace con ac s due o educed isi s o he amily [20, 22] Mis/o e use o he obo [18] The esiden does no ha e enough con ol ( o end/ e use a call and o manage who has access) [18] In asions o p i acy [22] Family Enjoymen when connec ing o he esiden ; eassu ance when seeing ha he esiden is doing well [22] Less guil o no pu ing enough a en ion o he elde pe son [20] Reduced a el ime and ela ed con enience [18, 22] Family and s a discuss abou ca e; he amily eels mo e in ol ed and connec ed wi h he acili y [22] Family membe s may wi ness esiden s’ dis up i e beha io [22] Guil because using he obo pa ially subs i u es eal isi s [20] S a Feeling good when seeing he esiden expe iencing enjoymen [22] Requi es li le e o om he s a , i he obo is easy o use [23] S a may eel unskilled and oo busy o lea n [22] Table 2 The p ima y use s in he h ee ield ials T ial Ca e acili y P ima y and seconda y use s o he obo Backg ound o he p ima y use 1 A Residen 1, F, 83yea . Two daugh e s No diagnosed memo y illness; mos ly mo ed in a wheelchai . No expe ience o echnology. One daugh e isi s 2–3 imes a week; he o he calls 2–3 imes a week. 2 B Residen 2, M, 85yea . Daugh e Mino symp oms o memo y illness. The daugh e isi s 1–2 imes a mon h and calls 1–2 imes a week. 3 B Residen 3, F, 93yea . Daugh e ; Son and his wi e Some symp oms o memo y illness. Ha d o hea ing. No expe ience o echnology. The daugh e has jus mo ed u he away, calls e e y day. The son isi s a ew imes a yea and calls 3–6 imes a week. In e na ional Jou nal o Social Robo ics 1 3 he elep esence connec ion. The seconda y use s used lap- ops o open he ideo connec ion o he obo . The sys em is shown in Fig.1. The obo use in i s d i ing mode was limi ed o he p i- ma y use ’s oom o a oid unin ended and unmoni o ed in e ac ions wi h o he esiden s a he wa d. Howe e , se - e al d i ing sessions in he common spaces we e sepa a ely a anged du ing he aining and ials in o de o ge expe i- ence o hem. In hese sessions, esea che s (also wi h he emo e use ) and ca e pe sonnel collabo a ed o ensu e ha o he esiden s we e no eco ded and no ha m would be caused o hem. In each ial, he da a was collec ed in p e- and pos -in e - iews (o he esiden , he amily membe s, and he pe sonal nu se), use obse a ions, and keeping logs o he use o he obo and he call eques bu ons. In T ial 1, we also ideo aped h ee call sessions (1–10min) o one daugh e h ough he obo . Ca e wo ke s pa icipa ed in ocus g oup in e iews a e he ials: h ee ca e wo ke s a he i s acili y (T ial 1) and i e ca e wo ke s and he manage a he second acili y (T ials 2 and 3). The esul s o he e y i s ial al eady indica ed ha ca e wo ke s a e wo ied abou many e hical issues ela ed o mobile elep esence a he wa d [8]. In o de o in es i- ga e his aspec mo e, we a anged an online ques ionnai e su ey o he ca e wo ke s a he second acili y (T ials 2 and 3) abou hei pe spec i e and e hical conside a ions o he elep esence obo in he ca e acili y con ex . The ques- ionnai e consis ed o s a emen s in i e sec ions, o which we epo h ee o he pu pose o his a icle: (1) open- ing and closing he elep esence connec ion, (2) accep able spaces o he emo e isi o o go by using he obo and (3) accep able ac i i ies o he emo e isi o o pa icipa e in by using he obo . Each sec ion con ained 4–5 s a emen s. The esponses we e gi en by using a 6-poin Like scale om “To ally disag ee” o “To ally ag ee”. The da a collec ion me hods a e summa ized in Fig.2. The s udy se ing was accep ed by he acili y managemen and he E hical Commi ee o he i s au ho ’s a ilia ion (T ial 1), and by he acili y managemen and he municipal- i y esponsible o p o iding he local elde ly ca e se ices (T ials 2 and 3). All pa icipan s signed an in o med consen o m o aking pa in he s udy. 4 Resul s The use o he elep esence obo du ing he h ee ials is summa ized in Table3. The ials aced some echnical di icul ies and p ac- ical challenges ha ha e been acknowledged ea lie as well (e.g. [22]), such as connec i i y ailu es due o he poo o slow in e ne connec ion. Some imes he connec- ion b oke many imes and had o be e-es ablished, which o en explains he se e al successi e sho ish calls pe one day. Audibili y and se ing he audio le el was a challenge o p ima y use s in T ials 1 and 3. Fo he la e esiden , we se up an ex e nal loudspeake in he oom, o ensu e he hea ing. 4.1 Residen s’ Pe spec i e The esiden s did no ha e s ong expec a ions o he obo : “No eally any expec a ions” (T ial 3) and ”O cou se I wish ha i would be o some use a leas ” (T ial 2). Use ulness was ela ed o communica ion and i s cla i y h ough he obo . The esiden o he i s ial looked o wa d o be in con ac wi h he amily membe s and, in pa icula , see he g andchild en h ough he obo . A e he ials, he expe ience o using he obo was posi i ely gea ed o all h ee p ima y use s. In pa icula , he ideo connec ion was app ecia ed, like in p e ious s ud- ies [4, 18, 21, 22], and seen o inc ease he eeling o amily Fig. 1 The elep esence obo was placed in he oom o he p ima y use in he ca e home (on he le ). The esiden could p ess a sepa a e bu - on o send an SMS eques o he daugh e o connec (in he middle). He daugh e used a lap op o connec wi h he esiden (on he igh ) In e na ional Jou nal o Social Robo ics 1 3 membe s’ p esence: “Yes i el close.” (T ial 3) and “Com- munica ion was kind o mo e na u al […] in pa icula wi h he child en, i was e ibly nice o see hei exp essions” (T ial 2). The elep esence connec ion allowed he p ima y use in T ial 1 o see he g andchild play piano. In T ial 2, he amily opened a connec ion om hei holiday ip. The obo was el easy o use in spi e o he audibili y p oblems. Two o h ee p ima y use s ound ha he sys em is especially good o connec wi h amily membe s bu pos- sibly no o he s: “I don’ know i i sui s any o he bu his kind o amily use” (T ial 3). The con en s o he communica ion h ough he obo was mainly “e e yday issues” and simila o when using a phone. P ima y use s p e e ed hei mobile phones o quick checks and also o longe discussions because o be e audibili y. P i acy was no a conce n and he p ima y use s did no seem o mind ha he connec ion could be opened any ime by hei amily membe : “We don’ ha e any sec e s om each o he ” (T ial 2). They we e no in e es ed in he obo ollowing hem o common spaces o he acili y: “I is be e ha i is he e in my own ga ” (T ial 2). 4.2 Family Membe s’ Pe spec i e The elep esence connec ion c ea ed a eeling o p esence o he esiden o he amily membe s and he p esence was s onge han on he phone: “I was like a sho isi [ o he esiden ]” (T ial 3). One o he pa icipan s belie ed ha he mo he el he same abou hei p esence: “She seemed, somehow, so happy e e y ime she ealized ha aha, he e’s somebody he e now” (T ial 1). Seeing he physical condi- ion and i edness o he esiden was impo an . One p i- ma y use (T ial 2) some imes seemed o be li le con used, and he amily membe explained his wi h he no el y o he sys em. In T ial 1, a amily membe old ha some imes hei mo he was less able o concen a e on he ideo image compa ed o he oice on he phone. The amily membe s did no ind ha he con en s o communica ion would ha e changed due o he obo . This is in line wi h he p ima y use s’ iew. The numbe o phone calls dec eased du ing he ials; using he obo eplaced phone calls o some ex en . The main conce ns o amily membe s we e ela ed o p i acy. In all ials, hey aised up he bo he some issue o Fig. 2 The imeline o da a collec ion du ing he ials. The ials we e successi e o each o he . When he e we e o e lapping e en s in T ial 2 and 3, he week coun is shown o bo h (T ial2/T ial3). In T ial 3, he i s aining and p e-in e iews we e ca ied six weeks be o e he ac ual ial (i.e. use o he obo ) s a ed Table 3 Analysis o calls wi h he elep esence obo du ing he ials T ial Leng h o ial To al N o calls Du a ion o calls N o calls pe week 1 12weeks 29 Typically 5–10min; 21% o calls a leas 10min Va iance 2–34min 2–5 (excluding weeks 7–9) 2 6, 5weeks 18 Typically 2–6min; 28% o calls a leas 10min Va iance 2–22min 1–5 (o en se e al calls pe day) 3 6weeks 22 Call du a ion a ied a lo be ween 2–16min; 36% o calls a leas 10min 0–5 (o en se e al calls pe day) In e na ional Jou nal o Social Robo ics 1 3 some imes eeling like spying and “going o he esiden ’s u ” (T ial 2), especially when he esiden was no awa e o he connec ion being opened (e.g. when sleeping). Family membe s showed ac i e s a egies, e.g. scheduling hei calls acco ding o he daily hy hm o he esiden , o a oid hese si ua ions. The emba assmen was balanced by eelings o elie , eassu ance and sa e y, when hey saw he esiden was well e en s/he did no esponse o he call. The seconda y use s wished ha he esiden would ha e mo e con ol o e he call. The communica ion was el one- sided and “I was always a su p ise wha is happening on he o he side” (T ial 3). Using he obo in a “su eillance mode” could be accep able i he esiden was su e ing om demen ia o simila illness, he esiden had allen o been in an acciden , o he obo was genuinely only in pe sonal am- ily use. Also in hese condi ions, he esiden would need o ag ee wi h he possibili y o su eillance. Fu he mo e, he pa icipan s commen ed ha he p ima y use should be able o choose whom she wan s o alk wi h and who is allowed o connec wi hou a speci ic pe mission. The de ice should signal in a salien way ha he connec ion is open. The emo e d i ing was no u ilized much. I was expe- ienced challenging due o he limi ed ield o iew o he su ounding space h ough he obo ’s came a. The main a ge o he seconda y use s was o see he esiden in he oom, and being able o u n he came a/display o he obo was enough. They did no ind d i ing in he common spaces use ul. Ins ead, ha migh e en cause he eeling ha he emo e use is “mo e like lu king he nu ses” (T ial 3). 4.3 Ca e Wo ke s’ Pe spec i e The ca e wo ke s’ expe ience o he ial was mainly posi- i e: he obo inc eased he amily membe s’ p esence o he esiden s, and he esiden s appea ed o be b igh ened up a e sessions o communica ion. Again, especially seeing he ace and exp essions o he ela i es was c ucial. The obo ’s cen al unc ion, pe cei ed by he ca e wo k- e s, was ha he obo enables amily membe s o pa icipa e mo e in he daily li e and ac i i ies o he acili y. In pa icu- la , amily membe s can mo e lexibly join he planning o ca e o he esiden . In addi ion, hey unde s and be e he heal h condi ion o he esiden as well as ca e wo k i sel : “issues ha we all day long deal wi h” (FG2). The obo was seen as an enable o inc ease collabo a ion wi h amilies in acili y ca e and imp o e amily ca e, bo h which a e gene al a ge s in he Finnish elde ly ca e sys em nowadays. The e we e some small occu ences in which he p esence o a amily membe h ough he obo di ec ly in luenced he daily ca e wo k. Fo ins ance, a esiden was in he oom dis- cussing wi h he daugh e h ough he obo . A ca e wo ke popped a he doo , when he daugh e called he ha he mo he should ake some es . The ca e wo ke ollowed he daugh e ’s sugges ion. O e all, he ca e wo ke s el com- munica ion wi h esiden s o be di e en due o he p esence o amily membe s; hey ge “ano he ouch” in hei wo k. They explain issues be e and “ he e’s a ce ain di e ence in he cus ome se ice oo” (FG2). The limi s o amily membe s’ pa icipa ion in he ca e wo k we e no clea . Fo ins ance, some ca e wo ke s can accep amily o pa icipan in in ima e ac i i ies such as washing a bed- idden esiden , i he esiden has gi en pe - mission. O he ca e wo ke s would deny such pa icipa ion. The ca e wo ke s we e also unsu e, would hey ha e he igh o end he call o he esiden , as opposing o he will o a (dis u bing o con ollable) amily membe . Wha i he esiden was no able o say aloud he /his wish abou ending he call? Mo eo e , i he calls we e ejec ed o ended by a wo ke , would amily membe s doub ha he e is some hing suspicious going on? In any case, he decision o e accep ing o ejec ing he call should be local, by he esiden . The ca e wo ke s el some anxie y because in he ials, he amily membe ully con olled opening he connec ion. An “O -bu on” would be handy o ( empo a ily) le no calls come h ough, o ins ance, in sensi i e ca e si ua ions. Remo e d i ing o he obo in common a eas was posi- i ely pe cei ed o enable amily membe s o pa icipa e e en mo e o he daily li e a he acili y and o see he ac i - i y and condi ion o he esiden . Remo e d i ing howe e includes many challenges. Fi s , he ca e wo ke s ound ou ha some esiden s (in common spaces in he acili y) we e con used abou he obo and did no ealize ha he human oice was coming om he obo . A leas one esiden ang ily old he obo o go away. Second, he e is a isk ha amily membe s would e idence emba assing si ua ions wi h o he esiden s (c . [22]), and hey could e en eco d such si ua ions in pu pose. (This kind o si ua ions o in en- ions we e no obse ed du ing ou ials.) As ph ased by one ca e wo ke , he obo should only “shoo my ela i e o me” (FG1). Thi d, amily membe s could hea ca e wo ke s’ nego ia- ions abou o he esiden s “Names would become public and possible ailmen s and oubles” (FG2). They did no like he idea “ ha you ne e know i he e is a obo lis ening behind a co ne ” (FG2). 4.4 E hical Ques ionnai e o Ca e Wo ke s We ecei ed 16 esponses o ou online su ey ques ion- nai e. The numbe is oo small o allow s a is ical analysis, so he esul s a e p esen ed he e in a desc ip i e manne and o complemen he quali a i e in e iew da a. The 16 esponden s included 13 ca e wo ke s, wo o he membe s o he pe sonnel, and a social wo ke ; 15 o hem wo ked a he wa d and one in day ca e se ices p o ided a he In e na ional Jou nal o Social Robo ics 1 3 ca e acili y. Mos (69%) o hem we e 30–49yea s old and all we e emale. Fi e esponden s had used he obo hem- sel es, i e had moni o ed o he s using i and six had only seen i as u ned o . The ca e wo ke s we e mos app o ing o he idea ha in case o an eme gency, amily membe s could isi he esi- den ’s oom and also ba h oom (Fig.3). Fo non-eme gen isi s, he app o al was mode a e o isi ing he oom o he esiden as well as he same spaces han physical isi o s (dining oom excluded). Visi ing o he esiden s’ ooms was no seen accep able. Rega ding ac i i ies in he acili y, he esponden s pe cei ed mos accep able ha amily membe s would pa icipa e in ca e nego ia ions and social ga he ings ou side he esiden ’s oom (Fig.4). Common meals and heal h checks o he esiden seem o be less accep able ac i i ies. The esponden s we e mode a ely in a o o ha he esi- den should ha e ac i e con ol o e accep ing calls h ough he obo (Fig.5). In con adic ion, hey ag eed ha accep - ing calls would be easy enough only i i does no equi e any ac ion om he esiden . The esiden should ne e heless be able o shu he connec ion possibili y down o p e e ed imes, and also ca e pe sonnel migh be allowed o do ha . Closing he connec ion should no howe e be he esponsi- bili y o he elde ly pe son alone. 5 Discussion In he h ee ield ials las ing om 6 o 12weeks, we we e able o con i m ha elep esence obo s do inc ease amily membe s’ p esence o hei elde ly pa en s in esiden ial ca e and hus posi i ely a ec he esiden s’ wellbeing. Fu he - mo e, elep esence obo s ha e s ong po en ial o inc ease amily membe s’ pa icipa ion in he daily li e in ca e acili- ies and in planning o ca e. Apa om ma u i y o echnology (connec i i y and audibili y issues; easy and sa e emo e d i ing), he main challenge seems o be he p o ec ion o p i acy - o he esi- den as he p ima y use , o o he esiden s in he acili y, and o ca e wo ke s. Mos impo an ly, he amily membe s and he ca e wo ke s el ha he p ima y use should ha e con ol o e accep ing o ejec ing he call, al hough his is ecognized o be in con lic wi h he usabili y o he obo o elde ly pe sons, as shown in he su ey esul s. Be o e he ials, all pa icipan s accep ed ha he calling du ing he ials was ully con olled by he emo e use . This se ing led o si ua ions o possibili ies ha we e el uneasy and une hical by he amily membe s and ca e wo ke s. I seems ha he p i acy and he usabili y o he sys em o he p i- ma y use need o be handled case by case, nego ia ed by he use s hemsel es and also du ing he ac ual use. The p i acy p o ec ion should howe e be he de aul . Al hough in his s udy he esiden s and amily mem- be s we e no much in e es ed in emo e d i ing in common spaces (pa ially due o he p ac ical di icul y o d i ing), he ca e wo ke s sugges ed ha i would inc ease he engage- men o he amily membe s. Howe e , a he same ime, he isk o in ade o he esiden s’ p i acy would inc ease also. I seems ha o ully in eg a e elep esence obo s in o esi- den ial ca e and, in pa icula , use hei mobili y po en ial o inc ease he amily engagemen and esiden s’ quali y o li e, clea guidelines a e needed o how and whe e he obo can be used. Based on he da a collec ed in he s udy, we he e p esen a d a o e hical guidelines o using mobile elep esence 5.4 4.1 3.9 3.3 1.7 1 2 3 4 5 6 In case o eme gency, ba h oom in addi ion o esiden 's oom The oom o he esiden bu no he ba h oom Same spaces han o he (physical) isi o s Common spaces o he ca e acili y (e.g. ea ing space) O he esiden s' ooms Fig. 3 Accep ance o di e en spaces ha amily membe s could isi h ough he obo (1 = low accep ance, 6 = high accep ance) 5.7 4.9 3.8 3.7 1 2 3 4 5 6 Ca e nego ia ions Mo ning assemblies and o he ga he ings Common ea ingsWhen heal h condi ion o he esiden is examined Fig. 4 Accep ance o di e en ac i i ies ha amily membe s could pa icipa e in h ough he obo (1 = low accep ance. 6 = high accep - ance) 5.4 4.7 4.2 4.2 1.9 123456 Residen mus be able o shu he connec ion possibili y down o p e e ed ime Accep ing a call is easy enough only i i equi es no ac ion om he esiden Accep ing a call always equi es ac ion om he esiden be o e opening he connec ion Ca e pe sonnel is allowed o shu he connec ion possibili y down o p e e ed ime Closing he connec ion is always he esponsibili y o he esiden Fig. 5 S a emen s conce ning he con ol o e accep ing and e using calls h ough he obo (1 = o ally disag ee, 6 = o ally ag ee) In e na ional Jou nal o Social Robo ics 1 3 obo s o esiden - amily communica ion in esiden ial ca e (Table4). In o de o allow emo e use s o d i e he obo in com- mon spaces, equi ed u he ac i i ies should be asking a signed pe mission om all esiden s o le ing he obo in o common spaces and asking a signed commi men om emo e use s ha hey do no misuse he in o ma ion acqui ed h ough he obo . The e would s ill be challenges i some esiden s would e use using he obo in common spaces. Fi s o all, hei choice should be espec ed, as he ca e acili y is hei home and hey should be able o easily make indi idual choices ega ding he se ices hey use, hei daily ou ines and hei pe sonal ways o li ing [11]. In o de o allow using he obo in common spaces in spi e o he e usal o some esiden s, echnical solu ions could be possible, o ins ance: “blind” au onomous d i ing o he obo be ween p i acy- secu ed a eas, o AI-based p e- ecogni ion o people who ha e signed he pe mission and au oma ed blu ing o o he s in he ideo image. In he la e , ans e o p i a e audio would s ill be a p oblem o be sol ed. As a bounda y condi ion o using a elep esence obo o inc ease amily p esence and engagemen , we s ill mus aise he quali y o he exis ing ela ionship be ween he esi- den and he elde ly. In ou ials, he amily membe s we e al eady ac i ely communica ing wi h hei elde ly pa en s, bu li ed a away and hus we e in e es ed in seeking addi- ional ways o communica e. The obo would no c ea e ela ionships om sc a ch, o imp o e p oblema ic ones. Howe e , he obo would s ill ha e po en ial in imp o ing social connec ions o bed- idden esiden s by le ing hem enjoy social e en s in he acili y (e.g. emo e-d i en by a ca e wo ke ), o a anging olun ee o e en he apy wo ke s o con ac he esiden s h ough he obo . Acknowledgemen s Open access unding p o ided by Technical Resea ch Cen e o Finland (VTT). Funding This s udy was unded by Tekes (G an Numbe 3724/31/2014) and S a egic Resea ch Council a he Academy o Finland (G an Numbe 292980). Compliance wi h E hical S anda ds Con lic o in e es The au ho s decla e ha hey ha e no con lic o in e es . OpenAccess This a icle is dis ibu ed unde he e ms o he C ea- i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i eco mmons .o g/licen ses/by/4.0/), which pe mi s un es ic ed use, dis ibu- ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. Re e ences 1. Bekhe AK, Zauszniewski JA (2012) Men al heal h o elde s in e i emen communi ies: Is loneliness a key ac o ? A ch Psychia Nu s 26(3):214–224 2. B ownie S, Ho s mansho L (2011) The managemen o loneli- ness in aged ca e esiden s: an impo an he apeu ic a ge o ge on ological nu sing. Ge ia ic Nu s 32(5):318–325 3. Pi honen J (2017) Good human li e in assis ed li ing o olde people: wha he esiden s a e able o do and be. Ac a Uni e si a is Tampe ensis 2272. Disse a ion, Uni e si y o Tampe e 4. Ces a A, Co ellessa G, O landini A, Tibe io L (2016) Long- e m e alua ion o a elep esence obo o he elde ly: me hodology and ecological case s udy. In J Social Robo 8(3):421–441 5. Nishio S, Ishigu o H, Hagi a N (2007) Geminoid: eleope a ed and oid o an exis ing pe son. In: de Pina Filho AC (ed) Human- oid obo . New De . I-Tech educa ion and publishing, Vienna, pp 343–352 Table 4 Summa izing he esul s as a d a o e hical guidelines o using a mobile elep esence obo in esiden ial ca e o communica ion be ween esiden s and amily membe s Le el o accep ance Type o use o a mobile elep esence obo in esiden ial ca e Sou ce in his s udy Well accep ed use Using a elep esence obo o main ain and ex end he exis ing (posi i e) social, in o mal ela ionship be ween he esiden and amily membe s (in a p i a e space) Elde ly esiden s, amily membe s, ca e wo k- e s (in e iews) Family membe s’ pa icipa ion in ca e nego ia ions wi h he esiden and he ca e wo ke (in a p i a e space) Ca e wo ke s (in e iews; e hical ques ionnai e) D i ing a elep esence obo e e ywhe e in he esiden ’s oom, including ba h oom, in case o eme gency Elde ly esiden s (in e iews) Ca e wo ke s (e hical ques ionnai e) Mode a ely accep ed use Family membe s’ pa icipa ion in in o mal social ga he ings in com- mon spaces Ca e wo ke s (e hical ques ionnai e; in e iews) Less accep ed use Family membe s’ pa icipa ion in common meals o isi ing in com- mon dining space Ca e wo ke s (e hical ques ionnai e) Visi s o o he esiden s’ ooms Ca e wo ke s (e hical ques ionnai e; in e iews) Family membe s’ pa icipa ing in heal h checks o hygiene ca e o he esiden Ca e wo ke s (e hical ques ionnai e; in e iews)