Health professionals’ perspectives on the implementation of social robots interventions for dementia care in France: An interview and focus group study

Use of social robots for therapeutic purposes

In therapeutic contexts, professionals frequently used the NAO robot to facilitate physical exercise sessions. Both NAO and PARO were also employed to alleviate or prevent stress and to help calm residents during moments of agitation or crisis. As one head nurse explained, “It provides a presence at night; it helps to manage stress.” Participants also described the use of robots to stimulate emotional memory—“[Such as] the animal we loved so much: a dog, a cat … PARO works right away” (Nursing Assistant)—to promote cognitive stimulation—“It fits in with cognitive stimulation approaches around reminiscences” (Psychomotor Therapist)—and to support emotional expression—“The patient will really verbalize affects that he would not verbalize without PARO” (Psychologist) (CUR—Target Condition A0002, A0009; CUR—Utilization A0001, A0009).

Some professionals also emphasized the robot's role in managing psychological or emotional states. One psychologist reported using the robot to help distract residents from pain: “It simply distracts from the pain.” Another explained how the robot could be used to facilitate affective regression in a controlled therapeutic setting: “I use the affective regression that PARO induces, but I know it and I control it, to have access to affects that I don't have during a talk without the robot” (Psychologist) (CUR—Target Condition A0002, A0009; CUR—Utilization A0001, A0009).

According to participants, therapeutic sessions involving social robots were typically conducted on an individual basis and lasted between 15 min and one hour (CUR—Utilization A0011). These interventions were primarily led by psychologists and psychomotor therapists, and less frequently by nurses or nursing assistants (CUR—Utilization G0009; TEC—Features of the Technology B0004; ORG—Management G0009). Some psychologists expressed interest in developing formalized outcome indicators to monitor residents’ progress and to facilitate the use of the robot by other staff members in a more structured therapeutic framework (TEC—Investment and Tools Required to Use the Technology B0010).

Use of social robots for recreational purposes

In recreational settings, professionals reported that PARO and NAO supported social interaction and stimulated conversation among residents. “They have fun, discussing with the robot,” noted a geriatrician, referring to residents with mild cognitive impairment. The robots drew attention and elicited emotional reactions—“It's cute!” (Nursing Assistant)—and were described as reducing feelings of loneliness. As one head nurse explained, adopting the resident's perspective: “It [the robot] needs me, it is all alone; by mirror effect, it does the patient good.” Participants also noted that the robots contributed to diversifying recreational activities: “In this institution, they’re always testing new things; the robot is just one more” (Nursing Assistant) (CUR—Target Conditions A0002, A0009; CUR—Utilization A0001).

Professionals also noted that family members occasionally reacted to the presence of the robot during visits, often expressing curiosity or amusement and, in some cases, mild concern regarding infantilization. While these reactions did not directly shape therapeutic protocols, they sometimes influenced how staff framed the activity or decided whether to introduce the robot in group settings.

According to professionals, these recreational objectives were often pursued by incorporating the robot into existing activities to encourage resident participation. For example, social robots were used during writing or reading sessions to engage residents more actively. In some cases, the robots became central to structured group sessions—such as physical exercise or musical quiz activities—designed around specific recreational goals and intended to enhance resident involvement (CUR—Utilization F0001).

Participants indicated that recreational sessions involving social robots typically lasted between 30 min and 1 h and 15 min, and included groups of four to 10 residents (CUR—Utilization A0011). These activities were most often led by occupational therapists or activity staff, who were responsible for designing and facilitating the sessions (TEC—Features of the Technology B0004; ORG—Management G0009).

Shifting applications of social robots between recreational and therapeutic use

The intended use of the robot—whether therapeutic or recreational—was generally defined prior to its introduction within the institution. According to participants, this orientation was shaped by several factors: initial training provided by robot vendors or distributors; the institution's involvement in experimental projects, reflecting a broader openness to innovation; guidance from in-house professionals identified as key resources; and prior experience with similar interventions, such as Snoezelen rooms, which, like social robots, aim to provide sensory stimulation and emotional support (TEC—Features of the Technology B0004; ORG—Health Delivery Process G0004).

However, the boundary between therapeutic and recreational use was often fluid, reflecting both the evolving needs of residents and the adaptive practices of care teams. In some institutions, professionals who initially used the robot to pursue structured therapeutic goals—such as cognitive stimulation or emotional regulation—gradually integrated it into recreational activities to foster engagement and enhance well-being in a more informal setting. Conversely, others began with recreational applications but shifted toward therapeutic use after observing positive effects on residents’ behavior, mood, or cognitive functioning.

Professionals frequently viewed the therapeutic and recreational uses of social robots as interrelated and mutually reinforcing. As one activity leader explained, “Recreational activities are a pretext for therapy,” while a head nurse reflected, “The nurses and nursing assistants used to say recreation was just playing dominoes, but now they see another dimension.” These interconnections were often reinforced through internal training and informal peer mentoring. For example, activity leaders reported learning from psychologists about the therapeutic value of touch during sessions with geriatric patients involving the robot (ORG—Health Delivery Process G0004).

Even when therapeutic objectives were prioritized, professionals often acknowledged the value of recreational robot use in contributing to broader aspects of residents’ well-being. As one nurse observed, “Therapy is associated with general well-being” (EFF—Health-Related Quality of Life D0012). These transitions between therapeutic and recreational applications were frequently aligned with broader person-centered care strategies, in which flexibility in the use of tools was essential to addressing individual needs and enhancing perceived benefits (CUR—Utilization A0012).

Implementation practices also evolved over time in response to the diverse and changing needs of residents. Group activities, initially the preferred format, were sometimes found to be impractical due to differences in cognitive and physical functioning among participants. In response, more individualized approaches were introduced, with one-on-one sessions becoming increasingly common. As one psychologist explained, “The activity leader goes from room to room in the ward with the robot and proposes short entertaining sessions with it to each voluntary patient” (CUR—Utilization G0009; TEC—Features of the Technology B0004; ORG—Health Delivery Process G0004).

Knowledge transfer in the context of SRIs: training, practices, and experiential learning

For both PARO and NAO robots, initial training was typically provided by the vendor at the time of purchase (ORG—Health Delivery Process G0003). “The salesman came to do a training session, maybe a week after the robot was introduced in the facility,” recalled a nursing assistant, referring to PARO. Training sessions generally lasted half a day for PARO and a full day for NAO.

Training for the PARO and NAO robots typically consisted of both theoretical and practical components. The theoretical component addressed topics such as emotional engagement, target populations, and professional attitudes toward robot use, while the practical component focused on technical aspects, including cleaning, maintenance, and applied use scenarios. Although professionals generally acknowledged the importance of training for the successful integration of social robots, many found the content insufficient in depth and relevance. Some criticized the limited theoretical input. As one psychologist noted, “There was only technical training which, in my opinion, took ten minutes and a few use cases.” Others pointed to a mismatch between the training materials and the varied educational backgrounds of staff. A psychomotor therapist remarked, “It may be simple for therapists, but not all nursing assistants are comfortable with written content.” Some professionals also found the sessions tedious and insufficiently aligned with their clinical practice. As one head nurse observed, “The session dragged on too long; more time should have been dedicated to hands-on practice to help staff become comfortable with the tool.” These reflections underscore the need for training programs to be better tailored to the diverse roles, competencies, and practical needs of healthcare professionals to ensure relevance and applicability in clinical settings (TEC—Training and Information Needed to Use the Technology B0013; ORG—Health Delivery Process G0003).

Additionally, because training was typically conducted immediately after the robot's acquisition and offered to only a limited subset of staff, many professionals, particularly in institutions experiencing high staff turnover, did not receive it. According to participants, the staff groups most frequently excluded from initial training included nursing assistants, night-shift personnel, and recently hired staff. In several institutions, only psychologists, psychomotor therapists, or activity coordinators received formal training, leaving broader care teams without structured instruction. As one nursing assistant stated, “I don’t know about the training, it was done before I arrived.” A psychologist similarly noted, “Only the psychomotor therapist did the training a year and a half ago.” Limited access to initial training was frequently identified as a barrier to broader adoption. As one head nurse explained, “There's little incentive to use PARO because the necessary knowledge wasn’t effectively transferred to the broader care team.” Professionals emphasized that inadequate dissemination and lack of continuity in training can significantly hinder the integration of social robots into routine care practices (ORG—Health Delivery Process G0003; ORG—Management Problems G0008).

Beyond initial training, successful integration of social robots into care routines often depended on preparatory work conducted prior to their formal introduction. In two institutions, professionals, such as psychologists and psychomotor therapists, had the opportunity to work with robots that had been lent to them before purchase. This preparatory phase, initiated by management in light of the significant financial investment, enabled clinical teams to assess the robot's potential impact on residents, adapt usage scenarios to their specific care context, and critically appraise the claims made by vendors. Notably, this included moderating overly optimistic messaging regarding the robot's capacity to restore cognitive function or replicate authentic human interaction. Such early-stage testing supported the development of realistic expectations, alignment with therapeutic goals, and smoother integration into interdisciplinary care plans (TEC—Investments and Tools Required to Use the Technology B0010).

Professional feedback, covering clinical, organizational, and ethical dimensions, was frequently formalized into internal resources such as summary cards, PowerPoint presentations, or staff training modules. These materials were developed by professionals from a range of disciplines, reflecting diverse perspectives and helping to support shared learning and consistent practices across teams. As one psychologist explained, “Internally, we focus on the real-life challenges. We present case studies based on familiar residents. We don’t need to be generic, we get right to the point and use tailored approaches” (ORG—Health Delivery Process G0003; ECO—Resource Utilization E0001). This emphasis on context-specific, experience-based learning, shaped by input from multiple professional roles, helped ensure that training and implementation strategies remained relevant to everyday clinical practice.

Despite strong initial engagement, several institutions reported a gradual decline in the use of social robots over time. This decrease was frequently attributed to a “novelty effect,” whereby initial enthusiasm waned as the robot became a familiar and routine element within the care environment (ORG—Culture G0010; ORG—Management G0008). In many cases, once the initial curiosity among staff and residents diminished, the robot's integration into regular care activities lost momentum. Professionals noted that without sustained motivation, ongoing training, and structured planning, the robot risked being underutilized or relegated to storage. This pattern highlights the importance of long-term strategies to maintain engagement, including periodic refresher sessions to reinforce staff knowledge and confidence, opportunities to share experiences and best practices, and regular updates on how to adapt the robot's use to evolving care needs and therapeutic goals.

Leadership, institutional positioning, and strategic visions for SRIs

Although the introduction of social robots influenced organizational routines, their integration typically complemented rather than replaced existing care objectives. Key clinical and healthcare staff played a pivotal role during the implementation phase, often emerging as internal champions who helped define the robot's role, deliver peer training, encourage its use, and facilitate communication among team members. These actors either assumed this role voluntarily or were designated by institutional leadership. As one psychomotor therapist explained, “I saw myself as a ‘resource person’ because I had found that solution at the time [how to use the robot more effectively]” (CUR—Utilization G0009; ORG—Structure of Health Care System G0101). Within geriatric services, psychologists often acted as key decision-makers regarding when and how the robot was used.

Administrative managers also played a critical role in initiating or supporting the integration of social robots, particularly when the initiative originated from clinical staff. Their responsibilities included securing acquisition funding, applying for external grants, validating usage protocols, and issuing reminders to encourage consistent use (ORG—Structure of Health Care System G0101). Effective coordination between administrative managers and designated key actors within the clinical team was essential to ensure ongoing follow-up and the establishment of feedback mechanisms regarding the robot's implementation and its effects on care delivery. Many professionals viewed this collaborative dynamic as both supportive and instrumental in promoting the sustainable integration of SRIs into everyday clinical routines (ORG—Health Delivery Process G0012).

In parallel, the financial dimension of acquiring social robots occasionally gave rise to internal tensions. Although most staff members were aware that the robot represented a considerable investment, few knew the exact cost. This lack of transparency sometimes fueled skepticism regarding institutional priorities. As one head nurse observed, “The price of the robot was circulating … people were asking why we spent so much money when we could have invested in staff instead” (ORG—Process-Related Cost G0006; ECO—Utilization E0009).

Some professionals were also tasked with managing access and safeguarding the device due to its high cost. To prevent damage or theft, robots were frequently stored in locked cabinets or staff offices. While these precautions were understandable, they sometimes reduced the robot's accessibility for other team members and contributed to hesitancy around its use. This restricted access also reduced spontaneous use and appears to have led to fewer sessions overall, indirectly limiting residents’ opportunities for engagement with the robot. As one geriatric physician recounted, “I entrusted it to a care assistant. It scared me, I told them, ‘You know it's expensive, be careful,’ so I’m not sure she wanted to use it again” (CUR—Utilization G0009; ECO—Utilization E0009; ORG—Management G0008).

Beyond internal debates over cost and resource allocation, administrative managers often viewed the social robot as a strategic innovation that could enhance the institution's external visibility. It was frequently leveraged as a communication asset in media campaigns, through interviews, videos, and photographs, to showcase the facility's modernity and commitment to forward-thinking care (ETH—Benefit-Harm Balance F0011). While this public exposure occasionally increased staff workload or stress, particularly during demonstrations or special events, it contributed to shaping a positive public image centered on openness to technological innovation and human-centered care. In several cases, the decision to invest in a social robot was supported by prior experience with other nonpharmacological interventions, such as multisensory stimulation or therapeutic environments. In institutional networks, pilot projects involving social robots were sometimes extended to additional sites, reinforcing the robot's role not only as a clinical tool but also as a driver of institutional visibility and innovation (ORG—Management Problems & Opportunities G0008).

Operational demands and resource-related challenges in daily practice

While administrative managers often emphasized the strategic value of social robots, professionals on the ground underscored the practical challenges of their implementation. The use of SRIs requires a substantial time investment, not only for direct interaction with residents, but also for preparatory and follow-up activities. These additional demands impact staff workload and underscore the need for institutional planning to allocate adequate resources and adjust workflows accordingly.

For instance, sessions involving the NAO robot frequently required two staff members: one to engage with the resident and another, typically acting as the “Wizard of Oz,” to operate the robot remotely and coordinate its speech and movements during the session. This configuration demanded coordination, rehearsal, and shared familiarity with the session's content to ensure smooth execution. Facilitators were also responsible for developing scripts and interaction sequences in advance, further increasing preparation time. As one activity leader explained, “At the beginning, it made the facilitators’ work heavier. We had to plan everything so the interaction would feel natural and enjoyable” (ORG—Process-Related Costs D0023; ORG—Health Delivery Process G0004; ECO—Resource Utilization E0001, E0009).

Similarly, the use of PARO introduced additional time-related demands, particularly concerning hygiene and maintenance procedures. The robot required thorough cleaning after each individual session, and this requirement was more strictly enforced during the COVID-19 pandemic. These safety measures, while essential, added to staff workload and required clear institutional protocols to ensure compliance. As one nursing assistant noted, “It takes time to clean it after each use by the residents, and we need to be even more cautious since the COVID-19 period” (SAF—Safety Risk Management C0062; ORG—Health Delivery Process G0001; ECO—Resource Utilization E0001).

The robot as a tool that is difficult to define in healthcare practices

For many professionals, the definition of a social robot took shape progressively through hands-on experience, rather than being clearly defined at the beginning of its use. Their understanding evolved through practice, reflection, and adaptation to specific care contexts. To explain what the robot represented in their clinical environment, professionals often relied on analogies. As one geriatric physician explained, “It can be a tool, a crutch,” suggesting that the robot could serve as a form of complementary support that would assist both patients and staff in their daily routines (ORG—Culture G0010).

To make sense of the robot's role or intended function within care settings, staff often drew comparisons with medications, therapeutic interventions, or familiar everyday objects. The most common analogy was with animal-assisted interventions. PARO, in particular, was frequently associated with pet therapy and regarded as a useful complement—more manageable and easier to control, especially in institutional environments. As one psychomotor therapist observed, “It's a good option, because even though we have cats, they can’t visit every resident. The robot gives them an opportunity to talk about their own animals” (TEC—Features of the Technology B0001, B0002). Other professionals drew parallels with nonpharmacological therapies such as Snoezelen environments, empathy dolls, and music therapy, as well as with other types of social robots or even human caregivers themselves (TEC—Features of the Technology B0001, B0002; ORG—Culture G0010). These analogies further illustrated the multifunctional and evolving nature of the robot in clinical practice, highlighting its potential to support a range of therapeutic interactions and social engagement within institutional care settings.

This ambiguity in defining the robot's role was also reflected in the diverse reactions it elicited among professionals. Acceptance varied across roles and individual attitudes, even within the same institution. Diverging perspectives occasionally gave rise to tensions or discomfort among staff. As one activity leader explained, “If you express that you’re uncomfortable with the robot, people say, ‘What's wrong with you? Are you crazy?’ I know not everyone shares the same view, especially in the research [department], where some people think it's fantastic” (ORG—Culture G0010).

Diverse approaches to introducing and framing social robots in care settings

Professionals described a range of approaches to introducing the robot to residents, reflecting different perspectives on communication strategies and clinical practice. Some adopted a transparent approach, seeking to manage expectations and minimize confusion among older adults. As one psychologist explained, “Personally, I try to avoid creating any confusion, I make it clear that the robot isn’t alive.” Others favored a more interpretive, resident-centered approach, allowing for individual meaning-making. A psychomotor therapist shared, “When a patient asks, ‘Is it real or fake?’ I usually respond with, ‘What do you think?,’ so they can interpret it in their own way.” Trainers and experienced staff generally encouraged this flexible and adaptive strategy, recommending that the robot be introduced in a natural and informal manner, avoiding overly scripted or artificial presentations that might confuse residents (TEC—Training and Information Required B0014; SOC—Patients’ Perspectives H0006; SOC—Communication Aspects H0203; ORG—Communication and Cooperation Between Stakeholders G0007).

However, these recommended practices occasionally led to a sense of professional hierarchy, with some staff members feeling that their experience or contributions were undervalued. One activity leader recalled, “When the psychologists, in charge of the robot, talked to me about NAO, I felt like saying, ‘Hey, I’m not eight years old! I’m your colleague, I’m part of the project!’” (ORG—Management G0008; ORG—Culture G0010).

The “plasticity of use” also extended to how the robots were physically positioned during sessions, with varied practices across institutions. In some settings, professionals emphasized placing the robot at eye level to encourage engagement and reduce perceived distance between the resident and the device. As one nursing assistant explained, “I usually put PARO on a table in front of them (patients) and NAO on the floor in front of them.”

In contrast, other professionals chose to place the NAO robot on a higher table to ensure it was visible and accessible to all participants. However, this setup was not endorsed by all professionals. One activity leader expressed their discomfort: “I saw a session where the robot was high up on a table, like on a pedestal in church, and I thought, ‘What is this? Some kind of satanic ritual?’” (ORG—Culture G0010).

Continuity of care values and ethical principles in SRI integration

Professionals agreed that the implementation of SRIs did not alter their core care objectives. Maintaining meaningful social connections for residents remained a key priority, as one nurse emphasized: “What is very important is the social link between the resident, their family, the caregivers, and their whole ecosystem.” They also underlined the importance of the professional–resident relationship, which remained central to care practices regardless of whether SRIs were involved. As one head nurse explained, “[Whether it's with or without the robot], what really matters to professionals is the relationship they build with the resident, it's at the heart of what we do.”

Professionals emphasized that the implementation of social robots did not compromise their core ethical principles, as the robot's use remained under the supervision and discretion of care staff (ETH—Benefit–Harm Balance F0010). Human empathy was viewed as irreplaceable in caregiving. As one head nurse stated, “Empathy is something very specific to humans.” Concerns about potential dehumanization of care were raised only in relation to unrealistic expectations regarding the robot's capabilities. One geriatric physician illustrated this point: “We can clearly see that after five minutes of interaction [with the robot], a lot of residents lose interest. I really don’t think a robot could ever replace a caregiver” (ETH—Respect for Persons F0008).

Moreover, many professionals believed that thoughtful and appropriate use of the robot was essential to ensure clinical relevance and respect for each resident's individual needs. As one psychomotor therapist explained, “We’ve already thought ahead about what we’re going to do [with the robot], who we’re going to involve, and when.” Others emphasized the value of maintaining a diverse therapeutic toolkit. As one psychologist noted, “Every patient is different … that's why I talk about a therapeutic arsenal. We need many tools that we can try.”

A recurring ethical concern involved how to engage with the beliefs or perceptions of residents with cognitive impairments. This included questions about whether to correct a resident's mistaken belief or to support their current understanding when it brought comfort or stability. As one geriatric physician reflected: “There was a time when we thought we had to correct the beliefs of people with dementia, like telling them their parents had passed away. But now we ask: is it really helpful to challenge that belief?” This perspective echoed broader reflections on how to approach residents’ interpretations of the robot itself, particularly when it was perceived as alive or emotionally responsive (ETH—Autonomy F0005; ETH—Autonomy F0007).

Professionals reported paying close attention to both verbal and nonverbal cues when offering the robot to residents, noting that engagement or refusal could be expressed through gestures, facial expressions, or withdrawal. They described adapting their approach in real time, either encouraging further interaction when the resident appeared comfortable or discontinuing the activity when signs of discomfort or disinterest emerged. In practice, consent was treated as a fluid, ongoing process rather than a single formal act.

From an ethical and institutional perspective, some professionals considered family reactions and the responses of other residents when deciding whether or how to introduce the robot in recreational activities. Concerns raised by family members, particularly around infantilization or authenticity, were occasionally discussed within teams, suggesting that these external perspectives can inform internal norms and usage decisions even if they do not directly alter clinical protocols.

Professional boundaries and ethical tensions in robot-mediated care

The introduction of social robots prompted many professionals to critically reflect on their caregiving values, particularly in relation to the ethics of care. A recurring theme was the tension between the robot's simulated emotional responses and the genuine empathy that professionals regarded as central to their role. As one head nurse observed, “The robot's artificial empathy was unsettling,” highlighting professionals’ strong commitment to the authenticity of their empathic engagement with residents (ETH—Autonomy F0005, F0007).

Concerns about infantilization also emerged. For instance, an activity leader expressed initial hesitation upon encountering the robot, questioning whether its childlike appearance could lead to residents being treated in a patronizing manner: “My first reaction was wondering if we weren’t going to infantilize older adults, because it's a robot [NAO] that looks like a little young man.” This concern was also shared by some families, as one animator noted: “We show it to families during visits; they often react very positively, but some are hesitant, fearing that the robot might infantilize the resident” (ETH—Respect for Persons F0008). Interpretations of residents’ reactions to the robot's playful behaviors and toy-like design varied across professional groups. Some activity leaders and nurses regarded residents’ affectionate or amused responses as potentially infantilizing, whereas psychologists and psychomotor therapists more often understood them as expressions of affectivity or emotional openness. This divergence suggests that ethical impacts and lines of questioning around SRIs may differ according to professional role and scope of practice.

Similarly, the issue of deception was raised, with some professionals questioning whether it was ethical to maintain the illusion of the robot being “alive.” As one psychomotor therapist explained: “If they [residents or patients] raise doubts, that's where I don’t lie to them” (ETH—Respect for Persons F0008).

Professionals also pointed out that misleading communications, such as promotional videos or photographs showing the robot moving autonomously, could generate unrealistic expectations. As one nursing assistant explained, “It looks like it's just walking around by itself! That's what the film shows. But it's not like that at all.” To correct such misconceptions, they emphasized that the robot should not be perceived as a third agent in the care relationship, but rather as a tool that mediates interaction. As one nurse stated, “[The robot] It's just the mediator that makes the connection” (ETH—Benefit–Harm Balance F0003).

Despite these clarifications, some professionals occasionally expressed unease about how the robot might alter their perceived professional role. As one psychologist reflected, “Sometimes I feel like I disappear behind the PARO robot.” Similarly, an activity leader remarked, “We’re standing a bit to the side [of the robot] to make sure everything's going well and that we’re not damaging the machine. I didn’t feel like I was in my role anymore, conducting the activity” (ETH—Respect for Persons F0008).

Importantly, professionals who were hesitant or opposed to using the robot were never forced to do so. Participation remained voluntary, respecting individual comfort levels and professional judgment (ORG—Culture G0010).

Collective ethical reflection and institutional support

Ethical considerations surrounding SRIs were not limited to individual reflections but were also addressed at the collective level within care teams. In some institutions, ethical concerns were actively discussed through internal resources and structured conversations. A geriatric physician mentioned that their team had created a short internal ethics guide to respond to questions raised by staff regarding SRIs, and that these discussions were used to reassure and support professionals who were uncertain about the implications of using the robot. As another head nurse explained: “You have to provide support and debriefing, because it has an impact on their professional identity, you can’t introduce it [the robot] just like that” (ETH—Autonomy F0007).

Beyond individual concerns, many professionals emphasized the value of establishing a shared space for collective ethical reflection. Rather than leaving staff to navigate ethical dilemmas in isolation, some institutions intentionally created forums, whether formal ethics committees or informal discussion sessions, where questions around consent, authenticity, or professional identity could be explored collaboratively. These shared deliberations helped normalize doubts, supported moral reasoning, and strengthened team cohesion. As one psychologist explained, “There really needs to be a shared space for ethical reflection, because each person may experience the robot's introduction differently depending on their sensitivity, experience, and role in the team” (ETH—Autonomy F0007).

Relational mediation and the flexible use of social robots in person-centered care

The purposes of employing social robots in our study were diverse but generally converged on the intention to enhance residents’ quality of life through engagement, stimulation, and recognition of their human dignity. Care teams intentionally used social robots to enrich everyday routines and to engage residents who might otherwise be withdrawn, agitated, or emotionally distant. PARO, for instance, was often introduced in contexts where a calming presence and emotional connection were sought,^11,30 while NAO was more frequently used in activities involving cognitive or motor stimulation.^16,31 In both cases, the robot was treated as a “third party” in the care relationship, a mediator that facilitated interactions that might not have occurred otherwise. This relational mediation created opportunities for professionals to reconnect with care recipients, not merely as service users, but as individuals with emotional, cognitive, and symbolic dimensions.

Indeed, the integration of social robots such as PARO and NAO into geriatric care environments reflects a shift in care practices, moving beyond a purely biomedical framework toward more holistic, person-centered approaches. Within these settings, older adults are often categorized as “vulnerable,” “frail,” or “dependent.” ³² Such terminology, which primarily defines individuals by their age and impairments, risks reducing them to simplistic labels and overlooking their full identity as persons. As several scholars have argued, this framing tends to promote a narrowly clinical perspective, one that inadequately captures the multidimensional nature of older adults, including their social, emotional, and moral identities.^33,34 In contrast, the introduction of social robots seems to offer an opportunity to move beyond the limitations of a purely medical model, toward an approach that acknowledges the full complexity of older adults as individuals. Professionals in our study did not view these devices merely as technological aids, but as symbolic actors that could mediate emotional, social, and relational dimensions of care.

Another notable finding of this study concerns the fluidity between therapeutic and recreational applications of SRIs. While professionals initially differentiated between therapeutic sessions, intended to reduce agitation, stimulate cognition, or support motor activity, and recreational sessions focused on novelty, group interaction, and enjoyment, this distinction often blurred in practice. Recreational activities frequently produced therapeutic effects, and therapeutic interventions were experienced as enjoyable and socially engaging. Moreover, the range of interaction formats (e.g., group settings, one-on-one sessions, and informal encounters) enabled professionals to adjust the robot's use to residents’ fluctuating abilities and preferences. This flexibility supported the delivery of personalized and context-sensitive interventions that addressed both individual and collective well-being. The observed “plasticity of use” underscores that social robots are not confined to fixed functions; rather, their value lies in their capacity to adapt to diverse care situations, resident needs, and professional initiative. These findings align with previous studies highlighting the adaptability of SRIs as a key component of their utility in long-term care settings. ³⁵ This finding also reinforces the relevance of person-centered approaches in dementia care, as articulated in Kitwood's work (1997), ³⁶ which emphasized the importance of recognizing the emotional and relational capacities of individuals with cognitive impairments. This perspective is further supported by recent consensus statements advocating for the personalization of nonpharmacological interventions. ³⁷

Although flexibility was generally viewed as an asset, our findings indicate that this “plasticity of use” can generate both positive and negative effects depending on context. Under favorable conditions (e.g., stable staffing, shared knowledge, supportive leadership), it enabled personalization and creative engagement tailored to residents’ needs. In resource-constrained settings, however, plasticity tended to result in limited standardization, uneven diffusion of know-how, and episodic use restricted to specific professionals. Without shared procedures or training, robot use often depended on individual motivation, creating unequal access among residents and staff. This suggests that flexibility should be balanced with basic organizational structures to support equitable and sustained implementation.

At the resident and family level, plasticity and personalization also moderated expectations of SRIs. Promotional depictions of autonomous or emotionally “intelligent” robots sometimes led to disappointment when performance did not align with these images. A minority of residents refused interaction, noting they “did not want to play with a robot,” indicating that SRIs are not universally acceptable or meaningful. Family reactions ranged from curiosity to concerns about infantilization, prompting staff to adjust how the robot was presented. These dynamics raised ethical questions regarding transparency, informed expectations, and respect for resident preferences, underscoring the need for careful communication when deploying SRIs in person-centered care.

Therapeutic engagement and symbolic mediation through social robots

Professionals reported a wide range of perceived benefits associated with the integration of social robots into care practices. These benefits included emotional and cognitive stimulation, enhanced social interaction, and organisational support. Social robots were perceived as tools that could foster interaction and promote connection, particularly among older adults at risk of isolation or limited engagement. Such outcomes highlight the multifunctional nature of these devices when thoughtfully embedded in daily routines.

One of the most frequently cited benefits was emotional engagement. Residents with dementia, including those showing signs of apathy, were observed to respond to social robots in ways that were often difficult to elicit through conventional care approaches. These observations confirm findings from previous studies showing that social robots can enhance emotional expression and interaction among older adults with cognitive impairment. PARO's tactile softness and interactive features, in particular, seemed to foster affective engagement even among individuals with advanced dementia.^11,30 Professionals noted that residents who were otherwise passive or minimally responsive began to smile, speak, or display affection when interacting with social robots. In some cases, robots served as mediators of reminiscence, evoking personal memories and facilitating storytelling, particularly when residents associated them with past pets or childhood experiences. From a cognitive and motor perspective, robots like NAO were used to support guided activities aimed at stimulating memory, attention, or coordination, further confirming the potential of SRIs to contribute to multidimensional care goals, as also reported in previous studies.^16,31

The nonjudgmental and neutral nature of the robot appears to create a safe space for older adults to express themselves without fear of judgment or embarrassment. This fosters open dialogue and emotional release. Residents were observed to project feelings onto the robot, and this act of projection often served as a medium for communication, not only with the robot itself, but also indirectly with professionals and peers. ³⁹ Such interactions support the therapeutic potential of SRIs by facilitating emotional expression and strengthening interpersonal connections.^22–24

Building on this emotional openness, the robot also supported symbolic and cognitive engagement. In particular, it helped sustain continuity in the person's psychic and moral life by evoking memories linked to emotionally significant objects or past experiences. This connection often emerged through physical proximity, such as stroking PARO's soft fur, or emotional resonance, like recalling a beloved pet. In these interactions, the robot was not merely a tool but took on the role of a symbolic stand-in for something or someone emotionally meaningful who was no longer present. This “absent presence,” the sense that the robot evokes the emotional trace of a lost or distant companion, made the past feel vivid and emotionally accessible. Through its tactile and behavioral features, the robot could reawaken memories or attachments, allowing the resident to re-engage with parts of their life history. In doing so, it reinforced the idea that the care recipient is not simply a passive subject of care, but an individual with a rich and ongoing personal narrative. As Sartre (1940) ⁴⁰ suggested in his theory of imagination, an object can temporarily “become” what it represents in the eyes of the individual. In this context, the robot does not just remind the resident of a pet, it momentarily assumes that emotional role, blurring the line between symbolic representation and lived emotional experience.

Between routine and renewal: how social robots may reshape professional practice

The introduction of social robots into care practices appeared to revitalize the daily routines of healthcare professionals. By expanding the repertoire of therapeutic tools available, these technologies opened up new possibilities for meaningful interaction and creative engagement within settings often marked by repetition and procedural constraints. As Laugier suggests, routinization in care work can give rise to a form of “ordinary opacity,” in which the significance of everyday gestures and interactions becomes obscured by their repetitiveness. ⁴¹ In contrast, the integration of social robots seemed to reintroduce a sense of purpose and novelty into daily care routines. Professionals described how the presence of the robot often sparked spontaneous reactions, created moments of joy or curiosity, and stimulated interactions that might not have occurred otherwise. These interactions were not only beneficial for residents but also rewarding for staff, who reported feeling re-engaged and inspired in their caregiving roles.

Moreover, the flexibility of SRIs enabled professionals to adapt their use across various contexts, thus fostering professional creativity and agency. Rather than following rigid protocols, staff could tailor the robot's use to align with residents’ preferences and capacities, which in turn allowed professionals to express their caregiving values more fully. In this way, the integration of social robots contributed not only to resident well-being but also to a renewed sense of purpose and engagement in professionals’ daily work.

Previous studies have also shown that robot-assisted interventions can enhance job satisfaction and help restore a sense of meaning among care professionals.^30,42 In our study, professionals described the robot as introducing a new dimension to their interactions with residents, one that was both therapeutic and imaginative. Unlike traditional nonpharmacological tools such as music therapy, sensory rooms, or empathy dolls, the social robot occupies a unique ontological position: it is neither animate like a living being nor inert like a conventional object. This ambiguity, which we interpret as a form of “technological strangeness,” seemed to evoke curiosity and fascination. Some professionals described this experience as a kind of “magic” that enriched the care environment and invited more spontaneous, engaging interactions.

Some professionals acknowledged that the robot's effectiveness can be difficult to explain logically. As one put it, “You have to believe in it,” reflecting how its impact often exceeded initial expectations. Even those who were initially skeptical described being surprised by the emotional engagement it fostered and the new opportunities it created for communication and connection. ⁴³ In this sense, social robots offer more than novelty, they may contribute to renewing the meaning of care itself. This renewal is not merely superficial. As Boudon suggests, shared belief in a tool's effectiveness within a professional culture can shape its impact. ⁴⁴ When thoughtfully embedded in daily routines, the robot functions as a symbolic mediator, concentrating intention, presence, and empathy in the care relationship. ⁴⁵ This perspective challenges widespread concerns about the potential for social robots to dehumanize care or erode professional expertise, as raised by scholars like Turkle (2006). ⁴⁶ Instead, the experiences described by professionals in our study suggest that, when implementation is thoughtful and well-supported, these technologies can reinforce rather than diminish humanistic values. Rather than replacing relational care, social robots may enhance professionals’ sense of purpose, fostering renewed commitment, creativity, and pride in their caregiving roles.

Institutional positioning and the visibility of innovation

From the perspective of institutional managers and administrative staff, the integration of social robots contributed to enhancing the external image and strategic positioning of the facility. These technologies were often presented as visible signs of innovation and personalization in care, frequently featured in communication materials such as promotional videos, interviews or reports. As reflected in the interviews, managers viewed these communication efforts as opportunities to publicly reinforce the facility's modern, human-centered approach.

In several cases, the decision to acquire one or more robots built on prior institutional experience with nonpharmacological technologies, and was supported by leadership committed to investing in gerontechnological innovation. In these contexts, the robot was not only a therapeutic tool but also a strategic asset, aligned with institutional development goals. Based on these findings, one could hypothesize that the adoption of social robots helped certain institutions construct a narrative of modernity, signaling their engagement with quality of care, well-being, and personalized geriatric care. The diversity of available interventions contributed to this image, suggesting a move away from standardized care toward individualized support.

Such framing may also serve practical functions. In a context of growing workforce shortages, visibly innovative practices could enhance the attractiveness of the institution to prospective employees and partners. As suggested by Granjon, modernity can operate as a symbol that makes abstract values, such as care quality, tangible, and publicly legible. ⁴⁷

Despite these promising observations, our findings indicate that robot-assisted initiatives remain fragile over time. Professionals reported that initial enthusiasm among residents, staff, and leadership often declined as novelty faded and organizational constraints re-emerged, reflecting patterns described in diffusion-of-innovation research in healthcare.

Sustained use was hindered by discontinuous funding, staff turnover, shifting care priorities, and the episodic nature of pilot projects. Robots were frequently acquired through temporary grants or research collaborations rather than recurring budgets, making maintenance, training, and replacement uncertain. Dependency on external funding, combined with leadership changes, evolving care policies, and limited formal procedures for integration into care pathways, interrupted usage trajectories even after early successes.

These dynamics suggest that adoption is not only a matter of technological acceptance but also of organizational sustainability and policy support. Ensuring long-term viability requires planning beyond pilot phases, including stable funding mechanisms, dedicated training structures, and explicit integration into care models rather than symbolic demonstrations of innovation.

Institutional communication strategies can enhance visibility and reinforce innovation narratives, yet they also raise ethical considerations related to privacy and the use of residents’ images for promotional purposes. Filming or photographing residents during innovative practices such as SRI sessions require careful consent procedures, particularly in dementia care settings. Clear institutional guidelines are therefore needed to ensure that communication practices remain respectful, transparent, and consistent with ethical standards of dignity and confidentiality.

Revealing and reinforcing existing organizational constraints

While professionals did not report that social robots generated new organizational tensions, their introduction often exposed and exacerbated pre-existing ones. These typically involved limited resources, such as time, staffing, and training, and occasionally highlighted hierarchical dynamics among professional roles within institutions.

One of the most frequently cited obstacles was time management. Although robots were generally well received, their use required significant preparation: scripting sessions with NAO, cleaning PARO after use, and coordinating staff schedules. These demands often clashed with the realities of staffing shortages, rotating shifts, and disruptions such as the COVID-19 pandemic. ⁴⁸ As a result, robot-assisted sessions were sometimes postponed or cancelled, undermining consistency and reducing their impact. Prior studies have similarly noted the additional workload that social robots can introduce in geriatric settings.^11,21,49 These difficulties are accentuated by the ongoing shortage of medical professionals willing to work in elder care, a gap that has prompted multiple public policies aimed at improving the sector's attractiveness and perceived value.^21,50

Training and knowledge transfer also emerged as persistent organizational challenges. In many cases, only a few designated “resource persons” (such as psychologists or managers) received formal training, resulting in knowledge silos that limited wider staff engagement with the technology. As our findings indicate, this selective training approach restricted the broader care team's ability to integrate social robots into daily routines. High professional turnover further exacerbated the problem: as trained individuals left, incoming staff often received little to no instruction, leading to a gradual erosion of expertise and a decline in robot usage. These dynamics reflect what has been described in the literature as “pilot project syndrome,” wherein promising innovations are introduced with initial enthusiasm but without the necessary long-term infrastructure to ensure sustainability. This reinforces calls from previous research for dedicated resources and institutional support to facilitate ongoing training and capacity-building in the use of social robots.^{10,11,19,21,49,51,52}

Issues of access and equity also emerged during implementation. In several facilities, robots were kept locked away to prevent damage or misuse, and their operation was limited to specific professional roles. While these precautions were often well-intentioned, they inadvertently created disparities between staff members and reduced the opportunities for informal or spontaneous use, interactions that had initially sparked enthusiasm and engagement. As highlighted in our findings, this concentration of expertise and authority around the robot risked reinforcing existing professional hierarchies, rather than fostering inclusive collaboration and shared ownership across the care team.

In summary, the successful introduction of a robotic device in an institution requires not only careful planning but also ongoing monitoring and adaptation over the long term. This ensures that the technology integrates effectively into care routines, aligns with institutional goals, and addresses the evolving needs of both residents and staff.^52,53

Difficulties in measuring and validating the outcomes of SRIs

Finally, implementation was rarely accompanied by follow-up mechanisms or structured evaluation. Although qualitative benefits were reported, there was little systematic collection of outcome data, and few institutions used standardized tools to monitor impact. This made it difficult to justify ongoing investment or to adapt practices based on resident responses. Although clinical outcomes were primarily described qualitatively by professionals, future implementations of SRIs could benefit from systematic outcome measurement aligned with the intervention's objectives. For example, cognitive stimulation and behavioral symptoms could be monitored using validated tools such as the Mini-Mental State Examination (MMSE), the Neuropsychiatric Inventory (NPI), or the Cohen–Mansfield Agitation Inventory (CMAI). Emotional well-being and quality of life effects could be assessed using instruments such as the Geriatric Depression Scale (GDS), the Quality of Life in Alzheimer's Disease scale (QoL-AD), or observational affect scales. Collecting such measures would strengthen clinical evaluability and facilitate comparison across settings. As in many healthcare innovations, the lack of outcome data weakened the feedback process necessary for continuous improvement. As Petersson et al. (2022) ⁵⁴ argue, both quantitative evaluation of clinical and organizational effects and qualitative assessment of healthcare professionals’ and patients’ experiences are essential to ensure meaningful and sustainable implementation. Furthermore, validation and ongoing evaluation of technologies, both before and after their integration into routine care, are needed to demonstrate quality improvements and optimize resource use.

More broadly, the clinical validation of social robots’ impact is challenged by the diversity of care settings, therapeutic goals, and comparator interventions. Standardized assessments often fail to fully capture the personalized, context-sensitive, and multidimensional outcomes that characterize SRIs. As a result, while the benefits may be apparent to professionals, translating them into generalizable evidence remains a significant barrier to broader adoption and policy support. Consequently, the clinical validation of these practices necessitates a more nuanced, multifaceted approach to assessment, one that accounts for the specific context, population, and intended therapeutic goals.^3,4,9

Given the HTA framework adopted in this study, future evaluations could more explicitly align mixed-method data collection with specific HTA domains and time points. Quantitative measures such as behavioral symptom scales or time-stamped resource utilization data could inform the Clinical effectiveness (EFF), Organizational (ORG), and Economic (ECO) domains, while qualitative interviews, observations, or video-based analyses could deepen understanding of Ethical (ETH) and Patient/social (SOC) dimensions. Collecting such data at baseline, mid-implementation, and post-implementation would strengthen temporal comparability and allow assessment of both immediate and sustained effects. This structured approach would support more robust HTA-informed evaluations of SRIs in geriatric care.

In the context of cost and efficiency analysis, our findings suggest that several categories of resource use are relevant for future evaluations. These include direct time-related costs (e.g., scripting and operating NAO, cleaning and maintenance for PARO), training and knowledge transfer demands, and organizational coordination activities associated with scheduling and interdisciplinary communication. While our qualitative design did not allow cost quantification, identifying these components provides a preliminary foundation for future economic evaluations of SRIs in geriatric care.

Navigating professional identity in relation to SRIs

As previously discussed, one recurring challenge reported by professionals was the difficulty in defining the nature and role of the robot. This ambiguity persisted throughout their experiences, reflecting the ontological indeterminacy of social robots, neither fully animate nor entirely inert. Their symbolic significance and technical complexity often made it challenging for caregivers to clearly situate them within the therapeutic landscape. As Emmanuel (2021) ⁵⁵ points out, the robot's identity is shaped by a series of implicit design decisions that may not always align with caregivers’ professional values or clinical aims. This misalignment reinforces the need for ongoing ethical reflection and participatory dialogue during the implementation of social robot interventions. ⁴⁶ Moreover, the robot's ambiguous status, situated between machine and “partner,” can unsettle established norms and expectations within care relationships. ⁵⁶

These uncertainties are particularly challenging in professions grounded in the ethics of care, where relational presence, empathy, and intuition are essential to practice. The robot, functioning as a third-party entity with preprogrammed behaviors, may inadvertently disrupt the practitioner–care recipient dynamic. While many professionals ultimately came to view the robot as a helpful tool, their initial hesitation often revealed deeper philosophical concerns about its compatibility with human-centered care principles.^{21,24,56–58}

Reaffirming the key role of professionals in care delivery

Recurring lack of clarity regarding the robot's operational role in care delivery, its place within professional relationships, and its strategic purpose within the institution also had direct implications for professional well-being. Some professionals voiced concerns about being replaced or marginalized, particularly in contexts where the robot was prominently featured in media or institutional campaigns. These campaigns often emphasized technological innovation, sometimes overshadowing the emotional labor and relational expertise that caregivers contribute. In facilities already facing staffing shortages or high workloads, this ambiguity could lead to feelings of devaluation or a diminished sense of purpose. While many professionals ultimately came to view the robot as a helpful tool, its unclear positioning occasionally challenged their professional identity and confidence in their caregiving role.^11,21

Respondents emphasized the importance of presenting the robot not as an autonomous agent, but as a tool, an instrument of care whose effectiveness depends entirely on the professional's intentions and guidance. As Damour highlights, science fiction-inspired narratives about artificial intelligence often project symbolic meanings onto robots that far exceed their actual capabilities, blurring the line between imagination and reality. ⁵⁹ These narratives can shape unrealistic expectations and contribute to misunderstandings about what robots can and cannot do in care contexts. In this light, several professionals underlined the importance of grounding social robotics in ethically reflective and pragmatically oriented practices, ensuring that care remains fundamentally human-driven, with technology supporting rather than supplanting professional presence, judgment, and values.