Needs, Functions, and Technologies of Technical Assistance Systems

in Nursing Context: A Systematic Review

Alexander Hammer

1,2 a

, Bastian Wollschlaeger

, Martin Schmidt

and Lena Otto

Institute of Biomedical Engineering, Technische Universität Dresden, Dresden, Germany

Chair of Wirtschaftsinformatik, esp. Systems Development, Technische Universität Dresden, Dresden, Germany

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

https://orcid.org/0000-0002-1984-580X

https://orcid.org/0000-0002-1101-0680

https://orcid.org/0000-0003-4012-0608

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

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

ort-De

endenc

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

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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)

Third Parties 11

Movement Disordered 4

Cognitive and Movement Disordered

(e.g. Parkinson’s)

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

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

Cognitive and communica-

tive

2 1

5 2

Behavioural and psycho-

logical problems

N4 Self-sufficiency 2

Coping with illness and

/or

therapy-related burdens

7 2

Everyday life and social

contacts

1 2 2

3 4

N7 Activities outside the home 3

1 1 2

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

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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

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

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; Grgurić 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

), 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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