Development of an ethical framework for the use of social robots in the care of individuals with major neurocognitive disorders: A qualitative study

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Objective This study has two main objectives: 1) to understand how professionals conducting social robot interventions (SRIs) perceive and approach the ethical issues linked to the use of social robots with older adults and 2) to establish ethical guidelines to help professionals carry out SRIs with older adults. Methods For this descriptive qualitative study, we conducted interviews with 20 healthcare professionals working in geriatric facilities. The interviews were recorded and transcribed, and a content analysis was performed to identify certain themes and recommendations concerning the use of social robots with older adults. Results Three main themes emerged from the analysis of the interviews: the clear and direct presentation of the robot, obtaining consent from the beneficiary concerning its use, and the emphasis on human contact in robot-mediated interventions. Additionally, the following subthemes were evoked: imposed social robotic use, extra time and effort, careful selection of beneficiaries for robotic therapy, adaptability, technical problems, and the need for guidelines and training in ethical social robot use. Conclusion The use of social robots should be guided by the same ethical guidelines followed in all therapeutic interventions; however, healthcare professionals express a need for special training and preparation for SRIs in geriatric settings. We have drafted several preliminary recommendations for carrying out SRIs with older adults. Future research should focus on standardizing guidelines and creating an accessible format for training. Trial Registration: IRB N°: 00012021-110 Ethics Social Robots Older Adults Major Neurocognitive Disorders Qualitative Research Introduction The aging of the global population is leading to an increased prevalence of chronic and disabling diseases, consequently creating a greater need for long-term care and adequate care services [1]. To better address these needs, various healthcare interventions using innovative technologies, such as social robot interventions (SRIs), have been developed [2,3]. Social robots come in different forms of embodiment and design [4]. For example, they can be human-like, incorporating human characteristics, such as the robot NAO, or animal-like, resembling a pet or cuddly toy, such as the robot PARO, which looks like a baby harp seal. The main feature of social robots is their ability to interact with humans through speech, gestures, or emotional behavior. In geriatrics, SRIs typically target older adults (OAs) with MND, such as those with dementia. These interventions fall within the scope of psychosocial interventions, i.e., nonpharmacological interventions aimed at improving the quality of life, cognitive skills, mood, or behavior of OAs with neurocognitive disorders through a wide range of activities [5]. The scientific literature on SRIs for dementia care has focused primarily on their impact, demonstrating positive effects on OAs' well-being, mood, and social interactions [3,6–8]. For example, SRIs using PARO have been shown to reduce stress, negative emotions, and behavioral symptoms, as well as improve social interactions and the quality of care experience [9]. Some studies have shown that the NAO robot can facilitate cognitive and muscular exercises [10,11] and provide medical information [12]. Social robots can also be used in mediation, acting as intermediaries between beneficiaries and therapists [12]. In recent years, the number and types of social robots used in geriatrics have increased [2,3,6,13]. SRIs have also been confirmed to be feasible and acceptable to OAs with dementia, informal caregivers, and care staff [14]. The emergence of these new therapeutic interventions raises deontological questions. Some authors have specifically addressed ethical concerns raised by SRIs, such as the reduction of human contact [15], misrepresenting or concealing the robot's true nature [16], and maintaining dignity and autonomy, which involves obtaining participants' consent [18] and protecting personal data [19]. However, research on ethical recommendations for SRIs tailored to older adults is sparse, and standardized ethical guidelines for health professionals have not yet been developed. Drafting ethical recommendations for SRIs requires a careful and comprehensive analysis of the situations experienced by professionals in the field. These recommendations will assist health professionals in maintaining ethical standards while conducting SRIs with individuals living with MND. This study had two main objectives: (1) to understand how professionals conducting SRIs perceive and approach the ethical issues of social robot use with older adults and (2) to establish ethical guidelines to help professionals carry out SRIs with older adults. Materials and methods To achieve these two objectives, we conducted semidirective interviews with professionals (N = 20) who practice robotic-mediated interventions in geriatric facilities. Recruitment Purposeful sampling was employed to recruit professionals with experience in using social robots with older adults (OAs) in nursing homes and geriatric hospitals in and around Paris, France. During 2022, 20 professionals were interviewed. The descriptions of the participants’ professions are listed in Table 1. Table 1 Participants’ Professions and Gender Ratios Profession # Interviewed Male/Female Ratio Geriatric physician 5 3/2 Psychologist 7 1/6 Neuropsychologist 4 2/2 Group leader 3 0/3 Physical therapist 1 0/1 Interview Method An interview guide for professionals in geriatric facilities who use or have used social robots in their daily practice was developed and is detailed in Annex 1. The semistructured interviews included, but were not limited to, the following three main research questions: 1. How should a robotic-mediated intervention be conducted? More specifically, how should the robot be presented to the beneficiary, and what procedures should be followed to obtain the participant’s consent? 2. What ethical issues are raised by robotic mediation in geriatrics? 3. What is the social robot’s role, and how does it affect human interaction, infantilization, and autonomy? Analysis The interviews were recorded and transcribed. The content of the interviews was analyzed via a thematic analysis method inspired by Braun and Clarke (2006) [20]. This method involves multiple readings of the interviews to thoroughly understand the content, identify the topics addressed, and categorize the comments to maximize the results. After initial coding of the interviews, the codes were organized into themes, which were reviewed and then arranged into a thematic map. Finally, the themes were defined and named, with examples provided to illustrate each theme. Results Overview Three main themes emerged from the analysis of the interviews: the clear and transparent presentation of the robot, obtaining consent from the beneficiary concerning its use, and the emphasis on human contact in robot-mediated interventions. Additionally, several subthemes were identified: imposed social robotic use, extra time and effort, careful selection of beneficiaries for robotic therapy, adaptability, technical problems, and the need for guidelines and training in the ethical use of social robots. Deciding on and Preparing the Robot’s Introduction into a Service The ethical use of robots should be considered not only from the patient's perspective but also from that of professionals, who may perceive it as an imposed and disruptive act. Moreover, when teams are understaffed, asking professionals to include a social robot in daily care can be overwhelming, especially if they are not consulted about its integration into their service. 1.1. Need for Professionals to Participate in the Decision to Implement SRIs None of the professionals reported being involved in the decision-making process regarding the type of robot or its potential usefulness within their team. For some healthcare professionals, the inclusion of the robot in their practice was challenging, possibly because the robot was imposed rather than requested. Therefore, for us, it was quite a shock because we did not ask for the robot. It was suggested to us. However, it was not a request from the psychology team, for example, the animation team, or the rehabilitation team. It came, well, it invited itself into our residence. (Psychologist) Professionals emphasized the need to be involved in decisions about how to acquire robots to prevent feelings of imposition. We mustn't forget that the users of this robot are the patients, but they're also the professionals because most of the patients are dependent and so it's going to go through professionals, so they're also users. (Geriatric physician) 1.2. Need to Reflect on Human Resources Before Implementing the Robot Professionals emphasized the need to evaluate the human resources required to implement SRIs before integrating robots into institutions. The implementation of SRIs demands extra time and effort from professionals because of the need for training. Professionals highlighted the necessity of anticipating that trained teams might leave, particularly in departments with high turnover rates, such as oncology. Consequently, the time and costs required to train new teams must be included in the decision to implement a robot in the institution. It takes an extremely long time to train people because you have to take time off work. But when you take time off, you have to find someone else to take your place, because the older adults aren't going to be on their own like that… (Group leader) Preparing activities with a social robot also requires additional effort from teams. They had to reorganize their roles and tasks, acquire new knowledge, and dedicate extra time to setting up the workshops. We had to do a lot more upstream work than we would have done without the Nao. We had to spend a lot of time preparing the whole session. You can't anticipate what's going to be said, for example, what words are going to be chosen for a text. (Psychologist) Professionals also stressed the time needed for the cleaning and maintenance of the robot. 1.3. Need to Respect Professionals’ Choice of Social Robot Use Many professionals have questioned the usefulness of social robots and their actual impact on patients, exhibiting a degree of mistrust. Therefore, some managers highlighted the benefit of demonstrating how the robot works instead of merely discussing it. When I wanted to present the robot to my team, I talked about it without showing it, and well, reactions were mixed,..., but then I didn't explain anything, I just put the robot in front of them (the team) and showed them what it could do, […] the team was quite fascinated by... and I said to myself, well already, if the professionals get a bit involved with the robot, it'll also give them a starting point. (Neuropsychologist) However, managers emphasized the importance of respecting professionals' preferences and perspectives on new technologies. [B]ut the more or less positive reception from the teams is natural. We respect each other’s choice of therapeutic practices: some use massage, touch, music, and some have agreed to use the robot. The aim is to see what can best suit and help each patient. (Psychologist) 1.4. Need for Professionals to Build Existing Protocols and Ethical Standards Professionals emphasized the advantage of building on existing interventions rather than creating new ones from scratch with the addition of a social robot. Attempting to develop entirely new interventions can generate additional stress for teams. Some of this extra time and effort could be economized by integrating the social robot into existing groups and activities. When the robot arrived, professionals preferred to use activities they had already mastered. They should feel reassured by using an activity where the robot is the only new element. [E]veryone has first chosen something in a field in which they're already comfortable, they've taken charge and now they're taking on a new teammate they don't know. So there can't be another unknown in the equation, because if we do the project, the thing, the Nao..., it's explosive, it won't work! (Physical therapist) 1.5. Need for Organized Team Training Healthcare professionals lamented the inadequacy of the training content available to them. In their view, the materials provided by the manufacturer were limited to technical issues and did not address other problems, such as the therapist's role during the intervention. A psychologist emphasized the need for guidelines concerning social robot use: Having a meeting is good, but if there's nothing to back it up, it's all downhill from there, because if you don't use the tool the next day, you need something to fall back on. (Psychologist) Professionals have suggested several ideas to improve training, such as proposing informational meetings with role-playing exercises or discovery sessions with robots. I think that the presentation of the robot and then perhaps some role-playing could be interesting, because adapting to the reactions of the patient in front of you as well, right. […] You have to adapt to each treatment, to events. (Physical therapist) Some interviewees suggested the use of videos as an efficient, fun, and accessible approach to training. Yeah, well, the problem with professionals [...] is that they also have very, very, very, very little time, […] but I think the best training for me is oral training, role-playing, and possibly much more video-based material that's shorter to watch and more enjoyable than reading. (Psychologist) We can even make videos so that people can access these resources gradually without the trainer being present. (Geriatric physician) 2. Preparing a robotic intervention As with any type of intervention, healthcare professionals using social robots stress the importance of tailoring activities on the basis of users’ profiles, relying on prior knowledge of the patient and their entourage. 2.1. Selection criteria for the selection of SRIs Professionals emphasized the need to define the profiles of individuals who could participate in SRIs. For example, the Paro robot was deemed appropriate for those in the advanced stages of MND, as it reassured them and elicited affectivity that facilitated interaction. However, there was no single rule for selection; instead, professionals relied on their experience and knowledge of individual situations to define target groups. For the memory workshop, I wanted a fairly high MMSE. So we're automatically on MMSEs above 20. And for the gentle gymnastics, I was less fussy and included more people with praxis problems. (Neuropsychologist) Healthcare professionals consider themselves capable of identifying individuals who might be more or less interested in the robot before proposing it. They could also anticipate who might initially refuse but later show interest after observing others or hearing positive feedback. We've had people who were refractory, and they're free too, who couldn't stand it at all. That's it. People say negative things to us, like 'I'm not interested. Oh no, but do you take me for a fool?' And then, well, they left, but that didn't stop some of them, after a while, from wanting to come back to the group and see what happened, and then, for some, it's always the same. (Group leader) Some reservations were expressed regarding patients with a history of psychosis, as the use of the robot could generate anxiety during or after use: [F]or some people, who had psychotic disorders, for example, it was really dangerous, because it created a state of withdrawal and I observed this with one person and it could then lead to crises, crying spells, crises because the Ben robot remains a machine that can break down. (Geriatric physician) 2 .2. Importance of Family Input The beneficiaries’ family and friends can be reassured. Healthcare professionals noted that informing and discussing with family members helped dispel preconceived notions and establish a relationship of trust with the institution. One professional shared this anecdote: There was a residence that did something really nice, in fact, before bringing in the robot, they had held a kind of meeting with the families [...] they had said, 'We're going to take part in a protocol, we're going to be sent a robot,' and they presented the robot [...] 'This is why we're going to use it with your loved ones.' (Psychologist) 3. Introducing the Robot to Older Adults The interviews highlighted specific ethical issues associated with SRIs that must be considered when the social robot is presented to beneficiaries. Professionals unanimously agreed that the robot should be presented transparently, with a clear explanation of its nature and purpose. However, the content of the presentation, as well as the methods and expressions used, should be adapted to each situation. 3.1. Taking into account the Robot’s Appearance Professionals should be careful in their description of the social robot, as its appearance and fairly autonomous movement capabilities can be misleading for some beneficiaries. I think the first thing is to make it clear that it's a robot. […] I think there are certain situations in which it's not necessarily obvious to understand this. I'm thinking of certain robots, let's call them animaloid, where you can sometimes believe that it's not really a robot, and so that's important. (Geriatric physician) 3.2. Explaining the Wizard of Oz Transparency is a recurring issue concerning the use of the Nao robot and the "Wizard of Oz" technique. In this technique, an engineer or trained professional controls the robot's movements and speech from a computer. This explanation is often abstract or difficult for some patients to understand, regardless of their cognitive status. Professionals have suggested the use of metaphors with remotely controlled objects or cordless phones to facilitate the understanding of beneficiaries. 3.3. The Importance of Playing Along Most professionals believe that some beneficiaries recognize social robots for what they are but choose to play along, much like interacting with an animated object or live animal. Overemphasizing that it is only a robot that can defeat the purpose of the SRI. I prioritize the patient's well-being. Some people talk to their dog as if it were their brother or sister. We're not going to say, 'Oh, but it's not a human, it's a dog!’ [...] We trust the relationship that develops between the two protagonists. We're not going to correct them; each has his own universe. (Group leader) Professionals find it natural to interact with the robot spontaneously, believing that this freedom allows the most beneficial effects to be observed. They feared that constantly reminding the patient of the robot’s mechanical nature would diminish the beneficial effects of the interaction. I think you have to accept that the patient is using a metaphor without having to convince him otherwise (...) he's reminiscing, that helps them generate emotions, so in itself the robot, it's there just as an object, but I wouldn't mind him talking to him, like you talk to a cuddly toy, […] I think it would be extremely tedious if the clinician was constantly saying, ‘it's a machine, I remind you it's a machine!’ It's useless. (Neuropsychologist) When I introduce them, I don't want to mislead them about the idea of the animal, but I also don't want to go into too much detail about how it works, so as not to prevent projection. (Psychologist) Some teams have stimulated residents' imaginations by personalizing the robot with a first name, profession, powers, or clothes. They organized sewing, drawing, and even poetry workshops with the residence's robot. Residents used positive adjectives and described the robot as “a superhero” or “a policeman.” The aim was to allow residents' imaginations to flourish and showcase their skills in drawing, sewing, and singing. Well, the robot is personalized […] They gave him a first name, something to wear, they humanized him, and what's relevant is that many people understood that there was someone behind the PC, but chose to talk to the robot, because, at the very least, if there's a robot, as an adult, if it's you, for example, who's behind it, I could say this is so and so then... But no [...] we only talked to Nao. Everyone knows what's going on, there's no mystery, no magic, we don't take them for fools either...but we choose to talk to the robot. (Group leader) 3.4 Clarifying Objectives for the Patient Transparency with the patient is strongly encouraged concerning the objectives of the robotic intervention. An onco-geriatrician suggested the following explanation: We know that the treatment we're going to give you for the bandages is going to be painful, so we suggest that you have this robot so that you can hold on to it for a bit and so that it hurts less [...] And when we're done, we'll leave it with you for a while, and then we'll do something else. (Onco-geriatrician) 3.5 Adaptability Faced with the question of standardizing the robot's presentation, most professionals advised keeping it simple and avoiding overly rigid protocols, as it "becomes impractical and painful for everyone." Adaptability is key. The institution, human resources, and materials available define the protocol or action plan best suited to each team. 4. Obtaining consent or assistance from older adults In geriatric settings with those with MND, obtaining informed consent and assent for social robot use can be challenging. The ability to identify patient discomfort is emphasized, with professionals highlighting the necessity of familiarity with the patient's background for effective communication. 4.1 Consent versus Assent The information provided to participants enables them to understand the terms of the intervention and give their agreement before their participation. A geriatrician urged us to always distinguish between consent and assent. Consent is understood in the sense of the law of March 4, 2022, and "comes from a person capable of giving it, notably from a cognitive [standpoint], after clear, fair information, appropriate to his or her state of understanding." This participant elaborates further: But most of the time, people with major neuro-cognitive disorders are not necessarily capable of giving consent in the regulatory sense of the term [...] But consent basically implies having understood the situation, having analyzed the different possibilities and alternatives that may exist, and thirdly, having made a choice and fourthly, maintaining it over time. (Geriatric physician) When it is not possible for the beneficiary to communicate verbally, professionals focus on obtaining assent. Assent is an intermediate solution for obtaining the agreement of people who are unable to consent to an intervention. The therapist assesses whether a person is "partly agreeing or partly disagreeing," considering that "a bit of disagreement [is] equal to no agreement [which corresponds to] refusal of consent [or] refusal to participate," says a geriatrician. Moreover, obtaining assent requires the professional’s supervision of the intervention to interpret a range of clues, whereas obtaining consent simply implies following a formalized procedure. Assent is always provisional and must be confirmed throughout the intervention, whereas obtaining consent is more circumscribed in time. As a result, gathering assent requires ongoing vigilance on the part of the therapist, who may decide to redirect or interrupt the workshop if a participant shows signs of discomfort. However, obtaining consent and assent can be combined. During an interview, one psychologist explained that residents or their relatives give their consent to participate in activities when they join the unit. Subsequently, team members rely on residents' verbal and nonverbal communication to gather their assent for activities. 4.2 Verifying Assent in Beneficiaries All professionals agree that the ability to identify a patient’s discomfort, contempt, annoyance, or detachment is an integral part of professional training and is acquired during professional practice. Indeed, professionals who have used social robots have described how people with impaired judgment or verbal expression are quite capable of communicating their rejection through gestures by diverting attention, grimacing, or shouting. Here, professionals emphasize the importance of getting to know the patient beforehand, finding out about his or her state of physical and mental health, life history, preferences, likes, and dislikes. Only through this experience can professionals anticipate and skillfully adapt exchanges with patients. It is not always easy, when you start using a tool, to decide whether to try again or stop for good. To this end, we devised a short questionnaire (Annex 2) on the basis of some of the issues that professionals identified as keys to deciding whether to use the robot after a few trials with a particular patient. Sometimes we screw up, I mean, we bring him to hear a singer, if he does that (gestures), it's because he doesn't like it. That's it! Or sometimes, he cries, ‘Help!’ Well, too bad for the artist. But what I'm saying is that there are expressions. (Group leader) 4.3 The challenges of ensuring consent The beneficiary’s reactions should be observed during every session to ensure consent; obtaining participants’ consent in an SRI is thus a demanding task. The therapist must play an active mediating role in the relationship between the robot and the beneficiary, observing his or her own practices to assess their implications. Verifying assent might be more appropriate for SRIs, similar to other activities where direct consent is rarely obtained, as this group leader expressed: Asking for agreement on something like wanting to talk with me is not natural. I come and start talking, and I'll naturally notice whether or not you want to talk with me. […] It's important to go beyond the medical aspect, to focus on the person, who he or she is, what he or she likes, not his or her limitations or disorders. (Group leader) 4.4 Giving Robot a Second Chance Just as professionals are vigilant concerning consent, many of them are also careful to take into account that refusal of the robot once does not always signify that it will never interest the beneficiary again. They suggest putting the patient's refusal into perspective and consider it useful to repeat the proposal more than once while measuring the degree of disinterest. If it is systematically rejected at each presentation, it is not advisable to insist. The question arises when there are doubts about the patient's availability at a given moment. We try to see how the person reacts; it's already a good indicator if they don't start screaming and crying and running and leaving, then maybe there's something to be done. I base it on gestures and behavior—tomorrow she'll refuse, so we can try again several times and see what happens as time goes by, and besides, if she doesn't want to, I don't insist. (Psychologist) 5. Conducting a Robotic-Mediated Intervention Most of the professionals interviewed considered that the use of social robots did not depend on any ethical or deontological reflection distinct from that applied in their professional practice or in the medicosocial context. However, they mentioned some aspects that could be specific to the use of robots. 5.1 Human Contact Professionals emphasized the need for healthcare professionals for the supervision of SRI. They insisted that the robot does not replace human interaction but can provide an opportunity for therapeutic mediation. I believe under no circumstances should they replace or substitute a human. In other words[...] it's a tool, a tool, and it must remain a tool […] the robot must remain under the healthcare provider’s control […] It’s a tool among other therapies. (Psychologist) The need for human presence and mediation between robots and beneficiaries is therefore recognized by all. This explains why those interviewed do not feel relegated to a subordinate role concerning the use of social robots in geriatrics. For some professionals, the human mediator is the cornerstone of these workshops. The participants also mentioned their need for training to fulfill this mediating role. 5.2 Coping with the Robot’s Technical Problem The professionals mentioned the robot’s limitations, as these forced them to use new strategies. If the robot exhibits delayed responses or errors in comprehension or if it runs out of battery or is broken, incomprehension and fatigue may arise among some participants. Some professionals emphasized that the presence of a mediator is necessary to compensate for the robot's technical shortcomings. We don't leave a patient with dementia alone with one of these solutions. We're talking here about patients who are unable to verbalize, and by default, we'll offer them this space, typically when they're very distressed. When you're very distressed, you don't want to be alone, you want to be with someone. (Psychologist) To address these issues, health professionals have suggested incorporating humor and improvising dialogs. For example, if Nao did not answer quickly enough, the facilitator would say to the robot: “Are you tired, Nao?” This would reassure the participants, who sometimes wondered if they were the cause of the problem. These exchanges with the robot were reworked and added to the “scenarios” as the experiments progressed. Even after several sessions it's complicated, there are always little elements of ‘Oh, why did he do that?’ So in the end, (...) you had the group leader [...] saying things like ‘So Nao, you still haven't answered the question.’ (Physical therapist) Interestingly, the older adults did not seem to hold the robot accountable for its mistakes. In contrast, the professionals felt that their lack of perfection facilitated participants’ amusement and empathy. They could let themselves enter the atmosphere and formulate jokes or encouragement for Nao. Similarly, hardware failure could be a source of concern and anxiety for some participants who believe that the robot “has hurt himself.” Respondents reported cases where users had difficulty understanding how the robot works. The robot seems to move autonomously. Again, using the example of the Nao robot and its remote control by a computer, the psychologist explained that participants “have difficulty understanding the fact that the computer always communicates with the robot.” The analogy with cell phones, with which most of the residents are familiar, enables the psychologist to explain how the robot functions when controlled remotely. The introduction of social robots in geriatric care settings raises ethical concerns, particularly regarding the potential infantilization of participants. The respondents emphasized the significance of the therapeutic environment during SRI. They argued that the perception of the robot and its susceptibility to infantilization are influenced, in part, by how it is presented to beneficiaries. However, the specific factors contributing to these situations were not consistently articulated by those interviewed. For example, a psychologist and a physical therapist differentiated between robots on the basis of their appearance. They believed that Paro appeared "too childlike" and likened it to a "big cuddly toy," whereas residents preferred NAO, which they did not perceive as being "for children." To support their perspective, they provided a definition of infantilization: In fact, it's more than that, it's the position of the group leader that makes the difference. For example, the person is manipulating the robot and a caregiver says to him or her: ‘That's a nice toy, you've got a nice toy.’ (In a deliberately naïve tone) […] Nao is never presented as a toy; it's not a toy. (Psychologist) Thus, the manner in which the therapist introduces the robot, along with broader linguistic elements chosen during interaction, such as syntax and intonation, either facilitates or mitigates infantilization. Consequently, the occurrence of infantilization is contingent upon the therapeutic setting created by the therapist rather than the inherent attributes of the object or activity proposed. Similarly, a geriatrician emphasized the importance of distinguishing between the content and form of messages when analyzing situations of infantilization: For the same object or the same sentence, in terms of content, it won’t be perceived in the same way. […] So clearly it’s not necessarily about the content of the message; it’s really more about the form. (Geriatric physician) According to these explanations, situations of infantilization can be attributed to the intentions and demeanors of the individuals responsible for conducting the intervention. 6. Observed effects of social robot use Even among experienced professionals, the decision to integrate robots into their practice was not straightforward and initially met with some reluctance. Nevertheless, after the robot was utilized, the majority of professionals found it beneficial, as indicated in Table 2. They were surprised by the observed effects of social robots on certain patients. Table 2 Observed effects of social robot use among older adults Observed Effects Paro Nao Maintaining focus on an activity x x Reducing professionals’ emotional burden x x Reducing patients’ anxiety x x Stimulating creativity and imagination x Promoting positive mood and atmosphere x x Encouraging communication of emotions and experiences x x Revitalizing and bringing new perspectives to the team x Reducing agitation among nonpsychotic older adults x Facilitating sleep x 6.1 Perceived Benefits Professionals have proposed several hypotheses to account for the positive effects of robots: the ease of interaction is attributed to the simplicity of the relationship, characterized by a lack of judgment, facilitated by the "neutrality" of the machine or its appealing appearance. Some professionals likened this effect to that of cuddly toys, dolls, or dogs. Others attributed the positive impact of Paro to a restoration of the sense of touch, highlighting that physical contact for these patients is often associated with unpleasant experiences, such as hospital transfers, bathing, or care provided by healthcare professionals. 6.2 Confiding through social robotics Some patients demonstrate the ability to express their fears or confide in professionals in the presence of social robots. It appears that these exchanges are facilitated by the impression of being listened to or by the simplification of interactions provided by the robot. Unlike humans, the robot does not expect anything, expresses surprise, holds moral judgments, or makes value-based assessments. According to certain professionals, the complexity and potential anxiety associated with human gestures and verbal or nonverbal communication are mitigated by the simplicity of interaction offered by a robot such as Paro. For instance, a group leader shared a striking anecdote involving Nao in a protected unit. A withdrawn lady, known for her reserved demeanor, exhibited an unexpected response to the robot's presence. The group leader set up Nao, initiating its singing and dancing routine, which initially surprised the residents. However, as the interaction unfolded, the lady began turning toward the robot, eventually expressing affection toward the group leader, a gesture that had not been previously observed. 6.3 Emotional Distancing through Robotic Mediation For certain healthcare professionals, integrating robots into their practice helps alleviate the emotional burden associated with specific interactions. Witnessing individuals confiding in the robot or using it as a mediator enabled these professionals to recognize that elderly individuals often sought to be heard rather than seeking definitive answers or solutions. These interactions empowered patients to express themselves without feeling guilty, allowing them to broach topics that might evoke strong reactions in direct human interactions, such as discussing mortality. As one psychologist reflected, initially, there was a sense of sadness regarding the reliance on a virtual entity for emotional expression. However, the presence of the robot provided a neutral platform for individuals to share personal thoughts or feelings indirectly. While not expecting a response, patients anticipated being listened to, thereby enabling them to engage in conversations they might otherwise avoid with a human professional. 6.4 Providing Novelty to Professionals Furthermore, the integration of robots introduced a sense of novelty to professional practice, inspiring teams to approach their activities differently and fostering creativity. The workshops facilitated by robots yielded rewarding outcomes for the teams, particularly in instances where resident engagement had previously been lacking due to repetitive activities. Some teams have even expanded their use of technology beyond robots to include other tools such as the Wii, therapeutic boards, and Snoezelen, among others. 7. Recommendations for Professionals The insights gleaned from interviews have enabled us to formulate practical recommendations to aid professionals in implementing SRI within geriatric institutions. These recommendations are directed toward healthcare management: Involvement in decision-making : Allow staff members to participate in the decision-making process regarding robot acquisition. The staff should discuss how robots can address beneficiary needs and integrate these interventions into the establishment's activity schedules, considering aspects such as planning the organization, human resources, and available materials. Additionally, the beneficiary’s family should be informed about the proposed SRIs and the benefits and reasons behind their selection should be discussed. Training and Preparation : Provide specific training for professionals on robot operation and the implementation of SRIs. Allow sufficient time for the preparation and implementation of these interventions. Adherence to Professional Principles : Encouraging stakeholders to define methods that align with their professional principles and the needs of individual beneficiaries. The same ethical guidelines were followed for other therapeutic interventions for social robot use. The social robot can be integrated into existing therapeutic modalities, avoiding the need to start from scratch. Ethical and Professional Discourse : Facilitating discussions on ethical and professional issues surrounding social robot use in older adults during team debriefing sessions. Considering the outcomes of SRIs enables professionals to assess individual and organizational impacts and identify areas for improvement in implementation. Recommendations for Professionals Conducting SRIs Targeted Beneficiary Identification : Identify potential beneficiaries for social robot interaction in advance, evaluating the relevance of SRIs on a case-by-case basis. Mindful Presentation : Paying careful attention to how the robot is presented, recognizing its influence on the beneficiary experience and potential for infantilization. Words and tones are chosen thoughtfully, adapting the presentation to the beneficiary’s preferences and needs. Respect the beneficiary's perception of the robot throughout its presentation and use. Consent or Assent : Prioritize obtaining consent or assent by observing beneficiary reactions during interaction with the robot. Creative problem solving : When encountering technical difficulties, employees employ creativity or humor to reassure beneficiaries and maintain engagement. Discussion This study aimed to gain insight into healthcare and medicosocial professionals' opinions on the introduction of SRIs for older individuals, particularly concerning the ethical considerations associated with these practices. Additionally, the study sought to develop professional practice recommendations to guide professionals in the implementation and utilization of social robots with older adults, with a focus on managing situations that may raise ethical concerns. In this qualitative study, we conducted in-depth interviews with 20 professionals from the healthcare sector with experience in SRIs. Through these interviews, we aimed to gather their perceptions, experiences, and views on various key aspects of SRIs, including the presentation of the robot to patients, procedures for obtaining informed consent from older adults participating in SRIs, and criteria for determining the suitability of these interventions for specific individuals. The participants highlighted several areas for attention, particularly ethical issues and the training of professionals, which are crucial considerations when implementing SRIs in institutions. Additional Preparation and Training Needs The analysis of the interviews underscored the importance of thorough preparation for robot acquisition and robotic interventions, as well as adherence to healthcare deontological guidelines. However, healthcare teams in retirement homes expressed a lack of available training on social robot use with residents. They noted that materials from social robot manufacturers often focus solely on technical aspects, neglecting crucial topics such as the professional’s role during SRIs. The necessity of training professionals for an ethical approach to SRIs has also been emphasized in other publications [9]. In our study, professionals emphasized the importance of role-playing exercises and training in the form of videos to facilitate learning, particularly for those with limited time. Selection criteria for potential social robot beneficiaries Professionals emphasized the importance of identifying whether a social robot would be of interest to a beneficiary. This point has also been emphasized in the literature, with special attention given to identifying residents’ preferences before introducing the robot [21]. Introducing the Social Robot to the Beneficiary The experts in our research suggested tailoring the presentation of the robot to suit the individual characteristics of each older adult and the specific activity involved. This approach aligns with the literature, which underscores the importance of adjusting the social robot’s use to the individual’s specific needs, interests, and life history while providing a straightforward and clear explanation [21]. Consent The issue of obtaining consent for SRIs was a significant focus of discussion. Professionals highlighted the challenge in determining the capacity to consent, particularly in cases where individuals had severe cognitive disorders. According to the professionals in this study, addressing the consent question was resolved during clinical practice by directly engaging with the person when they could articulate their wishes or by observing their nonverbal cues in situations where neurocognitive disorders hindered verbal expression. This approach aligns with the literature, where various authors have underscored the complexities of assessing consent capacity in such scenarios [21, 22]. Emphasis on Human Interaction and Adaptability Our study emphasized that social robots are tools used within a therapeutic context and cannot replace healthcare professionals. Instead, they are under the control of these professionals. In contrast to concerns about social robots replacing human-to-human interactions, they may actually facilitate communication between professionals and residents with dementia, as observed by Hung et al. (2019) with PARO [9]. Similarly, Koh et al. (2023) highlighted how social robots can empower professionals by providing opportunities to connect with residents [21]. Challenges Professionals conducting robotic interventions have encountered technical limitations, leading them to adopt new strategies. Humor emerged as a crucial tool in addressing issues such as delayed responses or misunderstandings by the robot, ensuring participants' comfort. Ethical concerns regarding potential infantilization were raised, with respondents emphasizing the importance of the therapeutic setting. They asserted that how the robot is presented influences its perception. Professionals have argued that the therapist's presentation, including linguistic elements such as syntax and intonation, plays a crucial role in either inducing or preventing infantilization. Consequently, infantilization was viewed as dependent on the professional's approach rather than the intrinsic properties of the robot or activity. This contrasts with Koh et al.’s (2022) findings, where healthcare professionals believed that infantilization depended on how much the robot resembled a real animal [22]. Ienca et al. (2016) proposed that infantilization can be avoided by involving the beneficiary in the decision to use the social robot, promoting a sense of empowerment [18]. Observed effects of social robot use The healthcare professionals in our study reported that incorporating the robot in interactions eased their emotional burden, revealing that older adults often seek acknowledgment and a listening ear rather than definitive answers or solutions. Some professionals highlighted the ease with which a social robot can be used as a form of mediation, an important tool in psychotherapy. Mediation involves the use of an object, described in some studies as a “common third,” [23] that fosters joint attention [24]. The robot can act as a mediating object between the therapist and the beneficiary, facilitating their relationship. In his work with autistic children, F. Tordo (2018) described the social robot as a form of clinical support that enables therapist‒patient relationships. It can be viewed as the therapist’s partner and can provide companionship to the beneficiary [25]. Tordo attributed the benefits of the robot to its limited range of reactions, which make it constant and predictable, as well as its unwavering nature, which is unaffected by the beneficiary’s emotions [26]. In this way, the social robot’s presence can allow for emotional distance, enabling the beneficiary to express certain disturbing thoughts that are difficult to articulate directly, as observed by the healthcare professionals in our study. Conclusion and Future Research This study aimed to identify ethical considerations for the use of SRI in geriatric settings. Through interviews with 20 experienced healthcare professionals, several guidelines emerged: for healthcare team managers, it is advisable to involve team members in decisions about robot acquisition and training, identify potential beneficiaries for SRI beforehand, introduce social robots transparently while allowing for individual adaptation, and adhere to ethical standards across all care settings. To the best of our knowledge, this study on social robot use in geriatric settings is unprecedented. While social robots are increasingly available to older adults, the ethical implications of their use remain understudied, and standardized ethical guidelines regarding their application have yet to be established. We have proposed some preliminary guidelines, but future research could focus on establishing a standardized guide and determining how it should be communicated, published, or disseminated. Online videos could represent a promising avenue for ethical training, serving as a quick and accessible reference for a wide audience. Future studies should explore this further to ensure the ethical and responsible integration of social robots in geriatric care settings. Limitations This study has several limitations that must be acknowledged. First, the research was confined to an urban setting in Paris and Issy-les-Moulineaux, thereby excluding data from rural areas, which could present different patterns and challenges. Furthermore, the study did not incorporate the perspectives of other adults and their families. Additionally, the research sample was restricted to healthcare professionals who had experience with a limited number of robots, which may not fully represent the diverse functionalities and full potential of social robots available today. These limitations suggest the need for further research to provide a more encompassing view of the ethical recommendations for the implementation of social robots in various settings and among different populations. Abbreviations Older Adults: OA Major Neurocognitive Disorders: MND Social Robot Interventions: SRIs Declarations Ethics approval and consent to participate This study is registered and has been assigned the number Clinical Trial Number: 20200706120641 by the European General Data Protection Regulation. Broca Living Lab submitted the ROBETHICS project to the Comité d'Éthique de la Recherche (CER) of Université Paris Cité (IRB N°: 00012021-110). Consent for publication All participants in our study signed consent forms granting permission for the dissemination and use of data shared during the interviews. To ensure privacy, any information that could identify individuals has been fully anonymized. Availability of data and materials Requests to access the datasets should be sent to [email protected] . Competing interests There are no conflicts of interest to declare. Funding Declaration This work was supported by Janssen Horizon. Authors' contributions Conceptualization and methodology, MP and A-SR; formal analysis and investigation, VCL; writing—original draft preparation, CW; writing, review and editing, HL and MP; project administration, LB, SD, and SD. All authors have read and agreed to the published version of the manuscript. Acknowledgments We would like to thank the healthcare professionals who participated in our study. References The OECD. Demography - Elderly population - OECD Data. 2022. http://data.oecd.org/pop/elderly-population.htm. Accessed Mar 1 2024. Abdi J, Al-Hindawi A, Ng T, Vizcaychipi MP. Scoping review on the use of socially assistive robot technology in elderly care. BMJ Open. 2018;8(2):e018815. Kachouie R, Sedighadeli S, Khosla R, Chu MT. Socially Assistive Robots in Elderly Care: A Mixed-Method Systematic Literature Review. Int J Hum-Comput Interact. 2014;30(5):369‑93. Henschel A, Laban G, Cross ES. What Makes a Robot Social? A Review of Social Robots from Science Fiction to a Home or Hospital Near You. Curr Robot Rep. 2021;2(1):9‑19. Vernooij-Dassen M, Vasse E, Zuidema S, Cohen-Mansfield J, Moyle W. Psychosocial interventions for dementia patients in long-term care. Int Psychogeriatr. 2010;22(7):1121‑8. Bemelmans R, Gelderblom GJ, Jonker P, De Witte L. Socially Assistive Robots in Elderly Care: A Systematic Review into Effects and Effectiveness. J Am Med Dir Assoc. 2012;13(2):114-120.e1. Robinson NL, Cottier TV, Kavanagh DJ. Psychosocial Health Interventions by Social Robots: Systematic Review of Randomized Controlled Trials. J Med Internet Res. 2019;21(5):e13203. Shishehgar M, Kerr D, Blake J. The effectiveness of various robotic technologies in assisting older adults. Health Informatics J. 2019;25(3):892‑918. Hung L, Liu C, Woldum E, Au-Yeung A, Berndt A, Wallsworth C, et al. The benefits of and barriers to using a social robot PARO in care settings: a scoping review. BMC Geriatr. 2019;19(1):232. Rouaix N, Retru-Chavastel L, Rigaud AS, Monnet C, Lenoir H, Pino M. Affective and Engagement Issues in the Conception and Assessment of a Robot-Assisted Psychomotor Therapy for Persons with Dementia. Front Psychol. 2017;8:950. Fasola J, Mataric M. A Socially Assistive Robot Exercise Coach for the Elderly. J Hum-Robot Interact. 2013;2(2):3‑32. Blavette L, Rigaud AS, Anzalone SM, Kergueris C, Isabet B, Dacunha S, et al. A Robot-Mediated Activity Using the Nao Robot to Promote COVID-19 Precautionary Measures among Older Adults in Geriatric Facilities. Int J Environ Res Public Health. 2022;19(9):5222. Broekens J, Heerink M, Rosendal H. Assistive social robots in elderly care: a review. Gerontechnology. 2009;8(2):94‑103. Yu C, Sommerlad A, Sakure L, Livingston G. Socially assistive robots for people with dementia: Systematic review and meta-analysis of feasibility, acceptability and the effect on cognition, neuropsychiatric symptoms and quality of life. Aging Res Rev. 2022;78:101633. Sharkey A, Sharkey N. Granny and the robots: ethical issues in robot care for the elderly. Ethics Inf Technol. 2012;14(1):27‑40. Wangmo T, Lipps M, Kressig RW, Ienca M. Ethical concerns with the use of intelligent assistive technology: findings from a qualitative study with professional stakeholders. BMC Med Ethics. 2019;20(1):98. Körtner T. Ethical challenges in the use of social service robots for elderly people. Z Für Gerontol Geriatr. 2016;49(4):303‑7. Ienca M, Wangmo T, Jotterand F, Kressig RW, Elger B. Ethical Design of Intelligent Assistive Technologies for Dementia: A Descriptive Review. Sci Eng Ethics. 2018;24(4):1035‑55. Fosch-Villaronga E, Lutz C, Tamò-Larrieux A. Gathering Expert Opinions for Social Robots’ Ethical, Legal, and Societal Concerns: Findings from Four International Workshops. Int J Soc Robot. 2020;12(2):441‑58. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77‑101. Koh WQ, Vandemeulebroucke T, Gastmans C. The ethics of pet robots in dementia care settings: Care professionals’ and organisational leaders’ ethical intuitions. Front Psychiatry, 2023 ;14. Koh WQ, Toomey E, Flynn A, Casey D. Determinants of implementing pet robots in nursing homes for dementia care. BMC Geriatr. 2022 27;22(1):457. Klein B, Gaedt L, Cook G. Emotional Robots. GeroPsych 2013; doi:/10.1024/1662-9647/a000085. Elias JZ, Morrow PB, Streater J, Gallagher S, Fiore SM. Towards Triadic Interactions in Autism and Beyond: Transitional Objects, Joint Attention, and Social Robotics. Proc Hum Factors Ergon Soc Annu Meet. 2011;55(1):1486‑90. Tordo F. Les médiations robotiques avec l’enfant autiste. In: Et si Alzheimer(s) et Autisme(s) avaient un lien ? Toulouse: Érès; 2018 p. 215‑23. Tordo F. Robothérapie. Synthèse des fonctions thérapeutiques de la médiation robotique. In: Robots, de nouveaux partenaires de soins psychiques. Toulouse: Érès; p. 77‑87. Additional Declarations No competing interests reported. Supplementary Files ANNEX1and2.docx Cite Share Download PDF Status: Published Journal Publication published 22 Apr, 2025 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 29 Jul, 2024 Editor assigned by journal 27 Jul, 2024 Submission checks completed at journal 27 Jul, 2024 First submitted to journal 17 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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11:58:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21155,"visible":true,"origin":"","legend":"","description":"","filename":"ANNEX1and2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4756721/v1/b89669980d909a1e6e7ffaa2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development of an ethical framework for the use of social robots in the care of individuals with major neurocognitive disorders: A qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe aging of the global population is leading to an increased prevalence of chronic and disabling diseases, consequently creating a greater need for long-term care and adequate care services [1]. To better address these needs, various healthcare interventions using innovative technologies, such as social robot interventions (SRIs), have been developed [2,3]. Social robots come in different forms of embodiment and design [4]. For example, they can be human-like, incorporating human characteristics, such as the robot NAO, or animal-like, resembling a pet or cuddly toy, such as the robot PARO, which looks like a baby harp seal. The main feature of social robots is their ability to interact with humans through speech, gestures, or emotional behavior.\u003c/p\u003e \u003cp\u003eIn geriatrics, SRIs typically target older adults (OAs) with MND, such as those with dementia. These interventions fall within the scope of psychosocial interventions, i.e., nonpharmacological interventions aimed at improving the quality of life, cognitive skills, mood, or behavior of OAs with neurocognitive disorders through a wide range of activities [5]. The scientific literature on SRIs for dementia care has focused primarily on their impact, demonstrating positive effects on OAs' well-being, mood, and social interactions [3,6\u0026ndash;8]. For example, SRIs using PARO have been shown to reduce stress, negative emotions, and behavioral symptoms, as well as improve social interactions and the quality of care experience [9]. Some studies have shown that the NAO robot can facilitate cognitive and muscular exercises [10,11] and provide medical information [12]. Social robots can also be used in mediation, acting as intermediaries between beneficiaries and therapists [12].\u003c/p\u003e \u003cp\u003eIn recent years, the number and types of social robots used in geriatrics have increased [2,3,6,13]. SRIs have also been confirmed to be feasible and acceptable to OAs with dementia, informal caregivers, and care staff [14]. The emergence of these new therapeutic interventions raises deontological questions. Some authors have specifically addressed ethical concerns raised by SRIs, such as the reduction of human contact [15], misrepresenting or concealing the robot's true nature [16], and maintaining dignity and autonomy, which involves obtaining participants' consent [18] and protecting personal data [19]. However, research on ethical recommendations for SRIs tailored to older adults is sparse, and standardized ethical guidelines for health professionals have not yet been developed.\u003c/p\u003e \u003cp\u003eDrafting ethical recommendations for SRIs requires a careful and comprehensive analysis of the situations experienced by professionals in the field. These recommendations will assist health professionals in maintaining ethical standards while conducting SRIs with individuals living with MND. This study had two main objectives: (1) to understand how professionals conducting SRIs perceive and approach the ethical issues of social robot use with older adults and (2) to establish ethical guidelines to help professionals carry out SRIs with older adults.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eTo achieve these two objectives, we conducted semidirective interviews with professionals (N\u0026thinsp;=\u0026thinsp;20) who practice robotic-mediated interventions in geriatric facilities.\u003c/p\u003e\n\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003eRecruitment\u003c/h2\u003e\n \u003cp\u003ePurposeful sampling was employed to recruit professionals with experience in using social robots with older adults (OAs) in nursing homes and geriatric hospitals in and around Paris, France. During 2022, 20 professionals were interviewed. The descriptions of the participants\u0026rsquo; professions are listed in Table\u0026nbsp;1.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eParticipants\u0026rsquo; Professions and Gender Ratios\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eProfession\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e# Interviewed\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMale/Female Ratio\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGeriatric physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePsychologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1/6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeuropsychologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2/2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup leader\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0/3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical therapist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0/1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003eInterview Method\u003c/h2\u003e\n \u003cp\u003eAn interview guide for professionals in geriatric facilities who use or have used social robots in their daily practice was developed and is detailed in Annex 1. The semistructured interviews included, but were not limited to, the following three main research questions:\u003c/p\u003e\n \u003cp\u003e\u003cspan\u003e1. How should a robotic-mediated intervention be conducted? More specifically, how should the robot be presented to the beneficiary, and what procedures should be followed to obtain the participant\u0026rsquo;s consent?\u003cbr\u003e\u003c/span\u003e \u003cspan\u003e2. What ethical issues are raised by robotic mediation in geriatrics?\u003cbr\u003e\u003c/span\u003e \u003cspan\u003e3. What is the social robot\u0026rsquo;s role, and how does it affect human interaction, infantilization, and autonomy?\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003eAnalysis\u003c/h2\u003e\n \u003cp\u003eThe interviews were recorded and transcribed. The content of the interviews was analyzed via a thematic analysis method inspired by Braun and Clarke (2006) [20]. This method involves multiple readings of the interviews to thoroughly understand the content, identify the topics addressed, and categorize the comments to maximize the results. After initial coding of the interviews, the codes were organized into themes, which were reviewed and then arranged into a thematic map. Finally, the themes were defined and named, with examples provided to illustrate each theme.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eOverview\u003c/h2\u003e \u003cp\u003eThree main themes emerged from the analysis of the interviews: the clear and transparent presentation of the robot, obtaining consent from the beneficiary concerning its use, and the emphasis on human contact in robot-mediated interventions. Additionally, several subthemes were identified: imposed social robotic use, extra time and effort, careful selection of beneficiaries for robotic therapy, adaptability, technical problems, and the need for guidelines and training in the ethical use of social robots.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDeciding on and Preparing the Robot\u0026rsquo;s Introduction into a Service\u003c/h2\u003e \u003cp\u003eThe ethical use of robots should be considered not only from the patient's perspective but also from that of professionals, who may perceive it as an imposed and disruptive act. Moreover, when teams are understaffed, asking professionals to include a social robot in daily care can be overwhelming, especially if they are not consulted about its integration into their service.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e1.1. Need for Professionals to Participate in the Decision to Implement SRIs\u003c/h2\u003e \u003cp\u003eNone of the professionals reported being involved in the decision-making process regarding the type of robot or its potential usefulness within their team. For some healthcare professionals, the inclusion of the robot in their practice was challenging, possibly because the robot was imposed rather than requested.\u003c/p\u003e \u003cp\u003e \u003cem\u003eTherefore, for us, it was quite a shock because we did not ask for the robot. It was suggested to us. However, it was not a request from the psychology team, for example, the animation team, or the rehabilitation team. It came, well, it invited itself into our residence. (Psychologist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eProfessionals emphasized the need to be involved in decisions about how to acquire robots to prevent feelings of imposition.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe mustn't forget that the users of this robot are the patients, but they're also the professionals because most of the patients are dependent and so it's going to go through professionals, so they're also users. (Geriatric physician)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e1.2. Need to Reflect on Human Resources Before Implementing the Robot\u003c/h3\u003e\n\u003cp\u003eProfessionals emphasized the need to evaluate the human resources required to implement SRIs before integrating robots into institutions. The implementation of SRIs demands extra time and effort from professionals because of the need for training. Professionals highlighted the necessity of anticipating that trained teams might leave, particularly in departments with high turnover rates, such as oncology. Consequently, the time and costs required to train new teams must be included in the decision to implement a robot in the institution.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt takes an extremely long time to train people because you have to take time off work. But when you take time off, you have to find someone else to take your place, because the older adults aren't going to be on their own like that\u0026hellip; (Group leader)\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePreparing activities with a social robot also requires additional effort from teams. They had to reorganize their roles and tasks, acquire new knowledge, and dedicate extra time to setting up the workshops.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe had to do a lot more upstream work than we would have done without the Nao. We had to spend a lot of time preparing the whole session. You can't anticipate what's going to be said, for example, what words are going to be chosen for a text. (Psychologist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eProfessionals also stressed the time needed for the cleaning and maintenance of the robot.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e1.3. Need to Respect Professionals\u0026rsquo; Choice of Social Robot Use\u003c/h2\u003e \u003cp\u003eMany professionals have questioned the usefulness of social robots and their actual impact on patients, exhibiting a degree of mistrust. Therefore, some managers highlighted the benefit of demonstrating how the robot works instead of merely discussing it.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWhen I wanted to present the robot to my team, I talked about it without showing it, and well, reactions were mixed,..., but then I didn't explain anything, I just put the robot in front of them (the team) and showed them what it could do, [\u0026hellip;] the team was quite fascinated by... and I said to myself, well already, if the professionals get a bit involved with the robot, it'll also give them a starting point. (Neuropsychologist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, managers emphasized the importance of respecting professionals' preferences and perspectives on new technologies.\u003c/p\u003e \u003cp\u003e \u003cem\u003e[B]ut the more or less positive reception from the teams is natural. We respect each other\u0026rsquo;s choice of therapeutic practices: some use massage, touch, music, and some have agreed to use the robot. The aim is to see what can best suit and help each patient. (Psychologist)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e1.4. Need for Professionals to Build Existing Protocols and Ethical Standards\u003c/h2\u003e \u003cp\u003eProfessionals emphasized the advantage of building on existing interventions rather than creating new ones from scratch with the addition of a social robot. Attempting to develop entirely new interventions can generate additional stress for teams. Some of this extra time and effort could be economized by integrating the social robot into existing groups and activities. When the robot arrived, professionals preferred to use activities they had already mastered. They should feel reassured by using an activity where the robot is the only new element.\u003c/p\u003e \u003cp\u003e \u003cem\u003e[E]veryone has first chosen something in a field in which they're already comfortable, they've taken charge and now they're taking on a new teammate they don't know. So there can't be another unknown in the equation, because if we do the project, the thing, the Nao..., it's explosive, it won't work! (Physical therapist)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e1.5. Need for Organized Team Training\u003c/h2\u003e \u003cp\u003eHealthcare professionals lamented the inadequacy of the training content available to them. In their view, the materials provided by the manufacturer were limited to technical issues and did not address other problems, such as the therapist's role during the intervention. A psychologist emphasized the need for guidelines concerning social robot use:\u003c/p\u003e \u003cp\u003e \u003cem\u003eHaving a meeting is good, but if there's nothing to back it up, it's all downhill from there, because if you don't use the tool the next day, you need something to fall back on. (Psychologist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eProfessionals have suggested several ideas to improve training, such as proposing informational meetings with role-playing exercises or discovery sessions with robots.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think that the presentation of the robot and then perhaps some role-playing could be interesting, because adapting to the reactions of the patient in front of you as well, right. [\u0026hellip;] You have to adapt to each treatment, to events. (Physical therapist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome interviewees suggested the use of videos as an efficient, fun, and accessible approach to training.\u003c/p\u003e \u003cp\u003e \u003cem\u003eYeah, well, the problem with professionals [...] is that they also have very, very, very, very little time, [\u0026hellip;] but I think the best training for me is oral training, role-playing, and possibly much more video-based material that's shorter to watch and more enjoyable than reading. (Psychologist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eWe can even make videos so that people can access these resources gradually without the trainer being present. (Geriatric physician)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2. Preparing a robotic intervention\u003c/h2\u003e \u003cp\u003eAs with any type of intervention, healthcare professionals using social robots stress the importance of tailoring activities on the basis of users\u0026rsquo; profiles, relying on prior knowledge of the patient and their entourage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Selection criteria for the selection of SRIs\u003c/h2\u003e \u003cp\u003e Professionals emphasized the need to define the profiles of individuals who could participate in SRIs. For example, the Paro robot was deemed appropriate for those in the advanced stages of MND, as it reassured them and elicited affectivity that facilitated interaction. However, there was no single rule for selection; instead, professionals relied on their experience and knowledge of individual situations to define target groups.\u003c/p\u003e \u003cp\u003e \u003cem\u003eFor the memory workshop, I wanted a fairly high MMSE. So we're automatically on MMSEs above 20. And for the gentle gymnastics, I was less fussy and included more people with praxis problems. (Neuropsychologist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHealthcare professionals consider themselves capable of identifying individuals who might be more or less interested in the robot before proposing it. They could also anticipate who might initially refuse but later show interest after observing others or hearing positive feedback.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe've had people who were refractory, and they're free too, who couldn't stand it at all. That's it. People say negative things to us, like 'I'm not interested. Oh no, but do you take me for a fool?' And then, well, they left, but that didn't stop some of them, after a while, from wanting to come back to the group and see what happened, and then, for some, it's always the same. (Group leader)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome reservations were expressed regarding patients with a history of psychosis, as the use of the robot could generate anxiety during or after use:\u003c/p\u003e \u003cp\u003e \u003cem\u003e[F]or some people, who had psychotic disorders, for example, it was really dangerous, because it created a state of withdrawal and I observed this with one person and it could then lead to crises, crying spells, crises because the Ben robot remains a machine that can break down. (Geriatric physician)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e2\u003c/b\u003e \u003cb\u003e.2. Importance of Family Input\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe beneficiaries\u0026rsquo; family and friends can be reassured. Healthcare professionals noted that informing and discussing with family members helped dispel preconceived notions and establish a relationship of trust with the institution. One professional shared this anecdote:\u003c/p\u003e \u003cp\u003e \u003cem\u003eThere was a residence that did something really nice, in fact, before bringing in the robot, they had held a kind of meeting with the families [...] they had said, 'We're going to take part in a protocol, we're going to be sent a robot,' and they presented the robot [...] 'This is why we're going to use it with your loved ones.' (Psychologist)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3. Introducing the Robot to Older Adults\u003c/h2\u003e \u003cp\u003eThe interviews highlighted specific ethical issues associated with SRIs that must be considered when the social robot is presented to beneficiaries. Professionals unanimously agreed that the robot should be presented transparently, with a clear explanation of its nature and purpose. However, the content of the presentation, as well as the methods and expressions used, should be adapted to each situation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Taking into account the Robot\u0026rsquo;s Appearance\u003c/h2\u003e \u003cp\u003eProfessionals should be careful in their description of the social robot, as its appearance and fairly autonomous movement capabilities can be misleading for some beneficiaries.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think the first thing is to make it clear that it's a robot. [\u0026hellip;] I think there are certain situations in which it's not necessarily obvious to understand this. I'm thinking of certain robots, let's call them animaloid, where you can sometimes believe that it's not really a robot, and so that's important. (Geriatric physician)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Explaining the Wizard of Oz\u003c/h2\u003e \u003cp\u003eTransparency is a recurring issue concerning the use of the Nao robot and the \"Wizard of Oz\" technique. In this technique, an engineer or trained professional controls the robot's movements and speech from a computer. This explanation is often abstract or difficult for some patients to understand, regardless of their cognitive status. Professionals have suggested the use of metaphors with remotely controlled objects or cordless phones to facilitate the understanding of beneficiaries.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.3. The Importance of Playing Along\u003c/h2\u003e \u003cp\u003eMost professionals believe that some beneficiaries recognize social robots for what they are but choose to play along, much like interacting with an animated object or live animal. Overemphasizing that it is only a robot that can defeat the purpose of the SRI.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI prioritize the patient's well-being. Some people talk to their dog as if it were their brother or sister. We're not going to say, 'Oh, but it's not a human, it's a dog!\u0026rsquo; [...] We trust the relationship that develops between the two protagonists. We're not going to correct them; each has his own universe. (Group leader)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eProfessionals find it natural to interact with the robot spontaneously, believing that this freedom allows the most beneficial effects to be observed. They feared that constantly reminding the patient of the robot\u0026rsquo;s mechanical nature would diminish the beneficial effects of the interaction.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think you have to accept that the patient is using a metaphor without having to convince him otherwise (...) he's reminiscing, that helps them generate emotions, so in itself the robot, it's there just as an object, but I wouldn't mind him talking to him, like you talk to a cuddly toy, [\u0026hellip;] I think it would be extremely tedious if the clinician was constantly saying, \u0026lsquo;it's a machine, I remind you it's a machine!\u0026rsquo; It's useless. (Neuropsychologist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eWhen I introduce them, I don't want to mislead them about the idea of the animal, but I also don't want to go into too much detail about how it works, so as not to prevent projection. (Psychologist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome teams have stimulated residents' imaginations by personalizing the robot with a first name, profession, powers, or clothes. They organized sewing, drawing, and even poetry workshops with the residence's robot. Residents used positive adjectives and described the robot as \u0026ldquo;a superhero\u0026rdquo; or \u0026ldquo;a policeman.\u0026rdquo; The aim was to allow residents' imaginations to flourish and showcase their skills in drawing, sewing, and singing.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWell, the robot is personalized [\u0026hellip;] They gave him a first name, something to wear, they humanized him, and what's relevant is that many people understood that there was someone behind the PC, but chose to talk to the robot, because, at the very least, if there's a robot, as an adult, if it's you, for example, who's behind it, I could say this is so and so then... But no [...] we only talked to Nao. Everyone knows what's going on, there's no mystery, no magic, we don't take them for fools either...but we choose to talk to the robot. (Group leader)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Clarifying Objectives for the Patient\u003c/h2\u003e \u003cp\u003eTransparency with the patient is strongly encouraged concerning the objectives of the robotic intervention. An onco-geriatrician suggested the following explanation:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe know that the treatment we're going to give you for the bandages is going to be painful, so we suggest that you have this robot so that you can hold on to it for a bit and so that it hurts less [...] And when we're done, we'll leave it with you for a while, and then we'll do something else. (Onco-geriatrician)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Adaptability\u003c/h2\u003e \u003cp\u003eFaced with the question of standardizing the robot's presentation, most professionals advised keeping it simple and avoiding overly rigid protocols, as it \"becomes impractical and painful for everyone.\" Adaptability is key. The institution, human resources, and materials available define the protocol or action plan best suited to each team.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4. Obtaining consent or assistance from older adults\u003c/h2\u003e \u003cp\u003eIn geriatric settings with those with MND, obtaining informed consent and assent for social robot use can be challenging. The ability to identify patient discomfort is emphasized, with professionals highlighting the necessity of familiarity with the patient's background for effective communication.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e4.1 Consent versus Assent\u003c/h2\u003e \u003cp\u003eThe information provided to participants enables them to understand the terms of the intervention and give their agreement before their participation. A geriatrician urged us to always distinguish between consent and assent. Consent is understood in the sense of the law of March 4, 2022, and \"comes from a person capable of giving it, notably from a cognitive [standpoint], after clear, fair information, appropriate to his or her state of understanding.\" This participant elaborates further:\u003c/p\u003e \u003cp\u003e \u003cem\u003eBut most of the time, people with major neuro-cognitive disorders are not necessarily capable of giving consent in the regulatory sense of the term [...] But consent basically implies having understood the situation, having analyzed the different possibilities and alternatives that may exist, and thirdly, having made a choice and fourthly, maintaining it over time. (Geriatric physician)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWhen it is not possible for the beneficiary to communicate verbally, professionals focus on obtaining assent. Assent is an intermediate solution for obtaining the agreement of people who are unable to consent to an intervention. The therapist assesses whether a person is \"partly agreeing or partly disagreeing,\" considering that \"a bit of disagreement [is] equal to no agreement [which corresponds to] refusal of consent [or] refusal to participate,\" says a geriatrician. Moreover, obtaining assent requires the professional\u0026rsquo;s supervision of the intervention to interpret a range of clues, whereas obtaining consent simply implies following a formalized procedure.\u003c/p\u003e \u003cp\u003eAssent is always provisional and must be confirmed throughout the intervention, whereas obtaining consent is more circumscribed in time. As a result, gathering assent requires ongoing vigilance on the part of the therapist, who may decide to redirect or interrupt the workshop if a participant shows signs of discomfort. However, obtaining consent and assent can be combined. During an interview, one psychologist explained that residents or their relatives give their consent to participate in activities when they join the unit. Subsequently, team members rely on residents' verbal and nonverbal communication to gather their assent for activities.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Verifying Assent in Beneficiaries\u003c/h2\u003e \u003cp\u003e All professionals agree that the ability to identify a patient\u0026rsquo;s discomfort, contempt, annoyance, or detachment is an integral part of professional training and is acquired during professional practice. Indeed, professionals who have used social robots have described how people with impaired judgment or verbal expression are quite capable of communicating their rejection through gestures by diverting attention, grimacing, or shouting. Here, professionals emphasize the importance of getting to know the patient beforehand, finding out about his or her state of physical and mental health, life history, preferences, likes, and dislikes. Only through this experience can professionals anticipate and skillfully adapt exchanges with patients. It is not always easy, when you start using a tool, to decide whether to try again or stop for good. To this end, we devised a short questionnaire (Annex 2) on the basis of some of the issues that professionals identified as keys to deciding whether to use the robot after a few trials with a particular patient.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSometimes we screw up, I mean, we bring him to hear a singer, if he does that (gestures), it's because he doesn't like it. That's it! Or sometimes, he cries, \u0026lsquo;Help!\u0026rsquo; Well, too bad for the artist. But what I'm saying is that there are expressions. (Group leader)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003e4.3 The challenges of ensuring consent\u003c/h2\u003e \u003cp\u003eThe beneficiary\u0026rsquo;s reactions should be observed during every session to ensure consent; obtaining participants\u0026rsquo; consent in an SRI is thus a demanding task. The therapist must play an active mediating role in the relationship between the robot and the beneficiary, observing his or her own practices to assess their implications. Verifying assent might be more appropriate for SRIs, similar to other activities where direct consent is rarely obtained, as this group leader expressed:\u003c/p\u003e \u003cp\u003e\u003cem\u003e Asking for agreement on something like wanting to talk with me is not natural. I come and start talking, and I'll naturally notice whether or not you want to talk with me. [\u0026hellip;] It's important to go beyond the medical aspect, to focus on the person, who he or she is, what he or she likes, not his or her limitations or disorders. (Group leader)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003e4.4 Giving Robot a Second Chance\u003c/h2\u003e \u003cp\u003eJust as professionals are vigilant concerning consent, many of them are also careful to take into account that refusal of the robot once does not always signify that it will never interest the beneficiary again. They suggest putting the patient's refusal into perspective and consider it useful to repeat the proposal more than once while measuring the degree of disinterest. If it is systematically rejected at each presentation, it is not advisable to insist. The question arises when there are doubts about the patient's availability at a given moment.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe try to see how the person reacts; it's already a good indicator if they don't start screaming and crying and running and leaving, then maybe there's something to be done. I base it on gestures and behavior\u0026mdash;tomorrow she'll refuse, so we can try again several times and see what happens as time goes by, and besides, if she doesn't want to, I don't insist. (Psychologist)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003e5. Conducting a Robotic-Mediated Intervention\u003c/h2\u003e \u003cp\u003eMost of the professionals interviewed considered that the use of social robots did not depend on any ethical or deontological reflection distinct from that applied in their professional practice or in the medicosocial context. However, they mentioned some aspects that could be specific to the use of robots.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e5.1 Human Contact\u003c/h2\u003e \u003cp\u003eProfessionals emphasized the need for healthcare professionals for the supervision of SRI. They insisted that the robot does not replace human interaction but can provide an opportunity for therapeutic mediation.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI believe under no circumstances should they replace or substitute a human. In other words[...] it's a tool, a tool, and it must remain a tool [\u0026hellip;] the robot must remain under the healthcare provider\u0026rsquo;s control [\u0026hellip;] It\u0026rsquo;s a tool among other therapies. (Psychologist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe need for human presence and mediation between robots and beneficiaries is therefore recognized by all. This explains why those interviewed do not feel relegated to a subordinate role concerning the use of social robots in geriatrics. For some professionals, the human mediator is the cornerstone of these workshops. The participants also mentioned their need for training to fulfill this mediating role.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Coping with the Robot\u0026rsquo;s Technical Problem\u003c/h2\u003e \u003cp\u003eThe professionals mentioned the robot\u0026rsquo;s limitations, as these forced them to use new strategies. If the robot exhibits delayed responses or errors in comprehension or if it runs out of battery or is broken, incomprehension and fatigue may arise among some participants. Some professionals emphasized that the presence of a mediator is necessary to compensate for the robot's technical shortcomings.\u003c/p\u003e \u003cp\u003e\u003cem\u003eWe don't leave a patient with dementia alone with one of these solutions. We're talking here about patients who are unable to verbalize, and by default, we'll offer them this space, typically when they're very distressed. When you're very distressed, you don't want to be alone, you want to be with someone. (Psychologist)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eTo address these issues, health professionals have suggested incorporating humor and improvising dialogs. For example, if Nao did not answer quickly enough, the facilitator would say to the robot: \u0026ldquo;Are you tired, Nao?\u0026rdquo; This would reassure the participants, who sometimes wondered if they were the cause of the problem. These exchanges with the robot were reworked and added to the \u0026ldquo;scenarios\u0026rdquo; as the experiments progressed.\u003c/p\u003e \u003cp\u003e \u003cem\u003eEven after several sessions it's complicated, there are always little elements of \u0026lsquo;Oh, why did he do that?\u0026rsquo; So in the end, (...) you had the group leader [...] saying things like \u0026lsquo;So Nao, you still haven't answered the question.\u0026rsquo; (Physical therapist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eInterestingly, the older adults did not seem to hold the robot accountable for its mistakes. In contrast, the professionals felt that their lack of perfection facilitated participants\u0026rsquo; amusement and empathy. They could let themselves enter the atmosphere and formulate jokes or encouragement for Nao.\u003c/p\u003e \u003cp\u003eSimilarly, hardware failure could be a source of concern and anxiety for some participants who believe that the robot \u0026ldquo;has hurt himself.\u0026rdquo; Respondents reported cases where users had difficulty understanding how the robot works. The robot seems to move autonomously. Again, using the example of the Nao robot and its remote control by a computer, the psychologist explained that participants \u0026ldquo;have difficulty understanding the fact that the computer always communicates with the robot.\u0026rdquo; The analogy with cell phones, with which most of the residents are familiar, enables the psychologist to explain how the robot functions when controlled remotely.\u003c/p\u003e \u003cp\u003eThe introduction of social robots in geriatric care settings raises ethical concerns, particularly regarding the potential infantilization of participants. The respondents emphasized the significance of the therapeutic environment during SRI. They argued that the perception of the robot and its susceptibility to infantilization are influenced, in part, by how it is presented to beneficiaries. However, the specific factors contributing to these situations were not consistently articulated by those interviewed. For example, a psychologist and a physical therapist differentiated between robots on the basis of their appearance. They believed that Paro appeared \"too childlike\" and likened it to a \"big cuddly toy,\" whereas residents preferred NAO, which they did not perceive as being \"for children.\" To support their perspective, they provided a definition of infantilization:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIn fact, it's more than that, it's the position of the group leader that makes the difference. For example, the person is manipulating the robot and a caregiver says to him or her: \u0026lsquo;That's a nice toy, you've got a nice toy.\u0026rsquo; (In a deliberately na\u0026iuml;ve tone) [\u0026hellip;] Nao is never presented as a toy; it's not a toy. (Psychologist)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThus, the manner in which the therapist introduces the robot, along with broader linguistic elements chosen during interaction, such as syntax and intonation, either facilitates or mitigates infantilization. Consequently, the occurrence of infantilization is contingent upon the therapeutic setting created by the therapist rather than the inherent attributes of the object or activity proposed.\u003c/p\u003e \u003cp\u003eSimilarly, a geriatrician emphasized the importance of distinguishing between the content and form of messages when analyzing situations of infantilization:\u003c/p\u003e \u003cp\u003e \u003cem\u003eFor the same object or the same sentence, in terms of content, it won\u0026rsquo;t be perceived in the same way. [\u0026hellip;] So clearly it\u0026rsquo;s not necessarily about the content of the message; it\u0026rsquo;s really more about the form. (Geriatric physician)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAccording to these explanations, situations of infantilization can be attributed to the intentions and demeanors of the individuals responsible for conducting the intervention.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e6. Observed effects of social robot use\u003c/h3\u003e\n\u003cp\u003eEven among experienced professionals, the decision to integrate robots into their practice was not straightforward and initially met with some reluctance. Nevertheless, after the robot was utilized, the majority of professionals found it beneficial, as indicated in Table\u0026nbsp;2. They were surprised by the observed effects of social robots on certain patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eObserved effects of social robot use among older adults\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObserved Effects\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNao\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaintaining focus on an activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReducing professionals\u0026rsquo; emotional burden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReducing patients\u0026rsquo; anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStimulating creativity and imagination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePromoting positive mood and atmosphere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEncouraging communication of emotions and experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevitalizing and bringing new perspectives to the team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReducing agitation among nonpsychotic older adults\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitating sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003e6.1 Perceived Benefits\u003c/h2\u003e \u003cp\u003eProfessionals have proposed several hypotheses to account for the positive effects of robots: the ease of interaction is attributed to the simplicity of the relationship, characterized by a lack of judgment, facilitated by the \"neutrality\" of the machine or its appealing appearance. Some professionals likened this effect to that of cuddly toys, dolls, or dogs. Others attributed the positive impact of Paro to a restoration of the sense of touch, highlighting that physical contact for these patients is often associated with unpleasant experiences, such as hospital transfers, bathing, or care provided by healthcare professionals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003e6.2 Confiding through social robotics\u003c/h2\u003e \u003cp\u003eSome patients demonstrate the ability to express their fears or confide in professionals in the presence of social robots. It appears that these exchanges are facilitated by the impression of being listened to or by the simplification of interactions provided by the robot. Unlike humans, the robot does not expect anything, expresses surprise, holds moral judgments, or makes value-based assessments. According to certain professionals, the complexity and potential anxiety associated with human gestures and verbal or nonverbal communication are mitigated by the simplicity of interaction offered by a robot such as Paro.\u003c/p\u003e \u003cp\u003eFor instance, a group leader shared a striking anecdote involving Nao in a protected unit. A withdrawn lady, known for her reserved demeanor, exhibited an unexpected response to the robot's presence. The group leader set up Nao, initiating its singing and dancing routine, which initially surprised the residents. However, as the interaction unfolded, the lady began turning toward the robot, eventually expressing affection toward the group leader, a gesture that had not been previously observed.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003e6.3 Emotional Distancing through Robotic Mediation\u003c/h2\u003e \u003cp\u003eFor certain healthcare professionals, integrating robots into their practice helps alleviate the emotional burden associated with specific interactions. Witnessing individuals confiding in the robot or using it as a mediator enabled these professionals to recognize that elderly individuals often sought to be heard rather than seeking definitive answers or solutions. These interactions empowered patients to express themselves without feeling guilty, allowing them to broach topics that might evoke strong reactions in direct human interactions, such as discussing mortality.\u003c/p\u003e \u003cp\u003eAs one psychologist reflected, initially, there was a sense of sadness regarding the reliance on a virtual entity for emotional expression. However, the presence of the robot provided a neutral platform for individuals to share personal thoughts or feelings indirectly. While not expecting a response, patients anticipated being listened to, thereby enabling them to engage in conversations they might otherwise avoid with a human professional.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003e6.4 Providing Novelty to Professionals\u003c/h2\u003e \u003cp\u003eFurthermore, the integration of robots introduced a sense of novelty to professional practice, inspiring teams to approach their activities differently and fostering creativity. The workshops facilitated by robots yielded rewarding outcomes for the teams, particularly in instances where resident engagement had previously been lacking due to repetitive activities. Some teams have even expanded their use of technology beyond robots to include other tools such as the Wii, therapeutic boards, and Snoezelen, among others.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003e7. Recommendations for Professionals\u003c/h3\u003e\n\u003cp\u003eThe insights gleaned from interviews have enabled us to formulate practical recommendations to aid professionals in implementing SRI within geriatric institutions. These recommendations are directed toward healthcare management:\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInvolvement in decision-making\u003c/b\u003e: Allow staff members to participate in the decision-making process regarding robot acquisition. The staff should discuss how robots can address beneficiary needs and integrate these interventions into the establishment's activity schedules, considering aspects such as planning the organization, human resources, and available materials. Additionally, the beneficiary\u0026rsquo;s family should be informed about the proposed SRIs and the benefits and reasons behind their selection should be discussed.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTraining and Preparation\u003c/b\u003e: Provide specific training for professionals on robot operation and the implementation of SRIs. Allow sufficient time for the preparation and implementation of these interventions.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eAdherence to Professional Principles\u003c/b\u003e: Encouraging stakeholders to define methods that align with their professional principles and the needs of individual beneficiaries. The same ethical guidelines were followed for other therapeutic interventions for social robot use. The social robot can be integrated into existing therapeutic modalities, avoiding the need to start from scratch.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEthical and Professional Discourse\u003c/b\u003e: Facilitating discussions on ethical and professional issues surrounding social robot use in older adults during team debriefing sessions. Considering the outcomes of SRIs enables professionals to assess individual and organizational impacts and identify areas for improvement in implementation.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eRecommendations for Professionals Conducting SRIs\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eTargeted Beneficiary Identification\u003c/b\u003e: Identify potential beneficiaries for social robot interaction in advance, evaluating the relevance of SRIs on a case-by-case basis.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eMindful Presentation\u003c/b\u003e: Paying careful attention to how the robot is presented, recognizing its influence on the beneficiary experience and potential for infantilization. Words and tones are chosen thoughtfully, adapting the presentation to the beneficiary\u0026rsquo;s preferences and needs. Respect the beneficiary's perception of the robot throughout its presentation and use.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eConsent or Assent\u003c/b\u003e: Prioritize obtaining consent or assent by observing beneficiary reactions during interaction with the robot.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eCreative problem solving\u003c/b\u003e: When encountering technical difficulties, employees employ creativity or humor to reassure beneficiaries and maintain engagement.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to gain insight into healthcare and medicosocial professionals' opinions on the introduction of SRIs for older individuals, particularly concerning the ethical considerations associated with these practices. Additionally, the study sought to develop professional practice recommendations to guide professionals in the implementation and utilization of social robots with older adults, with a focus on managing situations that may raise ethical concerns.\u003c/p\u003e \u003cp\u003eIn this qualitative study, we conducted in-depth interviews with 20 professionals from the healthcare sector with experience in SRIs. Through these interviews, we aimed to gather their perceptions, experiences, and views on various key aspects of SRIs, including the presentation of the robot to patients, procedures for obtaining informed consent from older adults participating in SRIs, and criteria for determining the suitability of these interventions for specific individuals. The participants highlighted several areas for attention, particularly ethical issues and the training of professionals, which are crucial considerations when implementing SRIs in institutions.\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section2\"\u003e \u003ch2\u003eAdditional Preparation and Training Needs\u003c/h2\u003e \u003cp\u003e The analysis of the interviews underscored the importance of thorough preparation for robot acquisition and robotic interventions, as well as adherence to healthcare deontological guidelines. However, healthcare teams in retirement homes expressed a lack of available training on social robot use with residents. They noted that materials from social robot manufacturers often focus solely on technical aspects, neglecting crucial topics such as the professional\u0026rsquo;s role during SRIs. The necessity of training professionals for an ethical approach to SRIs has also been emphasized in other publications [9]. In our study, professionals emphasized the importance of role-playing exercises and training in the form of videos to facilitate learning, particularly for those with limited time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section2\"\u003e \u003ch2\u003eSelection criteria for potential social robot beneficiaries\u003c/h2\u003e \u003cp\u003eProfessionals emphasized the importance of identifying whether a social robot would be of interest to a beneficiary. This point has also been emphasized in the literature, with special attention given to identifying residents\u0026rsquo; preferences before introducing the robot [21].\u003c/p\u003e \u003cdiv id=\"Sec40\" class=\"Section3\"\u003e \u003ch2\u003eIntroducing the Social Robot to the Beneficiary\u003c/h2\u003e \u003cp\u003eThe experts in our research suggested tailoring the presentation of the robot to suit the individual characteristics of each older adult and the specific activity involved. This approach aligns with the literature, which underscores the importance of adjusting the social robot\u0026rsquo;s use to the individual\u0026rsquo;s specific needs, interests, and life history while providing a straightforward and clear explanation [21].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eConsent\u003c/h3\u003e\n\u003cp\u003eThe issue of obtaining consent for SRIs was a significant focus of discussion. Professionals highlighted the challenge in determining the capacity to consent, particularly in cases where individuals had severe cognitive disorders. According to the professionals in this study, addressing the consent question was resolved during clinical practice by directly engaging with the person when they could articulate their wishes or by observing their nonverbal cues in situations where neurocognitive disorders hindered verbal expression. This approach aligns with the literature, where various authors have underscored the complexities of assessing consent capacity in such scenarios [21, 22].\u003c/p\u003e\n\u003ch3\u003eEmphasis on Human Interaction and Adaptability\u003c/h3\u003e\n\u003cp\u003eOur study emphasized that social robots are tools used within a therapeutic context and cannot replace healthcare professionals. Instead, they are under the control of these professionals. In contrast to concerns about social robots replacing human-to-human interactions, they may actually facilitate communication between professionals and residents with dementia, as observed by Hung et al. (2019) with PARO [9]. Similarly, Koh et al. (2023) highlighted how social robots can empower professionals by providing opportunities to connect with residents [21].\u003c/p\u003e\n\u003ch3\u003eChallenges\u003c/h3\u003e\n\u003cp\u003eProfessionals conducting robotic interventions have encountered technical limitations, leading them to adopt new strategies. Humor emerged as a crucial tool in addressing issues such as delayed responses or misunderstandings by the robot, ensuring participants' comfort.\u003c/p\u003e \u003cp\u003eEthical concerns regarding potential infantilization were raised, with respondents emphasizing the importance of the therapeutic setting. They asserted that how the robot is presented influences its perception. Professionals have argued that the therapist's presentation, including linguistic elements such as syntax and intonation, plays a crucial role in either inducing or preventing infantilization. Consequently, infantilization was viewed as dependent on the professional's approach rather than the intrinsic properties of the robot or activity.\u003c/p\u003e \u003cp\u003eThis contrasts with Koh et al.\u0026rsquo;s (2022) findings, where healthcare professionals believed that infantilization depended on how much the robot resembled a real animal [22]. Ienca et al. (2016) proposed that infantilization can be avoided by involving the beneficiary in the decision to use the social robot, promoting a sense of empowerment [18].\u003c/p\u003e\n\u003ch3\u003eObserved effects of social robot use\u003c/h3\u003e\n\u003cp\u003eThe healthcare professionals in our study reported that incorporating the robot in interactions eased their emotional burden, revealing that older adults often seek acknowledgment and a listening ear rather than definitive answers or solutions.\u003c/p\u003e \u003cp\u003eSome professionals highlighted the ease with which a social robot can be used as a form of mediation, an important tool in psychotherapy. Mediation involves the use of an object, described in some studies as a \u0026ldquo;common third,\u0026rdquo; [23] that fosters joint attention [24]. The robot can act as a mediating object between the therapist and the beneficiary, facilitating their relationship. In his work with autistic children, F. Tordo (2018) described the social robot as a form of clinical support that enables therapist‒patient relationships. It can be viewed as the therapist\u0026rsquo;s partner and can provide companionship to the beneficiary [25]. Tordo attributed the benefits of the robot to its limited range of reactions, which make it constant and predictable, as well as its unwavering nature, which is unaffected by the beneficiary\u0026rsquo;s emotions [26]. In this way, the social robot\u0026rsquo;s presence can allow for emotional distance, enabling the beneficiary to express certain disturbing thoughts that are difficult to articulate directly, as observed by the healthcare professionals in our study.\u003c/p\u003e"},{"header":"Conclusion and Future Research","content":"\u003cp\u003eThis study aimed to identify ethical considerations for the use of SRI in geriatric settings. Through interviews with 20 experienced healthcare professionals, several guidelines emerged: for healthcare team managers, it is advisable to involve team members in decisions about robot acquisition and training, identify potential beneficiaries for SRI beforehand, introduce social robots transparently while allowing for individual adaptation, and adhere to ethical standards across all care settings.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this study on social robot use in geriatric settings is unprecedented. While social robots are increasingly available to older adults, the ethical implications of their use remain understudied, and standardized ethical guidelines regarding their application have yet to be established. We have proposed some preliminary guidelines, but future research could focus on establishing a standardized guide and determining how it should be communicated, published, or disseminated. Online videos could represent a promising avenue for ethical training, serving as a quick and accessible reference for a wide audience. Future studies should explore this further to ensure the ethical and responsible integration of social robots in geriatric care settings.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study has several limitations that must be acknowledged. First, the research was confined to an urban setting in Paris and Issy-les-Moulineaux, thereby excluding data from rural areas, which could present different patterns and challenges. Furthermore, the study did not incorporate the perspectives of other adults and their families. Additionally, the research sample was restricted to healthcare professionals who had experience with a limited number of robots, which may not fully represent the diverse functionalities and full potential of social robots available today. These limitations suggest the need for further research to provide a more encompassing view of the ethical recommendations for the implementation of social robots in various settings and among different populations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOlder Adults: OA\u003c/p\u003e\n\u003cp\u003eMajor Neurocognitive Disorders: MND\u003c/p\u003e\n\u003cp\u003eSocial Robot Interventions: SRIs\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is registered and has been assigned the number Clinical Trial Number: 20200706120641 by the European General Data Protection Regulation. Broca Living Lab submitted the ROBETHICS project to the Comit\u0026eacute; d\u0026apos;\u0026Eacute;thique de la Recherche (CER) of Universit\u0026eacute; Paris Cit\u0026eacute; (IRB N\u0026deg;: 00012021-110).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants in our study signed consent forms granting permission for the dissemination and use of data shared during the interviews. To ensure privacy, any information that could identify individuals has been fully anonymized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRequests to access the datasets should be sent to [email protected].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Janssen Horizon.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization and methodology, MP and A-SR; formal analysis and investigation, VCL; writing\u0026mdash;original draft preparation, CW; writing, review and editing, HL and MP; project administration, LB, SD, and SD. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the healthcare professionals who participated in our study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThe OECD. Demography - Elderly population - OECD Data. 2022. http://data.oecd.org/pop/elderly-population.htm. Accessed Mar 1 2024.\u003c/li\u003e\n\u003cli\u003eAbdi J, Al-Hindawi A, Ng T, Vizcaychipi MP. Scoping review on the use of socially assistive robot technology in elderly care. BMJ Open. 2018;8(2):e018815.\u003c/li\u003e\n\u003cli\u003eKachouie R, Sedighadeli S, Khosla R, Chu MT. Socially Assistive Robots in Elderly Care: A Mixed-Method Systematic Literature Review. Int J Hum-Comput Interact. 2014;30(5):369‑93.\u003c/li\u003e\n\u003cli\u003eHenschel A, Laban G, Cross ES. What Makes a Robot Social? A Review of Social Robots from Science Fiction to a Home or Hospital Near You. Curr Robot Rep. 2021;2(1):9‑19.\u003c/li\u003e\n\u003cli\u003eVernooij-Dassen M, Vasse E, Zuidema S, Cohen-Mansfield J, Moyle W. Psychosocial interventions for dementia patients in long-term care. Int Psychogeriatr. 2010;22(7):1121‑8.\u003c/li\u003e\n\u003cli\u003eBemelmans R, Gelderblom GJ, Jonker P, De Witte L. Socially Assistive Robots in Elderly Care: A Systematic Review into Effects and Effectiveness. J Am Med Dir Assoc. 2012;13(2):114-120.e1.\u003c/li\u003e\n\u003cli\u003eRobinson NL, Cottier TV, Kavanagh DJ. Psychosocial Health Interventions by Social Robots: Systematic Review of Randomized Controlled Trials. J Med Internet Res. 2019;21(5):e13203.\u003c/li\u003e\n\u003cli\u003eShishehgar M, Kerr D, Blake J. The effectiveness of various robotic technologies in assisting older adults. Health Informatics J. 2019;25(3):892‑918.\u003c/li\u003e\n\u003cli\u003eHung L, Liu C, Woldum E, Au-Yeung A, Berndt A, Wallsworth C, et al. The benefits of and barriers to using a social robot PARO in care settings: a scoping review. BMC Geriatr. 2019;19(1):232.\u003c/li\u003e\n\u003cli\u003eRouaix N, Retru-Chavastel L, Rigaud AS, Monnet C, Lenoir H, Pino M. Affective and Engagement Issues in the Conception and Assessment of a Robot-Assisted Psychomotor Therapy for Persons with Dementia. Front Psychol. 2017;8:950.\u003c/li\u003e\n\u003cli\u003eFasola J, Mataric M. A Socially Assistive Robot Exercise Coach for the Elderly. J Hum-Robot Interact. 2013;2(2):3‑32.\u003c/li\u003e\n\u003cli\u003eBlavette L, Rigaud AS, Anzalone SM, Kergueris C, Isabet B, Dacunha S, et al. A Robot-Mediated Activity Using the Nao Robot to Promote COVID-19 Precautionary Measures among Older Adults in Geriatric Facilities. Int J Environ Res Public Health. 2022;19(9):5222.\u003c/li\u003e\n\u003cli\u003eBroekens J, Heerink M, Rosendal H. Assistive social robots in elderly care: a review. Gerontechnology. 2009;8(2):94‑103.\u003c/li\u003e\n\u003cli\u003eYu C, Sommerlad A, Sakure L, Livingston G. Socially assistive robots for people with dementia: Systematic review and meta-analysis of feasibility, acceptability and the effect on cognition, neuropsychiatric symptoms and quality of life. Aging Res Rev. 2022;78:101633.\u003c/li\u003e\n\u003cli\u003eSharkey A, Sharkey N. Granny and the robots: ethical issues in robot care for the elderly. Ethics Inf Technol. 2012;14(1):27‑40.\u003c/li\u003e\n\u003cli\u003eWangmo T, Lipps M, Kressig RW, Ienca M. Ethical concerns with the use of intelligent assistive technology: findings from a qualitative study with professional stakeholders. BMC Med Ethics. 2019;20(1):98.\u003c/li\u003e\n\u003cli\u003eK\u0026ouml;rtner T. Ethical challenges in the use of social service robots for elderly people. Z F\u0026uuml;r Gerontol Geriatr. 2016;49(4):303‑7.\u003c/li\u003e\n\u003cli\u003eIenca M, Wangmo T, Jotterand F, Kressig RW, Elger B. Ethical Design of Intelligent Assistive Technologies for Dementia: A Descriptive Review. Sci Eng Ethics. 2018;24(4):1035‑55.\u003c/li\u003e\n\u003cli\u003eFosch-Villaronga E, Lutz C, Tam\u0026ograve;-Larrieux A. Gathering Expert Opinions for Social Robots\u0026rsquo; Ethical, Legal, and Societal Concerns: Findings from Four International Workshops. Int J Soc Robot. 2020;12(2):441‑58.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77‑101.\u003c/li\u003e\n\u003cli\u003eKoh WQ, Vandemeulebroucke T, Gastmans C. The ethics of pet robots in dementia care settings: Care professionals\u0026rsquo; and organisational leaders\u0026rsquo; ethical intuitions. Front Psychiatry, 2023 ;14.\u003c/li\u003e\n\u003cli\u003eKoh WQ, Toomey E, Flynn A, Casey D. Determinants of implementing pet robots in nursing homes for dementia care. BMC Geriatr. 2022 27;22(1):457.\u003c/li\u003e\n\u003cli\u003eKlein B, Gaedt L, Cook G. Emotional Robots. GeroPsych 2013; doi:/10.1024/1662-9647/a000085.\u003c/li\u003e\n\u003cli\u003eElias JZ, Morrow PB, Streater J, Gallagher S, Fiore SM. Towards Triadic Interactions in Autism and Beyond: Transitional Objects, Joint Attention, and Social Robotics. Proc Hum Factors Ergon Soc Annu Meet. 2011;55(1):1486‑90.\u003c/li\u003e\n\u003cli\u003eTordo F. Les m\u0026eacute;diations robotiques avec l\u0026rsquo;enfant autiste. In: Et si Alzheimer(s) et Autisme(s) avaient un lien ? Toulouse: \u0026Eacute;r\u0026egrave;s; 2018 p. 215‑23.\u003c/li\u003e\n\u003cli\u003eTordo F. Roboth\u0026eacute;rapie. Synth\u0026egrave;se des fonctions th\u0026eacute;rapeutiques de la m\u0026eacute;diation robotique. In: Robots, de nouveaux partenaires de soins psychiques. Toulouse: \u0026Eacute;r\u0026egrave;s; p. 77‑87.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ethics, Social Robots, Older Adults, Major Neurocognitive Disorders, Qualitative Research","lastPublishedDoi":"10.21203/rs.3.rs-4756721/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4756721/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Despite the growing use of social robots in geriatric care, there is a lack of standardized ethical guidelines to inform and guide professionals in their implementation.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003e This study has two main objectives: 1) to understand how professionals conducting social robot interventions (SRIs) perceive and approach the ethical issues linked to the use of social robots with older adults and 2) to establish ethical guidelines to help professionals carry out SRIs with older adults.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFor this descriptive qualitative study, we conducted interviews with 20 healthcare professionals working in geriatric facilities. The interviews were recorded and transcribed, and a content analysis was performed to identify certain themes and recommendations concerning the use of social robots with older adults.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree main themes emerged from the analysis of the interviews: the clear and direct presentation of the robot, obtaining consent from the beneficiary concerning its use, and the emphasis on human contact in robot-mediated interventions. Additionally, the following subthemes were evoked: imposed social robotic use, extra time and effort, careful selection of beneficiaries for robotic therapy, adaptability, technical problems, and the need for guidelines and training in ethical social robot use.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e The use of social robots should be guided by the same ethical guidelines followed in all therapeutic interventions; however, healthcare professionals express a need for special training and preparation for SRIs in geriatric settings. We have drafted several preliminary recommendations for carrying out SRIs with older adults. Future research should focus on standardizing guidelines and creating an accessible format for training.\u003c/p\u003e\u003ch2\u003eTrial Registration:\u003c/h2\u003e \u003cp\u003eIRB N\u0026deg;: 00012021-110\u003c/p\u003e","manuscriptTitle":"Development of an ethical framework for the use of social robots in the care of individuals with major neurocognitive disorders: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-22 11:50:41","doi":"10.21203/rs.3.rs-4756721/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-29T06:30:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-27T04:12:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-27T04:10:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2024-07-17T13:48:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"610918db-295b-48cc-a687-a34a267fb015","owner":[],"postedDate":"August 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-28T16:02:18+00:00","versionOfRecord":{"articleIdentity":"rs-4756721","link":"https://doi.org/10.1186/s12877-025-05891-z","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2025-04-22 15:57:49","publishedOnDateReadable":"April 22nd, 2025"},"versionCreatedAt":"2024-08-22 11:50:41","video":"","vorDoi":"10.1186/s12877-025-05891-z","vorDoiUrl":"https://doi.org/10.1186/s12877-025-05891-z","workflowStages":[]},"version":"v1","identity":"rs-4756721","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4756721","identity":"rs-4756721","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}