Healthcare Informatics Research and Innovation

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Nurse Caring: From Robotic Surgeries to Healthcare Robots

Armiel Suriaga, MSN, RN Florida Atlantic University, Boca Raton, Florida

Abstract: The

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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 patient’s 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 today’s technologically advanced healthcare environment, and as Locsin (2005, 2017) has estab- lished, is an expression of caring in nursing. Healthcare Informatics Research and Innovation

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

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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

 

 

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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 today’s technologically driven healthcare system grounded in caring. It commences with the impli- cations of technology in the current and future practice of nursing. Healthcare Informatics Research and Innovation

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 today’s 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 surgeon’s 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 five million 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 patient’s 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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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. Healthcare Informatics Research and Innovation

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 patient’s 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. Healthcare Informatics Research and Innovation

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 medical–surgical 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 surgeon’s needs or intepret what’s 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 patient’s 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. Healthcare Informatics Research and Innovation

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

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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 robots—for 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. Healthcare Informatics Research and Innovation

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. Healthcare Informatics Research and Innovation

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

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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. Healthcare Informatics Research and Innovation

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 (0.1–10 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. Healthcare Informatics Research and Innovation

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

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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 patient’s 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 don’t have to question whether it diminishes over time. Healthcare Informatics Research and Innovation

As

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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. Healthcare Informatics Research and Innovation

The

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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. Healthcare Informatics Research and Innovation

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Disclosure

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. The author has no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

Acknowledgments

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. The use of robotic technology in healthcare setting has created a specialty area for nurs- ing practice. While other people are concerned about the potential replacement of human labor by robots, these artificially intelligent robots doing certain surgi- cal and nursing tasks are designed to enhance efficient patient care delivery. This article is intended for nurses and other healthcare professionals who are interested in robotics, or who want to keep abreast of what is going on in today’s healthcare environment. Its purpo- sive goal is to clarify the crucial roles of a professional nurse, particularly in robotic surgeries and in healthcare robots. It highlights the integral role of caring as the the- oretical underpinnings of technological advancement in healthcare. Healthcare Informatics Research and Innovation

We

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may be entering the robotic revolution, but one thing is certain, that caring is the intangible ingredient that makes this human experience with robotic machines as dignified and safe as possible. The author recognizes that while caring needs to be explicitly demonstrated, it is a challenging task for robotic engineers to mimic or articulate the genuine human expressions of caring in a machine equipped with artificial intelligence. As a caring profession, nursing is in unique position to guide robotic research and its implementation.

Correspondence regarding this article should be directed to Armiel Suriaga, MSN, RN, Florida Atlantic University, Boca Raton, FL. E-mail: asuriaga2016@fau.edu

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184 Suriaga

 

 

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