Needs, Functions, and Technologies of Technical Assistance Systems
in Nursing Context: A Systematic Review
Alexander Hammer
1,2 a
, Bastian Wollschlaeger
3b
, Martin Schmidt
1c
and Lena Otto
2d
1
Institute of Biomedical Engineering, Technische Universität Dresden, Dresden, Germany
2
Chair of Wirtschaftsinformatik, esp. Systems Development, Technische Universität Dresden, Dresden, Germany
3
Chair of Technical Information Systems, Technische Universität Dresden, Dresden, Germany
Keywords: Ambient Assisted Living (AAL), Health Smart Home (HSH), Technical Assistance Systems,
Care-Dependency, Systematic Review.
Abstract: Due to the ageing of society, health insurers and care sectors in many Western countries are facing major
challenges. Technical Assistance Systems (TAS) could have the potential to ease the situation, while at the
same time promoting the independence and self-determination of care-dependent people. However, TAS have
not yet been fully established in nursing. Reasons for this include an inadequate systematisation of the re-
search and development area and the lack of uniform terminology, which leads to poor comparability and thus
to missing financing models. To tackle this condition and help to select functions and technologies based on
needs, we conduct a systematic review identifying needs, functions, and technologies as areas of interest
addressed in 50 evaluated TAS approaches. Further, this work assesses gaps in TAS research and aims to
create a uniform understanding of assistance functions.
1 INTRODUCTION
An increasing average life expectancy (Destatis,
2019), combined with an ageing population (Nowos-
sadeck, 2013; Peters et al., 2010), are central chal-
lenges for many Western countries. The nursing rate
and the care costs both increase disproportionately
strong with an increasing prevalence of age-related
diseases. Due to the baby boomers’ retirement over
the next years, a decreasing working population must
face an increasing workload as well as increasing
costs in the nursing sector (RKI & Destatis, 2015).
Technical Assistance Systems (TAS) are men-
tioned as a promising approach for coping with this
trend in the 2015 health report by the Robert Koch
Institute (RKI) and the German Federal Statistical
Office (Destatis). TAS are expected to have great po-
tential to strengthen the independence and self-deter-
mination of care-dependent people as well as to re-
lieve caring relatives and caregivers (RKI & Destatis,
2015). TAS can be understood as technical aids for
supporting care-dependent people at home and in
a
https://orcid.org/0000-0002-1984-580X
b
https://orcid.org/0000-0002-1101-0680
c
https://orcid.org/0000-0003-4012-0608
d
https://orcid.org/0000-0003-3814-4088
inpatient care facilities regarding health-promotion,
preventive, curative, rehabilitative, and palliative care
(Lutze et al., 2019). However, there is no common
definition for TAS, usually also referred to as Health
Smart Homes (HSH; Wollschlaeger & Kabitzsch,
2019), Ambient Assisted Living- (AAL), and Assistive
Living-Technologies (Elsbernd et al., 2012), or
Assistive Devices (Marasinghe, 2016; Steel et al.,
2009). TAS can support various aspects of care- or
support-dependency (see Figure 1) in a psychologi-
cal, physiological, or health-related manner, affecting
care-dependent people’s autonomy, participation,
safety, or quality of life positively (Lutze et al., 2019).
In TAS, technologies are used to provide assistance
functions (hereinafter referred to as functions)
according to user needs and requirements (Woll-
schlaeger & Kabitzsch, 2019). Thus, the suc-cess of
TAS does not only require their availability at
acceptable costs but also the selection of functions
and technologies that are adapted to the needs and
requirements of potential users (Karlsson et al., 2011;
McCreadie & Tinker, 2005; Weiß et al., 2013).
Hammer, A., Wollschlaeger, B., Schmidt, M. and Otto, L.
Needs, Functions, and Technologies of Technical Assistance Systems in Nursing Context: A Systematic Review.
DOI: 10.5220/0010254804930500
In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) - Volume 5: HEALTHINF, pages 493-500
ISBN: 978-989-758-490-9
Copyright
c
2021 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
493
Figure 1: Aspects of care and support dependency, defined
in the new assessment instrument of German social long-
term care insurance from 2017 (Pick et al., 2019).
However, even though TAS are expected to have
the potential for supporting activities in the nursing
context, they have barely gained acceptance to date
(Lutze et al., 2019). Two reasons for this are the
inadequate systematisation of the broad and inter-
disciplinary research and development area of TAS
and the lack of a uniform terminology, which leads to
poor comparability. As a result, very few develop-
ment projects are brought to market as mature and
affordable TAS, subsidised from longterm care
insurance (Kunze & König, 2017; Weiß et al., 2013).
With this paper, we intend to help innovative TAS
projects to bridge the gap between being an
innovation and a market-ready solution. To this end,
we tackle the missing systematisation of the research
and development area of TAS by conducting a
systematic review identifying needs, functions, and
technologies as areas of interest addressed in
evaluated TAS approaches.
This paper provides the following main
contributions: i) An analysis of the current state in
TAS research concerning functions, addressed needs,
and used technologies, which ii) provides guidance
for new TAS projects to facilitate a needs-based
selection of functions and technologies, and iii) an
assessment of existing gaps in TAS research.
The remainder of the paper is organised as
follows: The next section introduces the method and
section 3 the findings of the literature review.
Subsequently, section 4 discusses the results in the
context of related research. Section 5 concludes the
paper with a summary and potential further research.
2 METHOD
Three aspects represent the core of this article, assis-
tive technologies, their functions, and needs related to
them. To identify all three aspects, a systematic liter-
ature review was conducted. We searched across the
three databases PubMed/Medline, Academic Search
Elite (EBSCOhost), and Web of Science, the former
covering studies in the medical field, the latter two
as these are interdisciplinary databases – covering di-
verse fields not included in PubMed. Relevant search
terms were identified and combined; synonyms were
tested for results. The final search string combines a
search for requirements (incl. synonyms such as
“need”) of assistive technologies (incl. synonyms
such as AAL, HSH) with a care (and relevant syno-
nyms) context. Applying the search string in the three
databases in July 2020 yielded 1,559 results.
After removing duplicates, titles and abstracts of
1,218 records were screened. During the screening,
those records were included, where hardware compo-
nents of the technology were described, the system
reported was already validated and the target group
were adults. Records were further excluded if no
needs or functions were named, or the study described
an assistance system that was already described more
comprehensively in other studies included. Only
peer-reviewed journal papers in English or German
language were included. No time restrictions were ap-
plied. After excluding 1,025 records, which did not
meet the inclusion criteria, 193 records were further
assessed regarding their eligibility by reading the full-
text articles. The inclusion criteria reported above
were again applied.
Finally, 50 studies were included for qualitative
content analysis according to Mayring (2015). The
goal was to extract information about the assistive
technologies, their functions, and needs related to
them. For identifying assistive technologies and their
functions, no pre-defined categories were applied, but
categories were built inductively. The needs of people
involved were initially categorised deductively, i.e.
based on pre-defined categories, namely the aspects
of care and support-dependency, defined in the new
assessment instrument of German social long-term
care insurance from 2017 (Pick et al., 2019), and de-
scribed above (see Figure 1). The existing categories
were further refined by additional inductive catego-
ries. Also, superior categories were identified to fur-
ther cluster the results of all three aspects.
3 RESULTS
3.1 Target Groups
The analysis of the 50 articles showed that TAS are
being developed for many different target groups (see
Care-Dependency
Su
pp
ort-De
p
endenc
y
Non-domestic activities
Housekeeping
Design of everyday life and
social contacts
Coping with/independent
handling of illness or therapy-
related demands
and stresses
Self-sufficiency (personal
hygiene, nutrition etc.)
Behavioural patterns and
psychological problems
Cognitive and com-
municative skills
Mobility
HEALTHINF 2021 - 14th International Conference on Health Informatics
494
Table 1), mainly older people (26 out of 50) or people
with typical age-associated diseases, such as Parkin-
son’s (2 out of 50), or Dementia and/or mild cognitive
impairment (MCI; 14 out of 50).
Table 1: Quantity of target groups, addressed in the research
and development process of TAS in the articles examined.
Target Group Quantity
Elderly 26
Cognitive Disordered
(mainly Dementia and MCI)
15
Third Parties 11
Movement Disordered 4
Cognitive and Movement Disordered
(e.g. Parkinson’s)
3
Increased Risk for Diseases 2
Visually Impaired 2
Verbal and Communication Impaired 1
3.2 Functions
The TAS functions presented in the 50 articles can be
divided into six inductively formed categories
(F1 – F6; see Table 2). These include the manual
emergency call, which is consciously triggered by the
user's action and serves to call for help, as well as the
status monitoring function, which enables self- or ex-
ternal monitoring of a condition (indoor/outdoor po-
sition, health, sleep) and, if necessary, the triggering
of an automatic emergency call. Activity monitoring
includes TAS that monitor the user’s activities to map
daily activities, detect anomalies (falls, behaviour dis-
ruption, wandering, seizures). The environmental
monitoring function describes the ability of a TAS to
monitor the user's surroundings to identify emergen-
cies or sources of danger. Both, the activity, and the
environmental monitoring can, if necessary, trigger
follow-up actions. Therapy/activation-functions aim
to positively influence people's behaviour or their
mental and physical health, e.g. by supporting thera-
pies or providing targeted information and recom-
mendations. TAS supporting users in their everyday
life were subsumed under the Assistance function.
Note that a TAS can have several functions, which
can be assigned to either one or more categories.
3.3 Functions and Technologies
In addition to the functions of the TAS, the technolo-
gies used to implement these functions were identi-
fied and divided into inductively formed categories
(T1 – T4): mobile security alarm, sensors, interfaces,
and robots. Again, multiple technologies can be used
in a single TAS to implement one or more functions.
As illustrated in Table 2, sensors were by far the
most frequently used technology, followed by inter-
faces. The most common sensors (mainly used for
monitoring) are environmental sensors, while the
most common interfaces are tablets and smartphones.
Interfaces are primarily used for therapy/activation
and assistance functions. In case of therapy/activation
they are often combined with environmental sensors
or cameras, e.g. for monitoring the execution of exer-
cises, providing feedback, or monitoring progress
(Pastorino et al., 2014). Although, robots were rarely
applied, they can be used for realising functions from
nearly all categories.
3.4 Functions and Needs
The need categories (N1 – N12) include the aspects
of care- and support-dependency mentioned before
(see Figure 1) as well as the inductively built catego-
ries safety, autonomy, health, and third-party needs
(see Table 2). The satisfaction of safety, autonomy,
and health needs are by far the most common goals of
TAS. In contrast, only a few TAS address housekeep-
ing, self-sufficiency, behavioural and psychological
problems, or activities outside the home.
TAS with activity monitoring often additionally
address the needs of third parties, as they allow the
detection of various anomalies, such as behavioural
disorders, and thus facilitate care work (Corno et al.,
2017) or bring peace of mind to relatives (Mitchell et
al., 2020). TAS with therapy/activation functions, in
addition, often address the need for coping with ill-
ness and/or therapy-related burdens.
Cognitive and communicative needs are almost
exclusively focused on by TAS with therapy/activa-
tion functions. The main aim here is to influence care-
dependents’ clarity and memory (e.g. Kerssens et al.,
2015) or to give them the ability to communicate their
needs (Bozomitu et al., 2019). Behavioural and psy-
chological problems are only addressed by functions
from the field of therapy/activation which aim to pos-
itively influence the behaviour of the person in need
of care and thus create a system to support emotional
self-regulation (Torrado et al., 2017) or to prevent
falls (Paul et al., 2017). Needs from the area of self-
sufficiency are only addressed by two TAS, which are
designed to support independent food intake (by us-
ing reminders, Borelli et al., 2019) or automatic cli-
mate regulation (Hudec & Smutny, 2017).
Needs, Functions, and Technologies of Technical Assistance Systems in Nursing Context: A Systematic Review
495
Table 2: Mapping between functions and the addressed needs of care-dependent people and the technologies used.
Legend: If a value is greater than 1.5 times the mean value of a column, i.e. that a function was implemented particularly
frequently in combination with a certain technology, it is highlighted in green. Values greater than 1.5 times the mean value
of a row, i.e. the corresponding technology is used particularly frequently for a special function, are highlighted in blue. If
both are true, the value is highlighted in grey. The highlighting was also provided for the technologies’ sub-categories (lighter
colours, which represent the same colour scheme). Since a single TAS can have several functions, combine several technol-
ogies and address multiple needs, the column and row totals do not match the total number of TAS per category.
Functions
F1 F2 F3 F4 F5 F6
Manual
Emer-
gency Call
Status
Monitoring
Activity
Monitoring
Environ-
mental
Monitoring
Therapy/
Activation
Assis-
tance
7 18 25 8 18 13
Technologies
T1 Mobile security alarm 1
1 1
T2 Sensors 42
3 15 24 6 11 4
T2.1 Environmental sensors 24 1 7 1 5 4 3
T2.2 Smart objects 12 1 3 7 1 1 1
T2.3 Smartphone sensors 5 2 2 3
T2.4 Audio sensor 3 1 1 1
T2.5 Camera 9 2 3 5 2
T2.6 Smart wear 4 3 2
T2.7 Medical measuring device 5 5 1
T2.8 Smartwatch sensors 3 1 2
T3 Interfaces 24
4 3 2 15 9
T3.1 Computer 5 1 5 1
T3.2 Smartwatch 5 2 3
T3.3 Smartphone 6 2 2 3
T3.4 Sound player 5 2 2 2
T3.5 Tablet 6 2 1 3 5
T3.6 SmartTV 2 2 1
T3.7 Braille 1
1
T3.8 Telephone 1 1 1
T3.9 Haptic actuator 1 1
T4 Robots 4
1 1 1 2 3
Needs
N1 Mobility 8
1 1 1 4 3
N2
Cognitive and communica-
tive
8
1
2 1
5 2
N3
Behavioural and psycho-
logical problems
2
2
N4 Self-sufficiency 2
2
N5
Coping with illness and
/or
therapy-related burdens
10
2
7 2
N6
Everyday life and social
contacts
9
1 2 2
3 4
N7 Activities outside the home 3
1 1 2
1
N8 Housekeeping 1
1 1
N9 Safety 22
5 10 15 5 3 5
N10 Autonomy 21
4 10 10 4 8 5
N11 Health 24
2 10 8 1 10 7
N12 Third-party needs 11
1 4 8 1 1 1
HEALTHINF 2021 - 14th International Conference on Health Informatics
496
4 DISCUSSION
4.1 Focus on Potential Users
The majority of the TAS is aimed at the elderly or
people with age-related diseases. This means that
functions from the monitoring areas predominate as
they are preferred to enable older people to live as au-
tonomously as possible in their own homes. On the
contrary, functions from the assistance area are un-
derrepresented as they are preferably aimed at other
target groups, such as communication support sys-
tems for people with communication problems
(Hudec & Smutny, 2017) or systems for self-regula-
tion for autistic people (Torrado et al., 2017). This im-
plicates that the spectrum of functions that are typi-
cally used in connection to older people, their needs,
and the technologies necessary for implementation, is
significantly more representative than for other target
groups and the TAS in these categories are over-rep-
resented. Since (caring) relatives and medical or nurs-
ing specialists are often the main users of the TAS,
and not the care-dependent people themselves, the
needs of these third parties also need to be considered.
4.2 Standardisation of Functions
To assess the pervasion of TAS functions from re-
search to practice, we compared the functions identi-
fied in this review with categories of functions al-
ready included in standardisation. A taxonomy of
standardised functions, which has been collated in
Wollschlaeger & Kabitzsch (2019), is depicted in
Figure 2. The TAS functions identified in this work
have been mapped with the categories of the taxon-
omy as indicated by colour
1
in Figure 2. It is apparent
that, in research, the TAS functions mainly focus on
the safety and security aspects, esp. on the category
“Protection of Health” (F1 F4, F6). Another area of
emphasis can be found in the categories “Communi-
cation & Multimedia” (some aspects of F5) as well as
“Fire and Average Protection” (F4). Interestingly,
most TAS functions for exercise and for influencing
behaviour (F5) are not represented in the taxonomy.
This might be due to them being quite recently devel-
oped use cases that have not yet been established and
introduced in the standardisation process.
Aspects such as “Usability” and “Intrusion Pro-
tection” are covered by standardisation, but are
mostly not in the focus of research as well as many
functions from the “Smart Home” category. An ex
1
darker colour represents TAS functions being mapped
more frequently to a category
Figure 2: Taxonomy of functionality categories contained
in standardisation, adapted from Wollschlaeger &
Kabitzsch (2019). The categories found in the systematic
review are indicated by colour.
planation for this might be that research papers that
focus on these aspects might have been excluded due
to missing validation. However, the differences be-
tween TAS research and standardisation indicate that
for successful TAS in practice, a more holistic view
is required, including re-use of existing technical
equipment and functionality.
4.3 Meeting User Needs
The results of our review suggest that all needs de-
rived from the new assessment instrument of German
social long-term care insurance were addressed by the
functions of TAS in the examined papers. The focus
of the investigated TAS seems to be the safety-, au-
tonomy- and health-related user needs. Our study
shows that there is a lot of catching up that has to do
with TAS, which address behavioural and psycholog-
ical problems or support self-care, activities outside
the home, and housekeeping for care- or support-de-
pendent people.
To put our results about user needs into perspec-
tive, they can be compared with the coverage of needs
identified by Lutze et al. (2019) in their literature re-
view on TAS-users’ benefits. In contrast to us, Lutze
et al. (2019) define autonomy as a super-category for
the modules of the new assessment instrument. Both
Lutze et al. (2019) and we have included safety as an
additional category. In total, a trend similar to ours
regarding the relative frequency of needs is emerging.
Lutze et al.'s (2019) results also confirm that few TAS
are developed, which address behavioural and psy-
chological problems or support self-care, activities
outside the home, and house-keeping.
In their comparison of the requirements for TAS
for cognitively impaired people with current research
approaches, based on a scoping review, Blackman et
Smart Home Assistance Systems
Comfort
Energy Efficiency
Communication & Multimedia
Accessibility
Usability
Building Services
Adaptability
Supportive (w.r.t. Strength)
Safety & Security Lighting
Shading
Heating, Cooling, Air
Conditioning
Protection of Health
Fire and Average Protection
Intrusion Protection
Needs, Functions, and Technologies of Technical Assistance Systems in Nursing Context: A Systematic Review
497
al. (2016) criticise the often-prevailing understanding
of "need", which leads to a failure of the actual pur-
pose of TAS. According to Blackman et al. (2016),
many TAS focus on physiological needs with the goal
of relieving medical and social resources, and needs
are often misunderstood as deficits, illnesses, or de-
pendencies. Thus, the aim of TAS to assist the elderly
in living an autonomous and dignified life and to re-
main included in the society is often neglected. This
contradicts this work’s results, which found that most
of the examined studies feature TAS with a focus on
the autonomous life of older people in the home en-
vironment or on maintaining a social life.
Furthermore, Blackman et al. (2016) criticise that
the majority of the publications analysed lack theoret-
ical underpinnings of TAS. Since we had to exclude
37 articles due to missing information on the ad-
dressed user needs, we can partially confirm this crit-
icism. A lack of references to needs in the research
and development of TAS has also been frequently re-
ported in previous research (Biniok & Lettkemann,
2017; Choi et al., 2019; Nagapuri et al., 2019). This
is another barrier for the adoption of TAS in practice,
as the focus on user needs is important for TAS to be
accepted by potential users and thus prevail on the
market (McCreadie & Tinker, 2005).
4.4 Technology Requirements
Requirements (additional to the needs) for the TAS
should be determined and matched with technologies
that meet these requirements best regarding the target
group or the individual. Elderly people e.g. often have
problems in operating smartphones (Costa et al.,
2015) due to the small displays (Paul et al., 2017).
User acceptance of TAS that record video or sound is
often low (Gerka et al., 2019; Tunca et al., 2014) as
users feel restricted in their privacy and are concerned
about personal data. This is also reflected in the low
number of TAS using cameras for monitoring pur-
poses. For sufficiently high reliability of activity, en-
vironment, or status monitoring systems, a larger
number of sensors is often necessary, which in turn
increases the costs and the energy consumption of the
TAS, and potentially harms the privacy of the users
(Grgurić et al., 2019). In general, TAS and the tech-
nologies used should, among other things, be charac-
terised by aspects such as reliability, robustness, the
protection of privacy, the security of private data, a
low environmental impact, and low costs (Borelli et
al., 2019; Grgur et al., 2019; Nazemzadeh et al.,
2015; Tunca et al., 2014). This is especially challeng-
ing when using sensor networks or modern internet
and cloud-based services (see Addante et al., 2019).
Similar to the area of functions, the technical per-
spective and the increasing importance of a person's
home for health care (Haux et al., 2016) advocates for
an additional, more holistic perspective on HSH.
Maeder and Williams (2017) view HSHs as systems-
of-systems and capable of becoming part of a health
services continuum. To this end, they encourage to
also shift the development strategy from a bottom-up
manner to an overarching approach. Considering
HSHs as systems of systems will most likely become
more relevant in the future as technology becomes
more mature and available as off-the-shelf compo-
nents so that utilising the existing residential infra-
structure or devices (such as entertainment or home
automation appliances) for health benefits seems
promising. In this context, the importance of integra-
tion and interoperability standards as open challenges
for HSHs are underlined by researchers such as
Memon (2014), Haux et al. (2016), or Maeder and
Williams (2017). This is in line with our observations
that a more holistic view of TAS is required for them
to be used in practice.
4.5 Limitations
Conducting a systematic literature review is always
limited by a certain subjectivity of the process. Ap-
plying other search strings or using other databases
could have led to different results. The in- and exclu-
sion process is subjective as well as the qualitative
content analysis. Furthermore, the process of select-
ing relevant literature was only carried out by one au-
thor. Thus, no statement can be made on the reliability
of the results, as provided by Mayring (2015) in the
form of calculating intercoder reliability.
No quality assessment of the articles analysed
took place. Rather, the selection of the TAS should
depend on the functional efficiency of the TAS.
The number of TAS presented in the literature re-
viewed varies greatly across the various categories for
functions, needs, and technologies, so that the fre-
quencies presented in this work should be interpreted
carefully. Since, e.g., monitoring functions were most
frequently integrated into the investigated TAS, needs
addressed by these functions may be overrepresented.
5 CONCLUSION
The purpose of this paper was to summarise the situ-
ation in the broad and interdisciplinary research area
of TAS to overcome their missing systematisation.
Therefore, we conducted a systematic literature re-
HEALTHINF 2021 - 14th International Conference on Health Informatics
498
view of 50 mature TAS and created a mapping be-
tween functions, implementation technologies and
addressed user needs. The focus of the examined TAS
lies on assistance systems that are intended to enable
elderly people or people with dementia to live an au-
tonomous and dignified life in their home environ-
ment. To this end, sensor technologies are the most
common technology used. The large variety of ad-
dressed needs implies that individual TAS will often
be used in combination with other TAS or appliances.
Our results support the demand for a more holistic
view of TAS as meaningfully networked technologies
to create an interoperating system for a specific con-
text instead of many individual systems. Therefore,
the interoperability and integrability of technologies
must be considered, while simultaneously examining
user requirements. Future work should adopt a view
on requirements based on a resource-focused mind set
(e.g. WHO ICF classification of Functioning, Disa-
bility and Health
2
), rather than a deficit-oriented per-
spective. To overcome the confusion in this research
field, it is furthermore important to strive for a uni-
form understanding of assistance functions in future
work. By offering an analysis of the current state and
guidance for further research and development pro-
jects, this paper contributes to this understanding.
ACKNOWLEDGEMENT
The work for this paper was partially funded by the
European Social Fund and the Free State of Saxony
(Grant no.100310385).
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