Will Staff Shortages in Long-Term Care Settings Lead to the Use of Robotics?
by Don Drake, Connelly Law Offices, Ltd.
There is no sector in healthcare services that is feeling the effect of the staffing shortage more than the Long-Term Care industry. Although many point fingers at the pandemic as the cause, those working in the field know this is a problem that existed long before anyone uttered the words COVID-19.
"The pandemic exacerbated these workforce shortages and drew attention to the challenges that providers face in staffing their facilities," said certified elder law Attorney RJ Connelly III. "Going back at least five years, I was having conversations with administrators and other senior care providers, and they all cited this as a growing concern for them. These concerns also included the excessive cost of overtime and an increased worry about staff burnout."
"The pandemic exacerbated these workforce shortages and drew attention to the challenges that providers face in staffing their facilities." ---Attorney RJ Connelly III
According to the United States Bureau of Labor Statistics, the nursing home industry has lost some 235,000 jobs since March of 2020, equating to 15% of the workforce. This number far exceeds those lost in all other areas of healthcare. In a poll conducted by the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL), 99% of nursing homes and 96% of assisted living communities said they are facing some degree of staffing shortages. Fifty-nine percent of nursing homes and 30% of assisted living communities characterized their staffing situation as “severe.”
To date, as we are beginning to return to some sense of normalcy, long-term care providers continue to say that the issue is not improving. Since June of this year, 86% of nursing homes and 77% of assisted living programs say the staff shortage has not improved with most saying it has gotten worse. There is also another problem that will have an impact on the growing number of seniors in care, a declining birth rate.
Fewer Born, Fewer Providers
Demographers anticipate that by 2060 almost one in four will be in the age group that may need long-term care, meaning there will be some forty-eight million more elderly individuals in our country just four decades from now.
The National Center for Health Statistics released a report that stated American births have fallen to record lows in recent years, extending a deep decline that began in 2008. This is problematic since birth rates are an important measure of a society’s demographic balance. If rates are too high, resources like education and housing are strained, and yet if they are too low, a country will face challenges replacing its workforce and supporting its seniors.
Technology and Home Healthcare
Most of us who work with seniors are aware of the new innovations in the home that have allowed seniors to continue living on their own. Devices hooked to phone lines that monitor pacemakers, defibrillators, and other medical hardware help to keep them from moving into long-term care facilities. But it’s not just medical assistance that seniors living independently need, they also need help with everyday chores like cooking, light housework, and managing finances.
Relatives are often not close enough to help with this work and evidence is beginning to show that when relatives do this work, it is neither healthy nor sustainable for either party. This has led to the explosive growth of professional home health care services. These businesses, however, struggle to keep their positions full and their employees professionally trained as well. The need for dedicated and experienced staff far outstrips the supply and as we stated earlier, the workforce shortage is only projected to get worse.
Turning to Robots
Without people to staff these positions in long-term care facilities and home care services, and costs of care skyrocketing, healthcare providers are considering robotics to help supply these services. It makes good business sense, they say -- a one-time investment with some upkeep, robots don’t call out sick or quit, and they provide consistent care without the emotional baggage of a human provider.
In the past, many providers and consumers had strong negative feelings about robotics being involved in the care of humans, but the attitudes are changing. Recent surveys of professionals and families in need of health aids for aging parents indicate an acceptance of robot help in providing care.
And as we alluded to earlier, European providers are using a prototype with several elderly people across the continent – the GiraffPlus robot.
This machine is designed to help elderly people who want to stay at home remain independent past the point they’d usually be unable to live alone due to physical or cognitive difficulties. Motion sensors track if someone is in a certain room while pressure sensors under beds and sofas can tell if someone is sitting down. There are also sensors that are activated when certain appliances are plugged in and sensors that monitor when doors and windows are open or closed. The sensors can measure room temperature and humidity, turning on heat or cooling systems.
This robot has other uses as well, it can be fitted to measure weight, blood pressure, and sugar levels and monitor the night movements of the senior. The machine also allows “virtual visits” from friends, family, and healthcare professionals by using a screen fitted to it. Despite some minor difficulties with robotics, its inventors see these problems as being corrected simply and quickly. In short, the elder care industry there sees the use of robots as something that will happen sooner rather than later.
Warm Hands Versus Cold Hands
Although we mentioned that surveys show some acceptance of using robot technology, many others in healthcare have a major concern, best summed up in this phrase – “warm hands versus cold hands”. These concerns are not to be taken lightly.
In many cases, daily caregiver visits are the only human contact some elders have with other human beings. Lacking the human touch, they say, will not only further isolate seniors but lead to a rapid decline in health. This concern became readily evident during the pandemic.
The practice of social distancing and canceling visits in long-term care facilities contributed to an epidemic of physical and emotional problems as seniors faced social isolation and loneliness. Isolation is best described as an objective lack of social contact while loneliness is a subjective feeling of being by yourself, and both have some profound consequences.
In a study by Julianne Holt-Lunstad, Ph.D., of Brigham Young University, she found that both isolation and loneliness are associated with increases in heart disease, dementia, and other health problems. Social isolation by itself increases mortality risk on a par with such risk factors as smoking, obesity, and lack of physical activity.
Those in favor of robots call these concerns ludicrous, stating that those healthcare professionals who cite these issues are “insecure and afraid of modern technology.” Do they have a point? Are healthcare professionals truly insecure about this technology or is human touch a real and necessary component of senior care? Well, there may be some answers to this by looking at the history of human care.
The Need for Human Touch
In the early 1900s, the United States was populated with thousands of orphanages where unwanted babies were dropped off for care. These institutions were sanitary, warm, and provided appropriate food for these children and yet most infants placed there died before they were seven months old. Doctors noted that these children were not sick, and many ate normally, but they just seemed to “waste away”, a condition they called “marasmus”.
At the same time, a pediatrician named Luther Emmett Holt spewed forth a revolutionary and horribly bad idea in childcare – keep away from your baby. He blamed parents for “spoiling” their children by coddling and holding them too much. According to Holt, a good parent needed to take a “hands-off” approach to parenting. New parents across the nation heeded the good doctor’s approach. Within a few years, pediatricians noticed a dramatic rise in infant deaths among normally healthy babies.
It soon became apparent that these children died from a condition commonly called “failure to thrive” – they were simply not getting enough human touch. Studies conducted at the time by devotees of Holt on babies who died in orphanages found that touch-deprived infants were half the size of normal children.
When Holt’s methods were dismissed and children were removed from institutions and placed into environments where they received physical nurturing, the “marasmus” reversed. They finally gained weight and began to thrive. The bottom line, touch is vital for the survival of the very young – and as it turns out, the very old.
"The bottom line, touch is vital for the survival of the very young, and as it turns out, the very old."
“When infants are exposed to a world full of new experiences, they rely on the touch of a nurturing caregiver to provide a sense of safety," said Attorney Connelly. "This touch helps us form patterns of consistency during vulnerable times. As we grow, the need for touch does not disappear and we continue to benefit from such human-to-human contact, as witnessed by some of the issues that arose during the height of the pandemic. As we age and become more dependent upon others, this becomes even more important as we rely on those around us to provide us once again with a sense of safety and nurturance.”
The research appears to back up Attorney Connelly's statement. In a study conducted by the University of Miami’s Touch Research Institute, they found that a warm, human touch can:
Lower blood glucose levels.
Slow the heart rate.
Lower blood pressure.
Improve pulmonary function.
Improve the immune system.
Enhance alertness and performance.
Other studies show that:
Hugs elevate mood, reduce stress, and may prevent Parkinson’s in some patients.
Eye contact and a pat on the back from a health care professional may increase the survival rate of patients with complex conditions.
Therapeutic touch calms people with dementia.
Touching makes caregivers appear more trustworthy, improving the mood of the patient.
A light touch makes people more agreeable when you request something from them.
Touch and Seniors
Attorney Connelly, who acts as a guardian for many clients, speaks about his own experiences regarding the importance of touch. “I visit our wards on a regular basis and it is often an emotional experience for both of us. When I walk in and hold out my hand for a handshake, they will grab my hand and hold onto it tightly, looking me in the eye and often tearing up. I can feel their loneliness and the gratitude they have because someone cares about them. It amazes me how such a small gesture can have such a profound effect -- not just on the senior but on me as well.”
Researchers in the United States reviewed 218 studies involving the health effects of social isolation and loneliness on approximately four million older adults and what they found was astounding. Lonely seniors had a 50 percent increase in early death compared to those who had a more active life and regular contact with others. In Europe, similar studies have comparable results.
"It amazes me how such a small gesture can have such a profound effect --- not just on the senior but on me as well." ---Attorney RJ Connelly III
The Telegraph, a British newspaper, reports that Britain is the “loneliness capital” of Europe, citing that its citizens are less likely to know their neighbors or have any strong friendships. The United Kingdom’s Local Government Association was so concerned about these results that they petitioned the government to treat loneliness as a major health issue. Following up on this report, the non-profit agency, Age UK, issued a press release calling this issue a blight on the lives of more than one million elderly people.
In another study, concerns were raised about the new reality of seniors staying in their homes. When connected with others and having an active social life, they seem to thrive. But for those without such support, it is a recipe for depression and chronic illness. So, although we may want to keep our seniors at home, the lack of human interaction may lead to more problems and even higher costs on the health care system through increased physical and mental illness. In such cases, robots may not be able to meet their needs.
A Personal Experience
At Shattuck Hospital in Boston, this writer was the director of a treatment program that provided care for multiple patients diagnosed with AIDS dementia. This type of dementia is caused by HIV itself and not by any of the opportunistic infections that commonly occur due to the infection. Although it's still not exactly known how the virus damages brain cells, what is known is that it presents with symptoms like other types of dementia.
One patient, I’ll call her Wanda, had spent months in another hospital after being found close to death on the streets of Mattapan. Once a bookkeeper who operated her own tax preparation service, she became involved with a man who was an active intravenous drug user and infected with HIV. Once she found out she had contracted the virus, her life spun out of control sending her into a depression and a life of heroin addiction. Her HIV had advanced to an AIDS diagnosis which eventually included dementia-like symptoms.
Upon admission to our program, she was totally disengaged from life, wearing diapers, using a feeding tube, and had extremely poor hygiene practices. We put into place a morning greeting for her along with a handshake and a mentor who would help her with personal care that included fixing her hair, applying make-up, and painting her nails.
The most positive part of this very modest touch routine was an increase in socialization. She bonded with the counselors, started talking about her early life, and although not always connecting to her stories, it was an enjoyable time for her. She began to joke and laugh. She started to feel comfortable sharing her sadness – about her loss of independence and the disconnection from her children. But she began to show enthusiasm for life once again.
"She no longer needed to wear protective undergarments, the feeding tube was removed, and her personality once again emerged."
Wanda was referred on an outpatient basis to a program in the city called the Boston Living Center, which provided services to HIV/AIDS patients including therapeutic massage. Once she became stable enough to leave the hospital and become involved with the Living Center, things changed even more for her. She no longer needed to wear protective undergarments, the feeding tube was removed, and her personality once again emerged. Although her dementia persisted, she showed considerable insight and awareness of her situation. Human touch and peer socialization were indeed the best medicine for Wanda, something a robot may not be able to provide.
This story is backed up by a similar program in place at the Methodist Home in
Chicago. According to the results of a six-month pilot program on massage therapy for Alzheimer's patients, correlations were found between gentle touch and the easing of anxiety and angry acting out in Alzheimer's patients.
The study found that back rubs were helpful for those confined to wheelchairs, experiencing chronic pain, exhibiting irritability, and even angry acting out. Foot massage proved helpful for those exhibiting hyperactive behavior or restlessness and “wandering” behaviors. Hand massage or face stroking seemed to calm those exhibiting anxiety, worry, sadness, and fearfulness. Massaging the temples, scalp and forehead helped relieve headaches and tension. Shoulder and neck massage seemed useful in alleviating tiredness, irritability, and mild upset.
Since the inability to communicate with language has been shown to increase anxiety and frustration for people living with dementia, utilizing touch as a form of nonverbal communication and a therapeutic modality, such as massage, for inducing relaxation proved successful.
In another study, people with Alzheimer's Disease who received hand massages and were spoken to in a calming manner had a reduction in pulse rate and in inappropriate acting out. Health-care professionals have speculated that massage may be beneficial in dementia care, not only because it is relaxing, but because it provides a form of social interaction often missing for them.
Is There a Future for Robots?
It remains to be seen if robots can provide the type of interactions seniors rely on from human caretakers. For instance, can a robot companion provide a soothing touch, understand the concerns of someone with dementia, or exhibit empathy spontaneously?
“There also exists multiple ethical concerns associated with the use of robots in senior care besides the reduction in the human touch,” Attorney Connelly said. “These include issues of loss of privacy, loss of personal choice and liberty, feelings of objectification and loss of control, and of course, possibilities of outsiders hacking into these control systems and gaining access to patient records or financial information."
Attorney Connelly cautions that using robots to provide services must be balanced with the individual's need for human caregivers. “My question is this, how far are we willing to go just to meet numbers. Yes, we want to provide a better quality of life for our seniors by delivering the services they need, and using robots can do this, but if human touch and social interactions are lacking, is this the quality of life we want for our loved ones and for ourselves?”
Although we have not yet reached a point where robot care has become a reality, it may be less than a decade away given the rapid advancements in technology and ongoing staffing shortages. We need to approach this by balancing the care benefits against the ethical costs. But one thing is certain, the choices we make today for our elderly will be the reality we will be living with tomorrow when we ourselves will need care. When that time comes, just how comfortable will we be when a cold plastic machine stands over us flashing an electronic smile and wishing us a good morning?