Healthcare Informatics Research and Innovation
Topic: Healthcare Informatics Research and Innovation:
Include intro, a currently emerging healthcare technology system, goals for the product, data supporting the product, healthcare settings (including education), conclusion.
You should carry out an investigation about one of the technologies used in Health Informatics, for example: EHR, CPOE, EMR, CDSS, eMAR, or electronic devices used in Health Care
5 pages (excluding cover and reference pages)
APA formatted paper
3 References within 5 years (I attach 2 references) (MUST USE AT LEAST 1 OF THE 2 REFERENCES ATTACH)
09_HumanCaring-D-18-00058_proof 2019/5/17 20:02 page 178 #1
Nurse Caring: From Robotic
Surgeries to Healthcare Robots
Armiel Suriaga, MSN, RN
Florida Atlantic University, Boca Raton, Florida
Abstract: The
ID:p0060
technological advancement in healthcare is shaking up the way nurses
render care. From robotic surgeries, electronic medical records, data analytics, artificial
intelligence, and humanoid healthcare robots, the continuity of nurse caring is further illu-
minated in situations of advancing technology that require a call for nursing. In this chang-
ing work environment, technological competence is undoubtedly imperative. However,
it takes more than just being technologically competent to address the complex needs of
patients. Understanding not only how, but why we need these technologies in patient care
delivery is a requisite to nurse caring.
Keywords: robotic
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surgery; healthcare robots; caring; nurse caring; technological competence;
operating theater
Nursing
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is not indifferent to technological
advancements in healthcare, and in fact, nurs-
ing is often at the center of implementation of
new healthcare technologies. The use of robotic
surgery, for instance, has been embraced pos-
itively by nurses along with other healthcare
practitioners. Since its introduction in the 1990s,
robotic surgery has created a specialty practice
area for nurses, who have been recognized for
their essential nursing role in any successful
robotic procedure (Abdel Raheem et al., 2017).
Nurses
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play an integral role in the operating
theater, which ranges from preparing the instru-
ments or machines, for example, da Vinci Surgi-
cal System (Intuitive Surgical, n.d.), positioning
a patient properly on the operating table, mak-
ing sure that the robotic arm is not resting on the
patients body so as not to block off circulation,
anticipating the need of the surgeon, to undocking
the robot, making inventories of instruments used,
and so on. (Lichosik, Arna-boldi, Astolfi, Caruso, &
Granata, 2014). Being technologically competent,
as in the case of a nurse in robotics, is a prerequi-
site in todays technologically advanced healthcare
environment, and as Locsin (2005, 2017) has estab-
lished, is an expression of caring in nursing.
I
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posit that nurses need to demonstrate car-
ing more explicitly than just being technologi-
cally competent and not merely the silent users
of the product of healthcare innovations. First, an
understanding of technology is fundamental to
effective caring, for example, knowledge of the use
of robotic surgery and other advanced technolo-
gies such as nanorobotics and healthcare robots,
the rationale for their use, how these technologies
benefit patients not only in one area of care or
for single use, but the added values for continued
adaptation and implementation. Second, I contend
that nurses, often the end users of technology for
patient care, are in a unique position to inform and
influence engineers, innovators, system designers,
and other stakeholders to proactively advise on
Pdf_Folio:178
178 International Journal for Human Caring, Volume 23, Number 2, 2019 2019 International Association for Human Caring
http://dx.doi.org/10.20467/1091-5710.23.2.178
https://orcid.org/0000-0001-5829-1531
http://dx.doi.org/10.20467/1091-5710.23.2.178
09_HumanCaring-D-18-00058_proof 2019/5/17 20:02 page 179 #2
which of these technologies are truly beneficial,
safe, and user-friendly. Nurses spend more time
with patients than any other members of the inter-
disciplinary team. This realization comes with an
assumption that nurses know their patients bet-
ter, know which equipment or machine works
well for the patient, and which one does not. To
be proactive requires caring, and to lead the dia-
logue on this issue as a patient advocate requires
compassion, conscience, confidence, competence,
and commitment to quality care, which in fact are
essential ingredients of caring (Roach, 2002). In
short, this is a call for nursing, grounded in caring
science, to be a driver of healthcare innovations,
and not merely a repository of the delegated tasks
of technology implementation.
The
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aim of this article is to reinforce the emerg-
ing role of a nurse in robotics and other areas
such as healthcare innovations, nanorobotics, and
healthcare robots, and to suggest how nurses
expertise can be tapped in this innovative field of
healthcare technology. In this article, I present the
basics of robotic surgery and the corresponding
role of a nurse in robotics, and then proceed to dis-
cuss the irreplaceable role of a nurse as a critical
link between high tech and high touch. This role
for nurses is particularly crucial as the introduction
of healthcare robots gains exciting momentum in
todays technologically driven healthcare system
grounded in caring. It commences with the impli-
cations of technology in the current and future
practice of nursing.
Understanding
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the Basics of Robotic Surgery:
A Prelude to Nurse Caring
Robotic
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technology is not new in todays
healthcare standard. However, understanding
the origin of robotic surgery and how it has rev-
olutionized surgery enables nurses to appreciate
their distinctive role. The first documented robot-
assisted procedure was in 1985 when PUMA
(Programmable Universal Machine for Assembly
or Programmable Universal Manipulation Arm)
560 robotic surgical arm was utilized in neuro-
surgical biopsy (Lanfranco, Castellanos, Desai, &
Meyers, 2004). This paved the way to a successful
robot-assisted laparoscopic surgery, a cholecystec-
tomy in 1987, followed by a robotic transurethral
resection. In addition, the Food and Drug Admin-
istration (FDA) approved the da Vinci surgical
system in 2000 and from then on, thousands of
robotic surgeries have been performed in the
United States and other areas of the globe.
For
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nurses to be technologically competent
in robotic procedures, understanding of basic
robotics is critical. Take, for example, the da Vinci
Surgical system which is considered the gold stan-
dard equipment in robotic surgery. Developed by
the American company, Intuitive Surgical (n.d.),
the da Vinci Surgical System utilizes space-age
technology that includes a surgeons console, a
patient cart with interactive robotic arms and a
high-performance video imaging system to cap-
ture three-dimensional images, and the EndoWrist
instruments. The robotic arms are attached to
trocarstrocars inserted into the patient through
tiny incisions, with which the surgeon controls the
movement depending on the type of procedure to
be performed, be it suturing or cutting the tissues,
and so on.
Robotic
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surgeries have been performed tens of
thousands of time to fivemillion people world-
wide (Intuitive Surgical, n.d.). Using the da
Vinci surgical system helps the surgeons improve
patient outcome: fewer incisions, less infection
risk, and less pain for the patient (Gill & Ran-
dell, 2017). The patient can go home the same
day or a few days after, depending on the type
of surgery. In contrast, traditional open surgeries
that could take days, or weeks to heal, thus costing
more money in hospitalization and recovery, caus-
ing complications, and contributing to unpleasant
symptoms like pain and infection. Robotic surgery
enhances the patients surgical experience in terms
of safety, and it improves quality of life. It also
cements the value of communication and team-
work in healthcare where nurses work closely with
surgeons, anesthesiologists, and technicians in the
operating theater for safe patient care (Gill & Ran-
dell, 2017).
Over
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the years, notable improvements are
realized in robotic surgery, such as improved
dexteritydexterity of the robotic arms/wrists, bet-
ter visual perception of depth, and high defini-
tion images captured during the procedure that
allows surgeons to have better view and con-
trol of the surgery. Benefits also include surgeon
ergonomics, where the surgeon remotely sits at
the console table, preventing undue fatigue, and
prolonged standing or bending during the proce-
dure. The da Vinci surgical system is multifunc-
tional. It can be used in different surgeries like
otolaryngologic surgery, neurosurgery, gyneco-
logical, cardio-thoracic, gastrointestinal, urologic,
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Nurse Caring: From Robotic Surgeries to Healthcare Robots 179
09_HumanCaring-D-18-00058_proof 2019/5/17 20:02 page 180 #3
orthopedic, and microsurgery (Shah, Vyas, & Vyas,
2014). One caveat to the da Vinci surgical system
is the operational cost. A single da Vinci Xi system
could cost more than 2 million US dollars in capital
outlay (Higgins, Frelich, Bosler, & Gould, 2017), a
fact that requires nurses to be careful in managing
the technology. An implication for future research
is its further utility is in telesurgery, whereby a sur-
geon can conduct surgery using the da Vinci surgi-
cal system from a distant place (and not just inside
the operating theater, but even in another city) and
monitor surgical progress on a computer screen.
This future possibility will add another layer of
implications for nursing.
Nurses
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Role in Robotics
Understandably
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, due to the technological com-
plexity of the operating theater environment, the
preparation and training of nurses who choose to
work in this specialty are also tailored for their dis-
tinctive role. Depending upon the level of expe-
rience and expertise and the positional hierarchy,
a nurse can be appointed as the operating the-
ater director, a nurse coordinator in robotics, scrub
nurse, and a circulating nurse. As a circulating
nurse, he or she prepares the instruments, changes
the instruments as needed by the surgeon, ensures
proper patient positioning, monitors the process,
and documents in the patients chart or electronic
medical record, inventories instruments and sup-
plies used, cleans the instruments, and maintains
a log of how many times they were used, as well
as to prepare for the next procedures. The scrub
nurse assists in the surgical procedure. In practi-
cal analysis, nurses may have brief interaction with
the patients, before going to the operating table
(preoperative), during the procedure (intraopera-
tive), and when the patient is wheeled to the post
anesthesia care unit (PACU) (postoperative). How-
ever, in this short encounter or nursing situation,
the nurse can integrate caring, continually striving
to create a healing environment, monitor patients
status, respond to machine beeping, administer
medications, and so on before the provider dis-
charges the patient home or to the community.
What
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does it take to work in surgical robotics?
It calls for high stake clinical knowledge appli-
cation. As a specialty area, a nurse in robotics
must at least demonstrate knowledge about
anatomy and physiology, pathophysiology, and
medicalsurgical nursing to work effectively with
other members of the surgical robotic team. Sev-
eral researchers (Lichosik et al., 2014; Raheem
et al., 2017) agreed that nurses should have a
thorough understanding about robotic proce-
dures, including how to trouble shoot during
robotic malfunctions to maintain a high standard
in the perioperative nursing and to ensure maxi-
mum patient safety. In addition, the expectations
are high for nurses to have critical thinking skills
and to be able to articulate the language of surgery
and interpret its meaning.
Kneebone
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(2013) mentioned that the operat-
ing theater can be overwhelming for a novice
staff, who happens to experience different sights
and sounds, from the patient being muted by
anesthesia to the sounds of machine beeping, of
alarms and the voices of surgeons and other col-
leagues muffled by surgical masks. Weldon and
colleagues (2013) recognized the role of nurses
in effective communication in the operating the-
ater, where they could anticipate the surgeons
needs or intepret whats going on. Being able to
speak up during count, and making sure every-
thing is accounted for before surgical closure adds
dimension to nurse caring. In addition, nurses are
expected to respond appropriately to stressful sur-
gical situations, such as emergency undocking of
the robotic system. In essence, working in the oper-
ating theater is not for the faint of heart. Nurses
can encounter technological stress that stems from
various surgical technologies and increased com-
plexity of the workload (Smith & Palesy, 2018).
In a focus group study of perioperative nurses,
four major themes were identified in the findings:
that nurses were constantly checking: on patients
safety and robot functions; for unexpected robot
machine errors; feelings of burden in a surgical
team; and the need for more education/informa-
tion (Kang, De Gagne, & Kang, 2016). However,
for some experienced nurses who transformed
themselves from novice to experts, the procedures
become second nature.
The
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Place of Healthcare Robots in Nursing
Robotic
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surgeries are not the only innovations that
are making waves in healthcare to date. Currently,
the use of healthcare robots or nursing robots
in countries like Japan, China, United Kingdom,
and other countries has gained public attention.
Humanoid robots, or those machines that resemble
human beings, also respond when talked to and
perform certain nursing tasks like giving health-
related instructions, administering medicines, and
turning or lifting a patient. Names are given
these machines or robots, for example, Pepper,Pdf_Folio:180
180 Suriaga
09_HumanCaring-D-18-00058_proof 2019/5/17 20:02 page 181 #4
QTrobots, Zorabots by Oz Robotics, ROBEAR (the
experimental nursing care robots).
These
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healthcare robots can provide compan-
ionship which helps older adults combat lone-
liness and depression. The aging population is
growing at an accelerated rate and according to
the Center for Disease Control and Prevention
(CDC), the number of adults 65 and older will
reach 71 million by 2030 (CDC, 2015). Although
the demands for healthcare services are outpac-
ing the supply, healthcare robots hold promise to
meet the demands of older adults in terms of com-
panionship and assistance with at least basic care
like transfer and personal hygiene. A study con-
ducted by Mann et al. (2015) revealed that people
have better response to robots than using a com-
puter tablets when it comes to healthcare instruc-
tions in promoting behavior. This is quite inter-
esting as an increasing number of older adults are
using technology, such as the use of smartphones
(80%) and having internet access (67%) (Andersen
& Perrin, 2017). The robotic revolution in Japan,
for instance, is catalyzed to meet the needs of
its aging population (Bremner, Reynolds, Ting, &
Kim, 2015). But how many of these tasks can be del-
egated to robots? Santonio de Sio and van Wyns-
berghe (2016) recommended a nature-of-activities
based approach to healthcare robot utility, a bal-
ancing decision on the nature of the human needs
versus the ethical implications of the activities.
In reflection, nurses need to be pragmatic in ask-
ing a question whether we are relinquishing a
care-oriented activity portion to the robots or the
practice-oriented role to them, thus: What is the
end goal of using healthcare robotsfor physical
assistance or companionship, or gradually replac-
ing a caregiver? Is it appropriate to call it then a
healthcare robot instead of nursing robot? I echo
the sentiment shared by some nurse leaders and
academicians present at the Anne Boykin Institute
2018 Summer Academy, held at Florida Atlantic
University in June 2018, about the language used
to call machine that performs some nursing tasks a
nursing robot. The issue is not a matter of language
or semantics, but calling it a nursing robot would
demean a profession which is deeply grounded in
caring science and research.
The
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place of healthcare robots in nursing is not
to replace nurses. They are designed to augment
the shortage of healthcare workers. Expansion of
the healthcare workforce is greatly needed to care
for the increasing older populations who may
not be able to take care of themselves physically,
like getting out of bed or transferring from one
surface to the other due to disabling condition or
infirmity. In Japan, for instance, healthcare robots
like Pepper, Paro, and Dinsow are utilized in the
long-term care homes to supplement the caregiv-
ing tasks like lifting a patient or even providing
entertainment. So, worrying that healthcare robots
may someday replace nurses should not stifle our
resolve to embrace technology. Let us clarify that
the role assigned to these humanoid robots is sup-
plementary, at least for now. The purpose of their
presence in the homes of older persons is perceived
to be relieving the burden or stress placed on care-
giving family members who may have no time to
care for the frail older adults who are either con-
fined in a wheelchair or is bedbound. It is no easy
task to lift another person who may weigh more
than the caregivers.
Caregiver
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burnout is a well-documented phe-
nomenon. In a study conducted by Kandelman,
Mazars, and Levy (2017), 44% of caregivers
burnout happened among nurse caregivers. Sim-
ilarly, a longitudinal study among Japanese care-
givers of frail older adults shed light on the
relationship between caregivers coping strategies
and burnout (Okabayashi et al., 2008). Caregivers
also needed a break from their caregiving job to
enhance their mental health and ability to care for
their older loved ones. Understandably, regardless
of cultural practice such as Japan, the family mem-
bers whom society expects to care for the aging
loved ones also need support. They are often too
busy with their own lives or they must earn a liv-
ing to support their growing family. Thus, having
healthcare robots take care of the physical tasks
of caregiving, like transferring a patient or pro-
viding robot-assisted activities or companionship,
makes more sense. In a more sophisticated technol-
ogy, some robots perform amazing tasks of storing
patients healthcare information in an e-cloud that
dramatically improves data retrieval and analysis.
Caring
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and Caregiving in the Context of Healthcare
Robots
However
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, caring is more than just caregiving.
Caring is a moral action (Barcaro, Mazzoleni, &
Virgili, 2018). With that said, nurses are morally
bound to care for patients who need nursing and
medical care. Caring also involves communicat-
ing with patients therapeutically and sensibly, rec-
ognizing nonverbal pain, and providing empathy,
which are considered innate human responses of
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caring human beings. In contrast, healthcare robots
today are void of moral and ethical choice. They
are programmed with algorithms to follow what-
ever tasks they are designed to do. On the other
hand, some robots are equipped with artificial
intelligence (AI) so that they can respond intel-
ligently when asked. But sensing hidden human
emotions or interpreting nursing implications in
nursing situations are yet seen in healthcare robots.
Are nurses ready to embed these unique human
attributes to a machine? Can humanoid or health-
care robots convey caring?
When
ID:p0150
the delegation from Japan headed by
Professor Tetsuya Tanioka talked about robotic
technology during the Anne Boykin Institute
Summer Academy, June 2018 at Florida Atlantic
University, one engineer/professor acknowledged
to nurse leaders and academicians present at the
conference that robotic engineers including AI sci-
entists need nurses to articulate what should be
embedded in a healthcare robot, and what lan-
guage of caring should be integral in its design
and development. This gesture acknowledged
the indispensable role of a professional nurse in
robotic technology. The expertise of a nurse is
undoubtedly useful in the design, programming,
and implementation phase of AI machines like the
healthcare robots. Nurses can give important feed-
back to engineers and work side by side with them
in designing a healthcare robot. In this process,
nurses can also learn from a humanoid robot. Yes,
a robot works tirelessly, does not complain, has no
drama and no call offs, and asks for no benefits;
nurses are not robots. As human nurses, we share
the compassion and commitment to care for others.
We are intelligent. We use critical thinking skills to
save lives. We learn from robots by appreciating
our humanness.
The
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Implications of Technology for the Practice and
Future of Nursing
The
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fast-changing technology embedded in health-
care is shaking up the way we deliver care. The
use of robotic surgery is becoming a household
name in surgical procedures. The age of big data
is upon us, so are AI and automated technol-
ogy. As more healthcare robots are introduced in
the market to fill the gap in caregiver shortage,
a healthcare professional may get lost in track-
ing these innovations. However, the practice of
nursing is guided by theories grounded in car-
ing. Locsin (2005) clarified our understanding of
the urgent need to be technologically competent as
an expression of caring in nursing. His theory of
Technological Competency as Caring in Nursing:
A Model for Practice was applicable then, and even
more now. The Transactive Relationship Theory of
Nursing (Tanioka, 2017) between human and intel-
ligent machine holds promise in our understand-
ing of the robotic technology.
In
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addition to healthcare robots and robotic
surgery, other forms of advanced technology are
becoming part of nursing practice. Nanorobotics
in healthcare can be another area for future
research where a super tiny device or nanorobots
(0.110 micrometers) are ingested in the body
and, once programmed, can autonomously circu-
late around the bloodstream to conduct repair,
infection surveillance, and even biopsy. Another
technological implication in nursing practice is
the utilization and analysis of big data. Nurses
generate voluminous patient medical informa-
tion when they document patients symptoms,
patients response to treatments, their pain, and so
on as they interact with their patients. Thus, nurses
are in a good position to analyze these data; they
need training, support, and funding to conduct
research that uses big data. By virtue that we care
for these data shows our concern; in the amount of
patient information may come the story of human
suffering and frailty, and yet the triumphs to sur-
vive and comfort one another is a unique trait
reserved for a caring human being.
As
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more technology is introduced and imple-
mented in the healthcare setting, our theoretical
underpinnings are focused on person as caring.
This makes more sense as the noble intention of
all these innovations is for the person, for his
health and well-being and quality of life. Nurs-
ing is blessed with theories on caring. For instance,
Boykin and Schoenhofer (2015) shed light on the
practical meaning of nursing as caring, that per-
sons are caring by virtue of our humanness. This
is a beautiful assumption: valuing the person, with
the capacity to nurture. We are fascinated by the
technological advancement in healthcare, and we
should be. It is a by-product of human ingenu-
ity and intelligence. We appreciate the humanoid
robots more so than plain, industrial robots that do
not look like humans. We are amazed when we see
robotic arms doing the supination and pronation
voluntary movements like human beings. When
we see Pepper talking and responding intelligently
when a person interviews it, we are mesmerized
by the idea that a thing we named robot can mimic
Pdf_Folio:182
182 Suriaga
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a human being. Talking and responding appropri-
ately is a natural function of being human. A robot
named Riba II can lift a person from bed to chair
and vice-versa. A human being can lift as well, but
because we do not want to hurt the back, we need
a machine to do it for us. We like it, especially if the
machine has sensors and it looks like us.
The
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list goes on. Philosophically speaking,
most of the inventions and innovations of science
and technology in healthcare and medicine are
designed to copy or mimic the functions of the
human body. The implications of technology in the
practice of nursing mean that nurses need to be
technologically competent. Nursing has provided
a holistic framework where nurses can be more
than technologically competent. In short, they can
be technologically competent and caring at the
same time.
Keeping
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abreast of what is going on in
healthcare innovations means that nurses care
about what is good for the patient and what is
not. Glauser (2017) stated that the more nurses
are involved in technology development and in
deciphering which of these technologies fit the
patients needs, the more the changing environ-
ment makes sense. However, as nurses strive
to adapt with technological innovations, sev-
eral things come to light: we need regulations
and standards of practice when it comes to
healthcarehealthcare robots and other technology
use in healthcare. There is a need for universal
terminologies or language and a code of ethics
concerning the appropriateness of robot-assisted
device or machine in healthcare setting. The poten-
tial liability that comes with robot utility needs
to be defined. Caring needs to be incorporated to
support implementationimplementation of robotic
elements so we dont have to question whether it
diminishes over time.
As
ID:p0180
new generations of nursing students are
entering the caring profession, and as new nurses
who are born in the digital age are joining the
workforce, it is amazing how they adapt and value
technology more than the generation of nurses
before them. In adapting technological innova-
tions, three words come to mind which I learned
when I attended the Global Educators Network
for Health Innovation Education conference in
Copenhagen last October 2018, sponsored by Har-
vard University in collaboration with Copenhagen
Business School, IESE, and EIT Health. These
three words are learning, doing, and becoming.
We learn about technology by understanding the
instructions, through in-service sessions and
repeated usage. We do use the machine to make
our work faster and better. What becomes of us
after learning and doing matters. Becoming a car-
ing nurse by learning and doing things efficiently
through technology is a positive outcome of inno-
vations. Embracing innovations and technology
means that we perceive things differently, either
we see its face value at hand, think of ways to
add to its functionality, reduce its complexity by
making it more user-friendly, or a combination of
all. Klein and Knight (2005) acknowledged that
we often adopted innovations but failed to imple-
ment them, as in the case of research results lost in
translation. Again, nurses are end users of inno-
vative products in healthcare. As such, nurses are
crucial in the make or break of innovation imple-
mentations, such as adapting humanoid robots in
healthcare setting. Nurses need to be at the discus-
sion table on healthcare innovations including any
technological project that involves patient care.
The
ID:p0185
crux of nursing is caring. As we get excited
for new invention and the new machines intro-
duced into the healthcare setting, one basic truth
remains: that nurses are here to give care. The
underpinnings of nursing grounded in caring are
illuminating our understanding that all these inno-
vations in healthcare are a product of a need-based
situation. Locsin (2017) explicitly demonstrated
this forward thinking when he stated that technol-
ogy and caring can coexist. In a nutshell, that is
true. So, the question of Caring Human Robots: Is it
Possible depends on how we phrase our answers.
Given a few more years, this question may sound
archaic; now this question stimulates crucial con-
sideration to ensure the continuing coexistence of
technology and caring in nursing.
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