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Engaging Robots as NursingPartners in Caring: Nursing asCaring Meets Care-Centered

Value-Sensitive Design

Savina O. Schoenhofer, PhD, RNNurse Consultant, Jackson, Mississippi

Aimee van Wynsberghe, PhDTechnical University of Delft, Delft, Netherlands

Anne Boykin, PhD, RNFlorida Atlantic University, Boca Raton, Florida

Abstract: Given

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global proliferation of healthcare robots in hospital and home settings,guidance for shared nurse–robot practice is essential if nurses are to be influential par-ticipants in the design, implementation, and evaluation of this new practice partnership.Van Wyneberghe’s Care-Centered, Value-Sensitive Design-approach, grounded in ethicaltheory and healthcare robotics, was identified as a likely fit with the grand nursing the-ory of Nursing as Caring. Following analysis of congruence and dissonance, a model fora new middle range theory was developed. The Dance of Living Caring has the potentialto maintain caring as nursing’s central value as robotic technology advances.

Keywords: Nursing

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as Caring; care-centered value-sensitive design; nurse–robot partners incaring; dance of living caring

It

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is increasingly recognized that the emergingtechnological advances in robotics will makehealthcare robots a viable option for a rangeof practices in the healthcare domain, practicessuch as surgery, delivery of resources, personalcare, and tele-presence and communication. Theseadvances will bring about significant changes inthe practice of nursing. Books about robots andnursing are beingwritten (e.g., see Tanioka, Osaka,Locsin, Yasuhara, & Ito, 2017; van Wynsberghe,2015), entire issues of prominent nursing journals

are focusing on this emerging reality (e.g., Journalof Nursing Scholarship, Asian and Pacific IslanderJournal of Nursing, Advances in Nursing Science) andseveral nursing and technology conferences havefocused on the topic of robots in healthcare as well(e.g., 2018 Summer Academy of the Anne BoykinInstitute for the Advancement of Caring in Nurs-ing; 2nd International Seminar and Workshop ofthe Rozzano Locsin Institute for Advancing theTheory of Technological Competency as Caringin Nursing; 2018 University of Leeds Faculty of

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International Journal for Human Caring, Volume 23, Number 2, 2019 © 2019 International Association for Human Caring 157http://dx.doi.org/10.20467/1091-5710.23.2.157

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Engineering Robotics in Healthcare). Theorists at theintersection of advanced robotic technology andcaring science for nursing and other human ser-vice disciplines have begun to address ethical andhuman rights issues of implementation (Barnard,2016; Borenstein & Pearson, 2010; Locsin &Ito, 2018; Locsin & Purnell, 2015; Sharkey &Sharkey, 2012; Sparrow & Sparrow, 2006; Val-lor, 2011). Even though robots of various types arebeing introduced into healthcare settings as carepartners, there is little in the literature to guidenurses in effective participation in design, imple-mentation, and evaluation of robots as partners incaring in nursing situations.

Purpose

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The

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purpose of this article is to explore theintersections of the values and assumptions under-pinning two frameworks, Boykin and Schoen-hofer’s (2001) Theory of Nursing as Caring (NAC)and van Wynsberghe’s (2015) Care-CenteredValue-Sensitive Design (CCVSD); to illuminateareas of convergence and divergence in theseframeworks; and to model a middle range theorythat reconciles divergences, maximizes conver-gence, and provides specific guidance to nurses innursing situations with robotic practice partners.In recognition of the lack of consensus about theclassification andmeaning of “robot” in this evolv-ing field, it is beyond the scope of this article toassert a universal definition of healthcare robots.We proceed from the notion that a healthcare robotis “other than fully human,” for example, an intel-ligent machine, a robot, humanoid, or somethingin between or beyond. We posit the followingassumption regarding the entity addressed inthis work: the robotic partner would be expectedto participate usefully/effectively in recognizingcalls for caring and responding with ways of car-ing that are appropriate to the situation, such thatthe one cared for experiences a sense of beingcared for, not merely attended to, but cared for asone who is known and who matters.

While

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robotics design is recognized as a multi-disciplinary practice, rarely are all the relevantstakeholders present at the design table. In someinstances, patients’ opinions are sought for usabil-ity issues, as in the case with many rehabilitationrobots. Surgical care providers were surveyed byVan Koughnett et al. (2009) in a study of surgeons’assessment of advantages of a robotic approach

to laparoscopy. However, to date there are fewacademic articles that seek the opinions of nursesto feed into requirements for design and imple-mentation. Given that nurses will often be thepredominant users of healthcare robots (vanWynsberghe, 2015), it is necessary to seek theirknowledge and expertise in the design and imple-mentation process to help assure the addition ofa practice partner capable of enhancing caring innursing situations. To do this effectively, new the-oretical models for nursing are needed.

Approach

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to a Middle Range Theory Grounded inCaring

Coherent

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systems and protocols to guide nursingpractice are best grounded in general nursing the-oretical frameworks, supported by middle rangetheories and models. Middle range theories, mod-els, and practical protocols need to be value-congruent with the broad nursing theoreticalframeworks that guide the practice of nursingin institutions and by individuals and groups ofnurses. It is our intention in this article to pro-pose a middle range theory that integrates NAC(Boykin & Schoenhofer, 2001) and CCVSD (vanWynsberghe, 2016, 2015). The aim is to develop atheory to help nursing professionals at all levelsreimagine and clarify their own role andpractice asnurse-in-partnership with a healthcare robot. Thefocus of this article is not on modifying CCVSD,nor on changing NAC, but in selecting conceptsand relationships from CCVSD that are congru-ent with the foundations of NAC, relevant tohealthcare robots. The intent here is not to cri-tique CCVSD per se, but to analyze it for “fit” withthe broader nursing perspective of NAC. Ideas/concepts from the CCVSD framework that areaddressed under divergences will be reframed inorder to be fully compatible with the values andassumptions of NAC.

The

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Theory of NAC

Boykin

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and Schoenhofer’s (2001) NAC is an extantgrand nursing theory in use globally today. It isbased on several assumptions, the most centralbeing that persons are caring by virtue of theirhumanness (p. 11), or as Roach (2002) declared,“caring is the human mode of being” (p. 3). Fur-ther, their understanding of caring was informedby Mayeroff’s (1971) assertion that caring is help-ing others grow and actualize themselves, helping

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them live themeaning of their own lives. The focusof the discipline and practice of nursing, from theperspective of the theory of NAC, is this: nursingis nurturing persons living caring and growing incaring. Each person is recognized as caring andthe nurse lives a commitment to knowing the onenursed as caring and responding to calls for caring.Nursing is practiced in the relationship of the nurs-ing situation, the shared lived experience of caringbetween nurse and nursed that enhances person-hood, that is, living grounded in caring (Boykin &Schoenhofer, 2001). Nurses enter the world of thenursed with the intention of knowing the personas caring, hearing calls for caring and creating car-ing responses specific to the situation (Boykin &Schoenhofer, 2001).

Care

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-Centered Value-Sensitive Design

Van

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Wynsberghe’s (2016, 2015) CCVSD approachis an intentional response to the design, develop-ment, and implementation of robots in healthcare.These robotsmay be used to aid a variety of health-care practitioners (e.g., surgical robots to assist thesurgeon, delivery robots to assist the pharmacist ornurse, etc.); they come in a variety of shapes andsizes (humanoid, creature-like, instrumental-like,etc.) and may have a variety of capabilities (e.g.,level of robot autonomy, mobility, sensing, natu-ral language processing, facial recognition, etc.).Given the number of robotic options, a frameworkfor their evaluation must be broad enough to cap-ture these differences in a meaningful way.

The

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CCVSD (van Wynsberghe, 2016, 2015)approach consists of an ethical framework andmethodology for the design, implementation, andevaluation of healthcare robots. The frameworkconsists of specific elements or points of refer-ence, taken from a care ethics perspective, to beused in the evaluation of: the practice for whicha robot could be used (e.g., bathing, feeding, lift-ing, etc.); the context in which the robot will beused (e.g., a nursing home, hospital, home setting,etc.); the type of robot intended to be designed orused (e.g., its capabilities, appearance, etc.); and,the care values (also referred to as the moral ele-ments) of a care practice according to care ethicistTronto (1993, 2010). These care values/moral ele-ments were posited as necessary for the provisionof good care and may be considered values thatform the buttress for the evaluation of a care prac-tice as either good or bad.

The

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methods for using the CCVSD frame-work in a retrospective manner consist of making

descriptions of all the aforementioned elementsand ultimately making a comparison between acare practice before the robot has been introducedand after the robot has been introduced. The evalu-ations are meant to act as a guide to designers andare thus intended to be used in an iterative fashion;designers go back and forth tweaking the robotprototype (and/or approach to implementation)until an acceptable design can be chosen, one thatpromotes the manifestation of the care values. Themethods for using the framework in a prospectivemanner beginwith defining the problem for whicha robot may be designed and brainstorming robotprototypes for a robot that could be nested withinan existing care practice. This iterative process ismeant to evaluate multiple prototypes accordingto the care values until an ideal solution is reached,that is, one that promotes the care values alongwith attention for the care receiver and care giverrelationship.

Values

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The

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values explicit and implicit in NAC maybest be illustrated in the Dance of Caring Per-sons (Boykin & Schoenhofer, 2001). The Dance ofCaring Persons, a person-centered, caring focused“model for being in relationship” (2001, p. 36) isa visual representation of the fundamental beliefsregarding the meaning of persons and valuesinherent in the theory of NAC (Figure 1).

Pross

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, Hilton, Boykin, and Thomas (2011)describe the Dance of Caring Persons as a “rela-tional model that supports a way of being withothers that respects and explicitly values eachperson” (p. 27). The personal knowing of self andcommitment to recognizing other as caring per-son fosters the connectedness of persons and thenature of relating in the Dance of Caring Persons(Purnell, 2017).

Values

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inherent in the Dance of Caring Personsreflect assumptions underlying the theory ofNAC:

• All

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persons are caring, worthy of respect andhave a worthwhile contribution to make tothe enterprise;

• Caring

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is a process that develops over timeand is enhanced in relationship with caringothers;

• Caring

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involves the capacity to recognizeand respond to that which matters; personsare whole in the moment while simultane-ously growing in wholeness or completeness

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Figure 1. Dance

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of caring persons.

Source: Boykin, A., & Schoenhofer, S. O. (2001).Nursing as caring: A model for transforming practice (p. 37). Sudbury, MA: Jonesand Bartlett.

as caring person. (Boykin, Schoenhofer, &Valentine, 2014)

In

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short, the Dance of Caring Persons is arelational model grounded in values of caring that“expresses the dynamic, fluid, multi-dimensional,multi-directional nature of human relationshipsand human systems” (p. 35).

In

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the CCVSD approach, care is not one valuebut rather a cluster of values that manifest them-selves throughout the practice of care. The carevalues are instrumental insofar as their manifes-tation results in the promotion of the dignity ofthose being cared for. From the perspective ofCCVSD, the care practice is essentially a responseto the needs of another, thus needs mark the start-ing point for care to begin. The values used forthe CCVSD approach are taken from the formula-tion of a care practice according to political scien-tist and care ethicist Joan Tronto (1993, 2010), andare: attentiveness, responsibility, competence, andreciprocity. Tronto outlines a care practice in fourstages and each has a corresponding moral ele-ment. These moral elements are intended to act asthe background against which the stage of the carepractice can be evaluated. Attentiveness refers tobeing aware of a patient’s needs while responsibil-ity concerns the moral agency necessary for bear-ing liability when things go wrong. Competencerefers to providing care well and is often linkedwith the resources available to provide care. Reci-procity concerns the need to monitor the changein the care receiver and to incorporate preferencesand intuitions of the person being cared for intothe care process. This is also grounded on the beliefof patients as individual beings with a life history

and story and that their care is to be unique andparticularized just as persons are.

These

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values, and their realization through carepractices, are significant for multiple reasons:

• They

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center on the relational nature of care,that care giving and care receiving happen asa manifestation of caring for another and/orreceiving care from another. In other words,caring is never a process that happens tosomeone; rather, it is a process that happenswith someone.

• They

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encourage the combination of caringabout and caring for patients; the dispositionand the action are inextricably linked.

• They

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are intended to lift the patient froma traditionally passive role into an activerole in which their responses and feelingsmust be included (through the element ofreciprocity).

Value

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Convergence

Based

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on the above discussions, broad value con-vergence between NAC and CCVSD can be iden-tified. These convergences are shown in Table 1.

Uncovering

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value convergences between thetwo approaches reveals multiple areas of con-fluence. In particular, each of these frameworksaddress the importance of being intentionally andauthentically present with those cared for in orderto know others as caring and hear calls for car-ing (Boykin & Schoenhofer, 2001) or recognizeneeds and engage in appropriate care practices(van Wynsberghe, 2013, 2015). From this starting

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TABLE 1. Value Convergence Between NAC and CCVSD

NAC CCVSD

Knowing

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persons as caring Caring in nursing isintentional;

Attentiveness

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—coming to know;Responsibility—commitment to meeting needs

Caring

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is a process; Persons living caring momentto moment; Direct invitation to share that whichmatters in the moment

Responsiveness

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—engaging with care receiver; Carevalues are expressed between nurse (care giver)and nursed (care receiver)

Caring

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is enhanced in relationship with caringothers; Caring is living in the context of relationalresponsibilities

Reciprocity

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—good care requires activeparticipation of the cared for; Ontological status ofhumans is relational

Note. CCVSD = Care-Centered Value-Sensitive Design; NAC = Nursing as Caring.

point, there are clearmoments of value congruenceand even convergence. In each approach, there isthe recognition of the uniqueness of persons to becared for and the resolve that individualized careis an essential expression of the dignity of a per-son. It is in the reciprocal nature of caring that car-ing happens between persons, not merely to per-sons. The engagement of nurse and one nursed asdescribed by van Wynsberghe’s definition of reci-procity is similar to Boykin and Schoenhofer’s con-cepts of “caring between” and “living caring andgrowing in caring.” This intentional engagementwith the other in a care practice (van Wynsberghe)allows the nurse to recognize the dynamic natureof calls for caring and caring responses in the con-text of nursing situations (Boykin & Schoenhofer,2001).

Areas

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of Divergence

To

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model a middle range theory that draws onCCVSD and that is congruent with NAC, it is nec-essary to first account for, and resolve any valuetensions or areas of divergence found between thetwo approaches. Examining areas of value diver-gence is not intended to emphasize dichotomies asmuch as to gain a richer meaning and understand-ing of each of the perspectives and their formula-tions and use. In the following sections we identifythree broad areas and propose the means to recon-cile these divergences and find common ground.

Care

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versus Caring. The initial divergence tobe recognized and reconciled is in the conceptsof “care” (found in van Wynsberghe’s work, 2013,2015) and “caring” (cf. Boykin & Schoenhofer,2001). Volumes have been written comparing, con-trasting, and equating these two terms and werefer the reader to concept analyses of the termsby scholars such as Leininger (1988), Morse,

Solberg, Neander, Bottorff, and Johnson (1990),and Finfgeld-Connett (2008) in nursing, Tronto(1993) in political science, and Reich (1995) inbioethics.

Boykin

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and Schoenhofer (2001) address car-ing in a general sense and caring in nursing ina specific sense. In addressing caring qua caring,they draw major understandings from Mayeroff(1971), “caring is helping another grow” (p. 1), andRoach (2002), “caring is the humanmode of being”(p. 3). More specifically, caring in nursing isdescribed as “the intentional and authentic pres-ence of the nurse with another who is recognizedas person living caring and growing in caring”(p. 13). The Dance of Caring Persons model explic-itly values all persons involved in the context ofnursing situations.

In

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contrast, van Wynsberghe’s (2013, 2015)point of departure is institutional care practices;linked care activities that “bring together both car-ing actions with caring dispositions” (p. 22). Thus,care is a series of activities carried out with acertain intention and the focus is on the activ-ities, their manifestation, and evaluation, ratherthan on an actor, that is, a description of thenurse in his/her role. The nurse is caring insofaras he/she is engaged in a care practice and canmeet the needs of the care receiver competentlythrough a care practice. While it is assumed thatcare givers are valued, their value is crystalizedin the form of how they provide (good) care. Thisis to avoid instances in which care givers are val-ued strictly for their presence when in fact theyare not engaged in any concrete actions to helpthose in need or as is sometimes the case they arepresent but are abusive or negligent to the carereceiver. To be sure, this is not to say that nurses aspersons are only valued insofar as they performtheir role as care giver; rather, to say that nurses

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in their role as care giver are valued specificallyin terms of their role in the provision of good care.This divergence is interesting when we considerthe role a robot will take on in care and/or caring.For van Wynsberghe, the robot becomes nestedwithin a care practice and can perform care insofaras it is an actor engaged in the activity. Thus, therobot is evaluated as an actor in care insofar as itcan contribute to the provision of good care ratherthan for its presence as a care giver in the care prac-tice. In NAC, the possibility exists that robots mayenhance caring in nursing situations; for example,through companionable presence, by helping todetermine that which matters in the moment, bycompetently responding to a call for caring andso on.

Context

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is another aspect of the divergentunderstandings of care and caring in the twoapproaches. In the CCVSD approach, the context iscare practices, while for NAC, the context is nurs-ing situations. These two contexts differ in that thecare practice is a general description of two actorsworking together to meet needs whereas nursingsituations are shared lived experiences in whichthe caring between nurse or robot as partner-in-caring and one nursed supports living caring andgrowing in caring.

Van

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Wynsberghe (2015) describes the connec-tion between care and care practices, with careas a concept, and care practice as contextualizedcare. The idea of care practice allows for the “mar-riage between action and disposition” (p. 27) andis defined as “the attitudes, actions and interac-tions between actors (human and non-human) ina care context that manifests care values: a carepractice facilitates the realization of care values”(p. 27). In the CCVSD approach, reiterating andemphasizing the broad notion of care practices isintended to show the prevalence and pervasive-ness of care; further, all technologies, such as anyversion of machine AI including robots, would benested within care practices.

NAC

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is a theory of and for nursing, and thecontext is the nursing situation, characterized asthe “shared lived experience in which the caringbetween nurse and nursed enhances personhood”(Boykin & Schoenhofer, 2001, p. 13). Within thenursing situation, the nurse enters the world of theone nursed in order to know the person as livingcaring in unique ways and expressing aspirationsfor growing in caring. The call for caring is heardwithin the nursing situation, a call to understandthat which matters. The nursing situation is also

the context for creating caring responses to calls forcaring, responses that nurture personhood.

The

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authors, in dialogic process, propose thatthis apparent divergence between caring and carebe reconciled by placing a greater emphasis oncaring, with explicit attention to moments forco-presence and mutuality. Thus, the robotic part-ner in nursing must also be evaluated in termsof its impact on the ability to encourage co-presence and mutuality. Further investigationswill be required to determine the extent to whicha robot can fulfill elements of co-presence andmutuality.

Need

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versus Call. The second area of diver-gence between NAC and CCVSD that requiresattention is the need for care as described byvan Wynsberghe (2015) versus the call for caringas described by Boykin and Schoenhofer (2001).More specifically, the critique these authors wantto draw attention to is the formulation of “call”as a more egalitarian way to frame the startingpoint while “need” suggests something of a sup-plicant to savior relationship essentially reinforc-ing the asymmetry in power between care giverand care receiver. Gadow (1984) counters what shecalls the philanthropic paradigm with the empa-thetic paradigm, in which intersubjectivity is posi-tioned at the center of the caring relationship.The empathic paradigm bridges or transcends thedual isolation of autonomy on one hand and thesubject–object isolation on the other with theconcept of intersubjectivity.

From

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the perspective of CCVSD, vulnerabilityis associated with the existential state of “being inneed of care,” as discussed by care ethicist Verk-erk (2001). This occurs only when the autonomousindividual, understood as the individual capableof making decisions isolated from relationships orresponsibilities to others, is put on a pedestal andassumed to carry on throughout life without theneed for help from others. In short, to be in needis to be vulnerable, and when one person in a rela-tionship is ascribed the status of needy, asymmetryis unavoidable and mutuality is difficult to main-tain. This asymmetry allows for the prevalenceof paternalistic forms of care and distances carereceivers from active participation in their owncare. But CCVSD, in it commitment to care ethics,aims to distance ”being in need” from ”beingvulnerable.”

In

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Tronto’s (2013) later work, she discussesthe concept of “democratic care” and articulates adefining feature of this, the starting point, being a

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recognition of the equal status of needs amongst allcitizens. This is not to say that all people have thesame or even similar needs, “but it is to say thatmeeting needs is a feature of the life of each andevery human, and that each of us is thus engagedin caring from the standpoint of the recipient ofcare” (p. 29). Thus, humans are all in need at var-ious moments throughout our lives to differentdegrees and wemust therefore rid ourselves of theshame of vulnerability.

V

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an Wynsberghe’s (2015, 2016) articulation ofthe CCVSD approach begins from and promotesthe perspective of care ethics, in fact the frameworkismeant to act as the starting point fromwhich onecan draw attention to the moral issues and/or ten-sions through the lens of care ethics. Thus, the useof the term and concept “needs” in combinationwith the broad conception of care as practices (asdiscussed above) carries with it the connotation ofVerkerk (2001) and Tronto (1993) and insists thatalthough the term ‘need’ is used it is not meantto inspire notions of vulnerability but rather toinsist on the omnipresence of needs.Moreover, it ismeant to illustrate that good care must be directedat a certain and specific end. This is to ensure thatthere is a way to evaluate the final care measuresbut also to ensure that care providers are not pro-viding care for which no need can be found.

From

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the perspective of NAC, persons areviewed as whole or complete in the moment. Theintent of this belief is that persons are alwayswhole and to encounter personmeans to encounterwholeness. There is no segmenting of person caredfor into parts. There is no deficit, no brokenness,no insufficiencies to be “fixed.” From the perspec-tive of NAC, the idea of need is rejected as itimplies that there is something lacking in the per-son that require fixing or fulfilling by the nurse,thus, a diagnosis and treatment approach. Rather,from the perspective of NAC, the nurse whenengaged in a nursing situation is focused on inten-tionally knowing other as caring person, hearingthe call for nursing and offering a caring responseto that which matters most in the moment. “Callsfor nursing are calls for nurturance” (Boykin &Schoenhofer, 2001, p. 14). The nurse responds withpersonal expressions of caring appropriate to thenursing situation.

Institutional

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Privilege versus Dance of CaringPersons. The last area where one can find diver-gence that calls for resolution is the privilegedposition given to the institution as a determinerof value priorities in the CCVSD approach versus

the Dance of Caring Persons approach in NAC.The CCVSD approach was created in the contextof guiding the design, introduction, and evaluationof robotic entities for healthcare institutions. NACwas created in the context of a general theory of thediscipline and practice of the profession of nurs-ing. Although it is beyond the scope and purposeof this article to delve into the significant bodyof literature addressing conflictual relationships atthe intersection of bureaucratic institutional valuesand professional values, those troublesome con-flicts speak to this particular area of divergence orincongruence between the two frameworks.

The

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CCVSD approach is situated in the valuepriority complex appropriate to its intent to bea “user manual” for institutional care practices.Thus, the role that the approach gives to theinstitution as determiner of value priorities forthe design and use of advanced healthcare tech-nologies including intelligent machines is notsurprising, and in fact, understandable. For exam-ple, in discussing needs as the starting point ofthe care practice, van Wynsberghe (2015) assertsthat “the needs of the institution and the needsof the care providers must come first” (p. 79).This unequivocal privileging of institution andhealthcare workers is explained in the sense thathealthcare workers and institutions must have theresources needed to meet the needs of the patients.Further,

While

ID:p0290

this may seem paternalistic at firstglance, the entire aimof theCCVSDapproach isto shape the care robot according to the valuesof the institution, an in-depth understand-ing of the practice and context of use and acommitment to the care ethics tradition. (vanWynsberghe, 2015, p. 84)

Institutional

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efficiency is “a top value in thehealthcare tradition” (p. 95), and the “needs of thecare practice (and ultimately the care-giver) mustbe placed at the fore to ensure that system of theinstitution efficiently as well as in accordance withthe values of the institution” (p. 95).

In

ID:p0300

the spirit of the Dance of Caring Persons,van Wynsberghe’s presentation of the CCVSDapproach contains numerous statements that rec-ognize the importance of input from all thoseinvolved in a care practice—the institution, thecare providers and the patient. A middle rangetheory to guide professional nursing practice nec-essarily must be grounded in a priority complex

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congruent with the values of nursing. Therefore,efficiency must be balanced as a value along witheffective caring—a focus on hearing calls for car-ing and respondingwith expressions of caring thatrespond directly to that which matters to the onebeing cared for. From the perspective of NAC,efficiency can certainly be an aspect of the valuecomplex, though not a first tier value.

Toward

ID:ti0055

a Middle Range Theory for IntegratingRobotic Partners in Nurse Caring

A

ID:p0305

middle range theory grounded in the valuesand concepts of NAC is sought that has promisefor guiding the integration of robots as partnersin caring in nursing situations. van Wynsberghe’sCCVSD approach offers concepts and structurethat contribute to that promise.

The

ID:p0310

Dance of Living Caring (Figure 2) is pre-sented as a model that brings key elements of theCCVSD approach together with NAC theory ina way that enriches a purposeful middle rangetheory of nursing practice with robots. In recogni-tion of the prospect of robots as partners in caringin the practice of nursing, the language of TheDance of Caring Persons has been modified. Theterm, Dance of Living Caring, reflects a key ele-ment of the focus of nursing from the perspectiveof NAC: nursing is nurturing persons living car-ing and growing in caring. (In this modification,the idea of “growing in caring” is not intendedto be minimized as an important element of thefocus of nursing but is subsumed in the concept of“living caring,” understood as an aspect of what itmeans to “live caring”). The Dance of Living Car-ing looks to the future, expanding the potential formeaningful contributors to the nursing partner-ship, entertaining the possibility that those futurepartners in caring may be robots, androids, andeven humanoids (Locsin et al., 2018).

In

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Figure 3 we have provided a more detailedaccount of the relationship between the twoapproaches (NAC and CCVSD) to arrive at themiddle range theory, connecting the key points ofresonance between NAC and CCVSD.

The

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Dance of Living Caring, intended tosuggest the key concepts and their structuralinterrelationships, reflects the Dance of CaringPersons and its foundational general theory ofNAC (Boykin & Schoenhofer, 2001), as influencedby van Wynsberghe’s (2015) CCVSD approach todesigning, implementing, and evaluating carerobots. The envisioned goal of this collaborative

work is a middle range theory to guide selectionand implementation of robots as partners in car-ing in nursing situations. The Dance of LivingCaring locates decisions about whether and howto introduce robots into healthcare situations in“the dance” rather than privileging any one stake-holder, an egalitarian ethic that is central to TheDance of Caring Persons and frequently echoed inthe CCVSD approach as well.

The

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second concept in the model, respect-ing and valuing persons as caring, directlyechoes the CCVSD approach concept of “com-mitment to reciprocal engaging” and to NAC’s“caring is relational.” The Dance of Caring Per-sons, of which this new model is an adaptation,is described as a relational model. The “caringbetween” is a central concept in the NAC theory,and is the relation that makes nursing possible. Toreiterate, the focus of nursing, as stated in NAC,is “nurturing persons living caring and grow-ing in caring” (Boykin & Schoenhofer, 2001, p.11). Further, the nurse is said to “enter into theworld of the other in order to know the otheras caring and to affirm, support—to ensure thatcare happens with them rather than to them—and to ensure that this role is valued in the veryevaluation of good care. By emphasizing theresponsiveness of care receivers the aim is alsoto encourage the focus of care givers not on theirown preconceptions of what ought to be donebut on engaging with the care receiver to identifyand reflect together. In this way, the relationshipbetween care giver and care receiver is made cen-tral and the process of care is strengthened ratherthan reducing care to a set of isolated or unconnected tasks.

Hearing

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and responding to calls for caring isthe third concept in the model. In NAC, this iswhat nurses “do.”Nursing is about caring—caringin ways that matter to the one nursed. A middlerange theory grounded in NAC, intended to guidenursing situations involving robots as partners innurse caring, would necessarily address hearingand responding to calls for caring. We have shownthat the concept of “needs” as traditionally con-ceptualized is not congruent with NAC and it isnot necessary to a model of a middle range the-ory for nursing based on the Dance of Living Car-ing. Given the purpose of this evolving model,the concept of “calls for caring” offers guidanceabout function to designers of robots, and also pro-vides institutional guidance for implementation ofrobots as care partners.

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Figure 2. Dance

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of living caring.

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Engaging Robots as Nursing Partners in Caring 165

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166 Schoenhofer et al.

NACPerson as caring

Caring is relational

Responding to that whichmatters

Dance of Living Caring Intentional knowing ofpersons as caring

Respecting and valuingpersons as caring

Hearing and responding tocalls for caring

CCVSDComing to know

Commitment to reciprocalengaging

Meaningful response toneeds

Figure 3. The dance of living caring.

Conclusion

We set out to propose a model that could lead tothe development of amiddle range theory to guidethe engagement of robots as partners in caring innursing situations. The model presented is anintegration of NAC and CCSVD, based on areas ofconvergence, with areas of divergence resolved.Further developmental work will include spellingout a middle range theory based on the Danceof Living Caring model, and testing the theoryusing various modes of inquiry, including philo-sophical analysis, research, and pilot-testing. Themodel itself should be disseminated to nurs-ing and healthcare policy groups in an effort toinfluence the adoption of caring and care val-ues as central elements in standard-setting forthe engagement of care robots in nursing andhealthcare. The model could also be an importantaspect of curriculum design addressing the useof advanced technology in nursing. While it isbeyond the scope of this article to offer specificguidance for nursing practice with robots as part-ners in caring, we believe it is important to lay thegroundwork for a middle range theory that canguide future nursing practice involving robots aspartners.

In conclusion, robots are being introduced intonursing environments and it is imperative thatnursing professionals have the tools to insure thatthe participation of robots in nursing situationsbe explicitly grounded in the central service ofnursing—caring.

References

Barnard, A. (2016). Radical nursing and the emergence of tech-nique as healthcare technology. Nursing Philosophy, 17,8–18. doi:10.1111/nup.12103

Borenstein, J., & Pearson, Y. (2010). Robot caregivers: Har-bingers of expanded freedom for all? Ethics and InformationTechnology, 12(3), 277–288. doi:10.1007/s10676-010-9236-4

Boykin, A., & Schoenhofer, S. O. (2001). Nursing as caring: Amodel for transforming practice. Sudbury, MA: Jones andBartlett.

Boykin, A., Schoenhofer, S., & Valentine, K. (2014). Healthcare system transformation for nursing and health care leaders:Implementing a culture of caring. New York, NY: SpringerPublishing.

Fingeld-Connett, D. (2008). Concept synthesis of the artof nursing. Journal of Advanced Nursing, 62(3), 381–388.doi:10.1111/j.1365-2648.2008.04601.x

Gadow, S. (1984). Technology and touch: Two paradigms ofpatient care. Journal of Religion and Health, 23(1), 63–69.doi:10.1007/BF00999900

Leininger, M. (1988). Leininger’s theory of nursing: Culturalcare diversity and universality. Nursing Science Quarterly,1(4), 152–160. doi:10.1177/089431848800100408

Locsin, R. C., & Ito, H. (2018). Can humanoid nurse robotsreplace human nurses? Journal of Nursing, 5(1), 1–6.doi:10.7243/2056-9157-5-1. Retrieved from http://www.hoajonline.com/nursing/2056-9157/5/1

Locsin, R. C., Ito, H., Tanioka, T., Yasuhara, Y., Osaka, K.,& Schoenhofer, S. O. (2018). Humanoid nurse robotsas caring entities: A revolutionary probability? Inter-national Journal of Studies in Nursing, 3, 146–154.doi:10.20849/ijsn.v3i2.456

Locsin, R. C., & Purnell, M. (2015). Advancing the theory oftechnological competence as caring in nursing: The univer-sal technological domain. International Journal for HumanCaring, 19(2), 50–54. doi:10.20467/1091-5710-19.2.50

Mayeroff, M. (1971). On caring. New York, NY: Harper & Row.Morse, J., Solberg, S., Neander, W., Bottorff, J., & Johnson,

J. (1990). Concepts of caring and caring as a concept.Advances in Nursing Science, 13(1), 1–14.

Pross, E., Hilton, N., Boykin, A., & Thomas, C. (2011). The“Dance of caring persons.” Nursing Management, 42(10),25–30. doi:10.1097/01.NUMA.0000405223.39798.e1

Purnell, M. J. (2017). Anne Boykin and Savina O. Schoenhofer:The theory of nursing as caring: A model for transformingpractice. In M. R. Alligood (Ed.), Nursing theorists and theirwork (9th ed., pp. 293–308). St. Louis, MO: Elsevier.

Reich, W. J. (1995). History of the notion of care. In W. T.Reich (Ed.), Encyclopedia of bioethics (pp. 219–331). NewYork, NY/London, England: Macmillan, Simon & Schus-ter, Prentice-Hall International.

“07_HumanCaring-D-18-00054_proof” — 2019/5/17 — 16:13 — page 167 — #11

Pdf_Folio:167

Engaging Robots as Nursing Partners in Caring 167

Roach, S. (2002). Caring, the human mode of being: A blueprint forthe health professions (2nd Rev. ed.). Ottawa, Canada: Cana-dian Hospital Association Press.

Sharkey, A., & Sharkey, N. (2012). Granny and the robots: Ethi-cal issues in robot care for the elderly. Ethics and InformationTechnology, 14(27), 27–40. doi:10.1007/s10676-010-9234-6

Sparrow, R., & Sparrow, L. (2006). In the hands of machines?The future of aged care. Mind and Machine, 16, 141–161.doi:10.1007/s11023-006-9030-6

Tanioka, T., Osaka, K., Locsin, R., Yasuhara, Y., & Ito, H.(2017). Recommended design and direction of develop-ment for humanoid nursing robots: Perspective fromnursing researchers. Intelligent Control and Automation, 8,96–110. doi:10.4236/ica.2017.82008

Tronto, J. (1993).Moral boundaries: A political argument for an ethicof care. New York, NY: Routledge.

Tronto, J. C. (2010). Creating caring institutions: Politics, plu-rality, and purpose. Ethics and Social Welfare, 4(2), 158–171.doi:10.1080/17496535.2010.484259

Tronto, J. C. (2013). Caring democracy; Markets, equality, and jus-tice. New York, NY: New York University Press.

Vallor, S. (2011). Carebots and caregivers: Sustaining the ethicalideal of care in the twenty-first century. Philosophy & Tech-nology, 24(3), 251. doi:10.1007/s13347-011-0015-x

Van Koughnett, J. A., Jayaraman, S., Eagleson, R., Quan, D.,van Wynsberghe, A., & Schlachta, C. M. (2009). Are there

advantages to robotic-assisted surgery over laparoscopyfrom the surgeon’s perspective? Journal of Robotic Surgery,3(2), 79–82. doi:10.1007/s11701-009-0144-8

van Wynsberghe, A. (2013). Designing robots for care: Carecentered value-sensitive design. Science and EngineeringEthics, 19(2), 407–433. doi: 10.1007/s11948-011-9343-6

van Wynsberghe, A. (2015). Healthcare robots: Ethics, design andimplementation. Burlington, VT: Ashgate Publishing.

van Wynsberghe, A. (2016). Service robots, care ethics, anddesign. Ethics and Information Technology, 18, 311–321.doi:10.1007/s10676-016-9409-x

Verkerk, M. (2001). The care perspective and auton-omy. Medicine, Health Care and Philosophy, 4, 289–294.doi:10.1023/A:1012048907443

Disclosure

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. The authors have no relevant financial inter-est or affiliations with any commercial interests related tothe subjects discussed within this article. This research issupported by the Netherlands Organization for ScientificResearch (NWO), project number 275-20-054.

Correspondence

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regarding this article should be directedto Savina O. Schoenhofer, PhD, Florida Atlantic University,Jackson, MS. E-mail: savibus@gmail.com