Experience of Healthcare Workers who Used AI Therapy Robot PARO During the COVID-19 Pandemic

Experience of Healthcare Workers who Used AI Therapy Robot PARO During the

COVID-19 Pandemic

Chapter 1: Introduction to the Study

The term “burnout” is commonly used among people who work in the human

services field to describe their work experiences (Maslach & Leiter, 2016). Freudenberger

(1973, 1974, 1975) reported on the phenomenon among healthcare workers who worked

at a free clinic, including Freudenberger himself, and coined the term “burnout.”

Freudenberger detailed the burnout syndrome and discussed what people could do to

change the culture of the field and the facility healthcare workers worked for in the

1970s. The healthcare worker burnout research trend started; healthcare worker burnout

has continued to be researched, raising awareness of unhealthy culture today. The

unhealthy culture of the healthcare field, such as seeking mental health support or taking

time for self-care was frowned upon or judged because the healthcare field instead

focused on the business and profit more than the healthcare workers’ well-being (Goetzel

et al., 2018; Maslach & Leiter, 2016; Stevens, 1996). Researchers reported increasing

suicide rates among healthcare workers from late 2000 to mid-2010 in the United States

(Davis et al., 2021; Elkbuli et al., 2020; Kingston, 2020; Rothenberger, 2017) as an

alarming phenomenon despite the fact that the issue of healthcare worker burnout was

well-researched and addressed for many years. Soon, COVID-19 came to the United

States, and a lockdown was enforced in March 2020 before the cultural and systematic

changes in the healthcare field were established. COVID-19 exacerbated and worsened

the healthcare workers’ stress levels and psychological wellness.

During the COVID-19 pandemic, healthcare workers deplored the lack of

physical and emotional support, help, and resources to care for patients with COVID-19

under the strict rules of isolation from the healthcare workers’ support system to avoid

spreading COVID-19. One study (Shibata et al., 2021) reported a few healthcare workers

who used an animal-shaped (i.e., a baby harp seal designed) socially assistive and

interactive robot PARO (a short description of “personal robot” in Japanese) while

treating patients with COVID-19 during the COVID-19 pandemic. This study is to

understand and explore the experience of healthcare workers who used PARO and find

out how PARO was used and how using PARO could contribute to a positive change in

the healthcare field.

This chapter discusses the background of this research, the problem statement,

purpose, research questions, the conceptual framework that this research was built on,

and research methods. In addition, this chapter elaborates on the nature of this research,

assumptions, and significance of this research.

Background

Many critical and vital social movements occurred in the 1970s in the United

States; such social movements dramatically influenced politics, healthcare, laws, and

human rights, and the influence of the social movements continues to be discussed and

argued today. One of the crucial movements in the healthcare field during the 1970s was

the free clinic movement along with healthcare worker burnout. The free clinic

movement was initiated by Dr. David E. Smith, stressing the impending needs to provide

quality healthcare services to all people, especially to underserved populations (Smith,

1976). Stemming from this movement, Freudenberger (1973, 1974, 1975) published

reports on the experience of healthcare workers who worked in free clinics, including

Freudenberger himself. Freudenberger coined the term “burnout” when providing

qualitative descriptions of how the healthcare workers were in free clinics. Freudenberger

published studies on healthcare worker burnout to seek social awareness and support and

make changes in the healthcare system and structure to reduce the severe distress of

healthcare workers. In Freudenberger’s reports, Freudenberger noted that the culture of

the work environment needed to change, which would need to be initiated by the

leadership and administrators of the organization. The healthcare worker burnout

phenomenon identified by Freudenberger and research on burnout among healthcare

workers was inherited by other researchers and healthcare practitioners (David et el.,

2021; Freudenberger, 1974; Kalmoe et al., 2019; Kingston, 2020; Maslach & Leiter,

2016). Many researchers pointed out that burnout syndrome was strongly and positively

correlated with severe depression, including suicidal ideation and substance use problems

among healthcare workers (Elkbuli et al., 2022; Gold, 2020; Holmes et al., 2020; Kalmoe

et al., 2019; Kingston, 2020; Moutier et al., 2021; Rothenberger, 2017; Shelley, 2019).

The research on healthcare worker burnout focused more on needed changes in the

culture of stigmatizing seeking mental health awareness, support, and treatment,

including severe depression (i.e., suicidal ideation and attempts) and substance use

problems among healthcare workers (Eliacin et al., 2018; Elkbuli et al., 2020; Knaak et

al., 2017; Maslach & Leiter, 2016; Moutier et al., 2012; Peterson et al., 2020).

The gap identified was that there had not been significant changes made in the

culture and attitudes in the healthcare field regarding healthcare workers seeking support

and help to improve healthcare workers’ psychological wellness. This study was to be

part of the research tradition of healthcare worker burnout and diversify seeking mental

health care and support without feeling judged, afraid, or guilty about the choices

healthcare workers would make to improve healthcare workers’ psychological wellness in

the healthcare work environment.

Problem Statement

The problem identified for this study was the dire need for significant changes in

the culture and attitude in the healthcare field regarding healthcare workers seeking

mental health care and support and reducing burnout symptoms, risk of self-harm, severe

depression, and substance use problems. The phenomenon of healthcare worker burnout

has been studied and reported since the 1970s (David et el., 2021; Freudenberger, 1974;

Kingston, 2020; Maslach & Leiter, 2016). Kingston (2020) reported that existing

intervention programs such as educating healthcare workers, creating wellness programs

in the work environment of healthcare workers, or increasing access to treatment

resources did not show significant positive changes in reducing physician burnout

symptoms. Researchers reported particularly focusing on more individualized innovative

interventions need to be considered in order to reduce burnout syndrome and risk of

selfharm and to improve the wellness management system at healthcare work sites

(Alikhani et al., 2020; Huckvale et al., 2019; Sasangohar et al., 2020; West et al., 2016).

When COVID-19 hit the United States in early 2020, healthcare workers’ work

experience and burnout symptoms were exacerbated (Alikhani et al., 2020; Kalmoe et al.,

2019; Laboe et al., 2021; Shelley, 2022); it was like a disaster striking an area that was

unprepared for the disaster. The COVID-19 pandemic revealed no notable cultural and

systematic changes had been made in the healthcare field to reduce burnout syndrome or

have practical psychological wellness support for healthcare workers. At the same time,

the COVID-19 pandemic also revealed dramatic changes in helping healthcare workers’

mental health support and intervention choices were needed badly (Alikhani et al., 2020;

Huckvale et al., 2019; Sasangohar et al., 2020; West et al., 2016). Researchers discussed

the need to utilize technologies for interventions to improve accessibility for

psychological wellness support with psychiatric patients (Huckvale et al., 2019) and the

need for more individualized interventional strategies (West et al., 2016), such as

interventions and support strategies particularly to detect the signs of burnout syndrome

sooner in order to lower the suicide risk of healthcare workers, reducing severe

depressive symptoms (Davis et al., 2021; Sasangohar et al., 2020).

Socially assistive and interactive robotics have been developed and researched

since the late 1990s. PARO (a short description of “Personal Robot” in Japanese

language) is one of the socially assistive and interactive robots created during that time.

Initially, the purpose of developing PARO was to create an “animal type robot” that could

interact with humans emotionally, based on the pets and animal-assisted therapy concepts

(Shibata et al. 2001). Animal-assisted therapy has been known as an evidencebased

treatment strategy and utilized to treat children and adults with mood problems and

trauma symptoms (Levinson, 1969; Kruger & Serpell, 2006; Mims & Waddell, 2016).

PARO has been researched since PARO was introduced as a socially assistive robot with

an artificial intelligence (AI) system and a therapeutic medical device for older adults

with dementia in the late 2000s (Shitaba, 2010). The use of PARO received positive

reviews, such as that using PARO helped improve older adults’ moods (Moyle et al.,

2017; Petersen et al., 2017; Pu et al., 2019; Thodberg et al., 2016), reduced the use of

medications (Kelly et al., 2021; Petersen et al., 2017), and helped reduce pain (Pu et al.,

2019). Geva et al. (2020, 2022) particularly reported that PARO was effective with

healthy older adults in reducing physical pain and increasing oxytocin levels.

One study (Shibata et al., 2021) reported that a few healthcare workers used

PARO during the COVID-19 pandemic while at work. This current study is to explore

and understand healthcare workers who used PARO during the COVID-19 pandemic in

order to fill the gap identified by the literature review of this study, which was the

ongoing need for significant changes in the culture and attitudes in the healthcare field

regarding healthcare workers’ need for mental health support to improve healthcare

workers’ psychological wellness, including reducing the risk of self-harm and substance

use problems.

Purpose of the Study

This study was qualitative research and built on constructivism as a philosophical

orientation with relativism as ontological foundation. Constructivism asserted humans’

interpretation and subjective experiences constructed the nature of truth and reality; the

nature of truth existed inside humans’ perspectives (Burkholder & Burbank, 2016). This

qualitative research aimed to explore and understand the lived experiences of healthcare

workers who used PARO during the COVID-19 pandemic by interviewing healthcare

workers who used PARO during the COVID-19 pandemic and interpreting and analyzing

the data drawn from the interview transcripts and finding meanings healthcare workers

who used PARO constructed in order to answer the research questions. Aligned with the

relativist philosophical orientation of this research clarified, the reality was built by the

subjective views of the healthcare workers who used PARO during the COVID-19

pandemic. Therefore, hermeneutic phenomenology was selected for this qualitative study.

One study (Shibata et al., 2021) mentioned the use of PARO by healthcare

workers who worked with patients/clients during the COVID-19 pandemic. It was

challenging to find a study of using PARO by healthcare workers during the COVID-19

pandemic because no other studies reporting of the phenomenon found. The purpose of

this qualitative research was to explore and understand the lived experiences of the

healthcare workers who used PARO during the COVID-19 pandemic and find out what

meanings these individuals found through interpretation of the data collected through

qualitative interviews.

Research Questions

The questions below were prepared to understand and explore the lived

experiences of healthcare workers who used PARO during the COVID-19 pandemic and

find out the healthcare workers’ experience using PARO during the COVID-19 pandemic;

subquestions to gain answers to research questions are listed in Appendix A. RQ1: What

were the lived experiences of healthcare workers who utilized PARO during the COVID-

19 pandemic?

RQ2: How could using PARO prevent worsening psychological conditions of

healthcare workers who work in mentally and emotionally stressful

environments?

Conceptual Framework for the Study

The existential psychotherapy framework (Yalom, 1980) was chosen for this

qualitative study. Existential psychotherapy concepts were founded on existentialism and

existential phenomenology, which originated and was studied in Europe. The existential

psychotherapy concepts explained human beings’ struggles and existence in life through

understanding the individual’s experience of self-awareness, exploring freedom and

responsibility, one’s relationship with others and the world, and the meaning of having

existential neurosis and existential crisis, and constructed individual’s understanding of

their life purpose (Corey, 2017; Yalom, 1980). The existential psychotherapy concepts

also described the duality of human nature, such as wanting to feel easy and free from

hardships and agony yet looking for challenges, and denoted challenging situations as

opportunities to grow and find different perspectives to attain homeostasis. The

existential psychotherapy concepts supported and navigated throughout this study,

addressing the psychological, behavioral, and stress management of healthcare workers

who had difficulty reaching out for help for their mental health care using PARO.

Nature of the Study

This research aimed to explore and understand the lived experience of healthcare

workers who used PARO during the COVID-19 pandemic. Because the phenomenon of

healthcare workers who used PARO during the COVID-19 pandemic was rare and new, a

qualitative research method was selected. Particularly, hermeneutic phenomenology was

selected because the philosophy of hermeneutic phenomenology was aligned with

constructivism epistemology and the conceptual framework of this study. Hermeneutic

phenomenology employed interviewing as the primary data collection method. Data

collection and data analysis was conducted by explicitly identified researcher

preconceptions, collecting codes and meaning units by perusing the interview transcripts

repeatedly and eliciting themes and summary of the research participants’ views of the

reality of the phenomenon through hermeneutic analysis (Peoples, 2020a; Van Manen,

2023). The coding process was manually performed in order to familiarize me (i.e., the

data collecting tool) with the transcripts and vicariously understand the lived experiences

and lifeworlds of the study participants. Affective codes and in vivo codes were of focus

when collecting meaning units because the nature of this research was to understand the

study participants’ affective and lived experiences during the COVID-19 pandemic

(Saldaña, 2016). Research participants were recruited by snowball sampling, considering

the scarce nature of the study participants. The plan was to start the snowball sampling by

reaching out to the healthcare worker in the report by Shibata et al. (2021) first and ask if

that healthcare worker knew other colleagues who used PARO during the COVID-19

pandemic. Creswell and Creswell (2018) noted the range of phenomenological research

participants to be between three and 10. Still, it was critical to continue to find research

participants until data analysis reached data saturation (Creswell & Creswell, 2018;

Merriam & Tisdall, 2016).

Definitions

Burnout: Freudenberger (1974) defined burnout as “to fail, wear out, or become

exhausted by making excessive demands on energy, strength, or resources” (p. 159) after

working in a free clinic and observing other clinic workers. The Centers for Disease

Control and Prevention (CDC, n.d.) described burnout as “the harmful physical and

emotional effects when job requirements do not match workers’ resources or needs”

(para. 1).

Burnout symptoms: In this study, the term was used to describe symptoms

described in burnout syndrome, including symptoms that could lead to burnout syndrome.

Burnout syndrome: The World Health Organization (WHO, 2019) defined

“burnout” as a syndrome conceptualized as resulting from chronic workplace stress that

has not been successfully managed” (para. 4). WHO also clarified that burnout syndrome

had three dimensions: (a) feeling and energy depletion and exhaustion, (b) feeling of

negativism or cynicism, and (c) low professional efficacy. Burnout [syndrome] was

identified as an International Classification of Disease in ICD-11, with the condition

meeting the three dimensions noted above. In this study, burnout syndrome was treated as

a cluster of psychological symptoms that fit the definition of burnout syndrome defined

by the WHO.

Healthcare workers: In this study, the definition of healthcare workers was broad;

the term includes not only medical professionals (i.e., physicians, nurses) but also mental

health professionals and nursing assistants who provide direct in person patient/client

care. Critical identifiers of healthcare workers for this study were whether the healthcare

workers have worked with patients in person independently, performing and fulfilling the

healthcare workers’ assigned duties effectively.

Socially assistive and interactive robot: In this study, the definition of socially

assistive robots was drawn from Feil-Seifer and Matarić (2005), who defined socially

assistive robots and socially interactive robots separately. Feil-Seifer and Matarić defined

socially assistive robots as robots that enhanced social interactions by the users. PARO

has been studied and used as a medical device as a socially assistive robot when used by

older adults with dementia or children with mood and behavior management issues. Feil-

Seifer and Matarić defined socially interactive robots as robots that created social

interactions between the robot and the user. In this study, PARO was described as a

socially assistive and interactive robot because the use of PARO could be defined

depending on how the user used PARO.

Assumptions

Assumptions needed to be identified when establishing research rationale and

milieu because critical information that the research relied on and pertinent to the answers

to the research questions and methodology could not always be proven true (Simon &

Goes, 2013). Considering the assumed information to be true was necessary; otherwise,

the research would become meaningless (Crawford et al., 2016). Clarifying qualitative

research assumptions helped enhance trustworthiness of a qualitative study. The

following assumptions were considered for this hermeneutic phenomenological research,

which was to explore the experiences of healthcare workers who used PARO during the

COVID-19 pandemic:

1. Research participants responded truthfully to the interview questions.

2. Research participants understood the purpose and nature of the study (i.e.,

sharing the study participants’ experiences of using PARO during the

COVID-19 pandemic).

3. As the researcher, I was equipped to manage unwanted researcher biases (i.e.,

preconceptions).

Scope and Delimitations

Scope of the Study

“The scope of a study frames the group to which the study might be applicable”

(Crawford et al., 2016, p. 301). This hermeneutic phenomenology research explored and

understood the lived experiences of healthcare workers who used PARO during the

COVID-19 pandemic. Also, this qualitative research explored the healthcare workers who

experienced burnout syndrome prior to the COVID-19 pandemic. Therefore, the scope of

this phenomenological research was healthcare workers who used PARO during the

COVID-19 pandemic and experienced burnout syndrome before the COVID-19

pandemic.

Delimitations of the Study

Crawford et al. (2016) noted that delimitations of a study would clarify the study

participant selections by setting boundaries. For this hermeneutic phenomenological

research, no limit in healthcare worker disciplines; however, this study delimited

healthcare workers who did not have burnout syndrome before the COVID-19 pandemic.

Another delimitation for this study would be healthcare workers who did not provide

direct patient/client care.

Limitations

One of the biggest challenges was collecting research participants. Although

PARO has been developed, researched, and utilized as a therapeutic medical device for

patients with dementia since 2005 in Japan, in 2009 in Europe and the United States

(Shibata, 2012), PARO was not known widely outside of people who were interested in

using PARO as a treatment device. PARO was primarily known for treating mood and

behavior of older adults with dementia but not for healthcare workers; so far, one study

(Shibata et al., 2021) addressed the use of PARO by healthcare workers during the

COVID-19 pandemic.

Another challenge would be replicability and researcher reflexivity. Simon and

Goes (2013) noted that a notable limitation of qualitative research was related to validity

and reliability. Because the nature of qualitative research was to study the phenomenon in

a natural setting, it was challenging to replicate the study findings (Simon & Goes, 2013).

As such, as expecting the study participant search to be difficult because the topic of this

study was a rare phenomenon, it would be fair to say that the study outcome would not be

replicable or generalizable. As noted earlier, researcher biases (i.e., preconceptions) in

hermeneutic phenomenology were expected; researcher preconceptions were identified

explicitly prior to the data analysis (Peoples, 2020; Van Manen, 2023). Still, because I am

a clinical mental health therapist who also had experienced the COVID-19 pandemic and

burnout experiences, it was crucial to be aware of my role as the researcher and focus on

that role when interviewing, collecting data, and analyzing data. Particularly interviewing

and talking about the burnout experiences of participants, focusing on the affective and

experience based meaning units in the interview transcripts of the participants during the

COVID-19 pandemic, catching the moments of deviating from the researcher role and

tasks would need to be checked in constantly.

Lastly, the study participants were not identified as vulnerable and could make

decisions independently. This research was not an experimental study, and participation in

this study was voluntary. The research participants sought for this study were adults (i.e.,

18 years old or older) working independently and professionally with the licenses or

certifications of the disciplines of the healthcare workers’ specialty. However, being

asked to talk about burnout experiences for this study might trigger strong emotional

reactions by remembering the burnout syndrome. Although the participants might have

enough support and resources, mental health care resources were provided in the

informed consent form in case the research participants needed such resources.

Significance

The problem identified for this qualitative research was a long-standing issue of

healthcare workers’ burnout syndrome and exploring effective resolutions, such as

changing the culture and attitude in the healthcare field. In the United States, the

phenomenon of healthcare worker burnout was worsened shown by the increased suicide

rate among healthcare workers between 2000 and 2020 (Elkbuli et al., 2020; Peterson et

al., 2020; Rothenberger, 2017). While researchers have continued to report the

phenomenon since the 1970s in the United States, no significant changes have been made

to alleviate the phenomenon, the United States has experienced the COVID-19 pandemic.

The COVID-19 pandemic exacerbated healthcare workers for the lack of protective

resources, fear of contracting the virus, no vaccines developed, seeing deaths of patients,

needing to determine who would use the bed next, working long hours, and being isolated

from the healthcare workers’ support system.

Researchers identified some of the causes of the U.S. healthcare workers not

seeking mental health help, including psychiatric and substance use problems being

stigmatized among colleagues, concerns about the risk of losing the healthcare workers’

practice licenses, along with lack of staff, long work hours and irregular schedules (Davis

et al., 2021; Elkbuli et al., 2022; Kalmoe et al., 2019; Kingston, 2020; Knaak et al., 2017;

Salvagioni et al., 2017; Shelley, 2019). In recent years, including during the COVID-19

pandemic, stronger voices raised the need to change the entire culture and attitude in the

healthcare field toward improving the healthcare workers’ work conditions and

psychological wellbeing, such as burnout syndrome (Moutier et al., 2012; Norcross et al.,

2018; Sindhu & Adashi, 2022; Søvold et al., 2021). Meanwhile, animal-assisted therapy

has been widely recognized to treat many emotional and psychological symptoms of

people from young to adults. PARO was created based on the ideas of animal-assisted

therapy concepts.

The significance of this study was not only to find another way to prevent and/or

reduce healthcare workers’ burnout syndrome from escalating but also to be part of

changing the culture and attitude in the healthcare field to facilitate accepting and being

open to individualized stress management in the workplace. Researchers discussed

utilizing technology, such as digital phenotyping in order to detect signs of severe

distress, such as burnout syndrome and suicidal ideation (Huckvale et al, 2019;

Sasangohar et al., 2020). PARO has been most commonly used as a socially assistive

therapy robot for older adults diagnosed with dementia (Moyle et al., 2017; Petersen et

al., 2017; Pu et al., 2019; Thodberg et al., 2016). However, Gena et al. (2020, 2022)

reported that healthy older adult research participants also benefited from using PARO to

reduce pain and improve mood by increasing oxytocin levels. PARO was an AI robot

capable of accommodating the users’ emotional state and interacting with the users

independently, just like therapy animals (Shibata et al., 2012).

With all that said, this study contributed to positive social change; this research

was part of influencing the current phenomenon of healthcare worker burnout syndrome

and changes in the culture of the healthcare field in the United States.

Summary

Chapter 1 outlined the construct of this qualitative study. The problem identified

was healthcare worker burnout syndrome experienced by providing direct patient care in

a demanding work environment despite long years of the same issues researched and

reported. Some changes were slowly made at the healthcare worker level, such as

creating and participating in a wellness program for healthcare workers (Norcross et al.,

2018). CDC also recognized burnout as a notable health condition and included burnout

syndrome in the international classification of diseases (2019). However, it was noted that

existing resources had not made significant changes in facilitating healthcare workers to

actively and safely utilize mental health resources due to the stigma, work demand, staff

shortage, and overall culture and attitude in the healthcare field. Researchers loudly

reported the dire need for changes in the culture and attitude within the healthcare field

involving leadership, administrators, and policymakers. Changes in the culture of

healthcare field could also mean respecting and understanding the individual needs of

healthcare workers’ stress management and self-care, including utilizing technology that

could safely monitor the risk of self-harm or severe mood changes and communicate with

different devices faster (Huckvale et al, 2019; Sasangohar et al., 2020; West et al., 2016).

Understanding the healthcare workers who used PARO during the COVID-19 pandemic

could reveal the role of using PARO as a small part of filling in the identified gap.

Chapter 2 showed the literature review that discussed and supported the

background of this study and the conceptual framework aligned with the epistemology

based on this study.

Chapter 2: Literature Review

Introduction

The problem identified for this qualitative study was the critical and urgent need

for significant changes in the healthcare field. Healthcare workers who worked under

intense work demands, such as working with patients with COVID-19 in hospitals,

experienced severe burnout symptoms. Although healthcare worker burnout has been

pointed out and studied for many years (David et al., 2021; Freudenberger, 1974;

Kingston, 2020; Maslach & Leiter, 2016), it has continued to be a problem among

healthcare workers. Kingston (2020) wrote that it has become worse in the United States

in the last 50 years. When COVID-19 spread, it worsened because COVID-19 brought

new challenges, such as no treatment or vaccinations, social isolation, and lack of

resources and workforce. Kingston noted that the existing resources and system did not

help improve the burnout syndrome or alleviate the conditions. One primary reason was

the stigma for physicians or other healthcare workers about seeking psychological and/or

psychiatric treatment due to physicians’ pride and fear of losing physicians’ licenses

(Awan et al., 2022; Elkbuli et al., 2020; Kalmoe et al., 2019; Kingston, 2020; Shanafelt et

al., 2021). For many complicating reasons, it was fair to say that healthcare workers were

difficult care recipients because they would not seek treatment voluntarily or accept it

easily.

The purpose of this study was to explore the experiences of healthcare workers’

using PARO (a short description of “personal robot” in Japanese), a socially assistive AI

robot designed to resemble a baby harp seal, during the COVID-19 pandemic. Very few

healthcare workers used PARO while working at a hospital to treat patients with

COVID19 or during the COVID-19 pandemic. PARO was also used to treat patients who

were considered “difficult to treat” due to these patients’ not trusting mental health care

treatment or clinicians in general (Lane et al., 2016). Exploring and understanding the

experiences of healthcare workers who used PARO could help reframe what it meant to

have genuinely effective interventions, which was defined by healthcare workers for

healthcare workers.

This chapter addressed the history of healthcare worker burnout, the influence of

the COVID-19 pandemic on healthcare worker burnout, socially assistive and interactive

AI robot PARO, ethical concerns regarding using AI robots, the conceptual framework,

and how the conceptual framework aligned with the purpose of this research and builds

the foundation of this qualitative study.

Literature Search Strategy

The information to support the problem statement along with the evidence to

describe the phenomenon of the topic of this study was collected via peer-reviewed

journal articles and books, both electronic and printed. The areas to search the literature

for this qualitative study were healthcare worker burnout before and during the COVID19

pandemic, PARO, AI, socially assistive and interactive robots, robot-assisted therapy, and

existing systems to help and/or prevent severe psychological distress of healthcare

workers. Electronic peer review psychological databases such as Psychology Databases

Combined Search, which would search through PsycARTICLES, PsycBOOKS,

PsycEXTRA, PsycINFO, and PubMed via the Walden University Library and Google

Scholar were used. The terms used to obtain relevant, valid, and reliable literature were

healthcare workers, burnout, COVID-19, psychological distress, healthcare workers

suicide, mental health wellness for healthcare workers, PARO, AI robots, robot-assisted

therapy, adult mental health care, healthcare workers character traits, and depression,

mood and stress reduction, intervention for burnout healthcare workers.

The phenomenon of healthcare worker burnout, how healthcare worker burnout

was understood and treated, and how COVID-19 affected healthcare worker burnout in

the United States were searched via Psychology Databases Combined Search, PubMed,

Google Scholar, and the Walden Library. The information on PARO, socially assistive

and interactive robots, the history and development of socially assistive and interactive

robots, and how socially assistive and interactive robots were utilized were searched via

IEEE Explore Digital Library, Google Scholar, and the Walden Library.

To date, only the article published by Shibata et al. (2021) reported healthcare

workers who used PARO during the COVID-19 pandemic while treating patients/clients

with COVID-19. Although PARO has been built and used since the early 2010s, PARO

was still considered a new device. One report of healthcare workers who used PARO was

found in publications.

Conceptual Framework

Existential psychotherapy concepts (Yalom, 1980) were the conceptual framework

of this qualitative study. Why particularly existential psychotherapy concepts were

employed, not humanistic theory or existential philosophy, was discussed later in this

section.

Because the purpose of this qualitative study was to explore the subjective views

and lived experiences of the study participants who used PARO during the COVID-19

pandemic, existential psychotherapy concepts suited the constructivist epistemology and

strengthened the alignment of this study. Existential psychotherapy concepts embrace

authentic human experiences and value individuals’ personal and subjective worldviews

(Corey, 2017; Yalom, 1980). The essence of existential psychotherapy concepts is seeking

and finding new meanings and perspectives in what people do in their lives. In other

words, having no purpose and meaning in life would make people anxious, stressed, and

depressed, causing a state of meaninglessness (i.e., existential neurosis). Existential

neurosis would lead to feelings of emptiness, boredom, cynicism, and apathy (i.e.,

existential vacuum; Corey, 2017; Frankl, 1959; Yalom, 1980). According to existential

psychotherapy concepts, people experience burnout symptoms, including moral injuries,

severe depressive symptoms, and suicidal thoughts and attempts because of experiencing

emptiness, boredom, cynicism, and apathy led by the state of existential neurosis.

Facing death by talking about death openly and directly with clients is also a

critical element of existential psychotherapy concepts. Facing death is a fact of human

life, but at the same time, death can cause existential neurosis; often, death is an

unwelcome topic to explore and be familiar with. According to existential psychotherapy

concepts, discussing death openly and directly as a natural part of life would help clients

find solace, have different perspectives of life and a new purpose, and live more

meaningfully and authentically (Yalom, 1980). Still, a view of life, incidents, experiences,

and finding meanings and different perspectives depend on the individual.

The essential and key philosophy of this framework is to understand, respect, and explore

human experiences, value the uniqueness and authenticity of people’s experiences, and

believe in people’s ability to find their own meanings in their lives (Corey, 2017; Yalom,

1980).

Also, existential psychotherapy concepts frame the duality of human emotional

experiences. A person could go through adversity and tragic incidents and experience

existential neurosis and existential vacuum, and still find new ways or different

perspectives of the predicament and gain hope and motivation, making sense of the

adverse experiences in their own understanding of their world. Psychotherapeutic

interventions would be needed in a case where the experience of existential neurosis and

existential vacuum was beyond the capacity of the individual’s internal, emotional, and

psychological resources to find meanings and different perspectives and was stuck in the

state of existential neurosis and existential vacuum. Another example of a human

experience of duality is that people suffer from adversity, stress, and life’s challenges;

however, when people have no challenges or stress in their lives, people also experience

existential neurosis and existential vacuum (Frankl, 1959; Yalom, 1980). People come out

of the existential crisis when they find the purpose and meaning in their lives through

struggles and adversity. Frankl (1959) wrote, “What man actually needs is not a

tensionless state but rather the striving and struggling for a worthwhile goal, a freely

chosen task” (p. 105). The key concept is to find value and meaning in what people do,

and the value and meaning are related to people’s positive future in order to go through

struggles, adversity, and even boredom (Frankl, 1959; Yalom, 1980).

Through the framework of existential psychotherapy concepts, healthcare

workers’ severe burnout experiences, especially at the beginning of the COVID-19

pandemic, would be explained that healthcare workers were mentally, emotionally,

physically, and spiritually inundated by the severity of work conditions triggered by the

COVID-19 pandemic. Healthcare workers did not have enough protective equipment or

workforce, were isolated from their family and friends, had never experienced a

pandemic, had no vaccinations, were forced to make choices about who to save due to the

lack of beds and ventilation equipment availability, and faced countless deaths of patients

with COVID-19. Healthcare workers faced many layers of existential crises, such as

existential neurosis, existential guilt, and existential vacuum that led healthcare workers

to feel empty, apathetic, hopeless, lost morale, increased use of substances, and suicidal

thoughts and attempts. No emotional energy was left to regain their motivation or find

different meanings in the treatment facilities where patients and healthcare workers were

fighting for life. Because of the nature of COVID-19 being extremely contagious and the

unknown facts about the virus, healthcare workers could not reach out to their support

system or utilize their own self-care strategies but to isolate themselves from each other

and avoid any human contact. No adequate or suitable interventions for their

psychological wellness tools or strategies were available during the beginning of the

COVID-19 pandemic. The priority was to protect healthcare workers’ physical health

from contracting COVID-19, although healthcare workers’ mental, emotional, and

spiritual health worsened simultaneously. When healthcare workers’ mental, emotional,

and spiritual health were not taken care of, finding new meaning or different and hopeful

perspectives would be extremely challenging without effective interventions.

Aside from providing practical assistance, such as enough personal protective

equipment, more workforce, or a feasible work schedule, it would have been helpful if

treatment resources were prepared that suit healthcare workers’ worldviews, beliefs, and

emotional needs. Not all healthcare workers experienced suicidal thoughts or attempted to

end their own lives because of burnout symptoms; research on healthcare worker burnout

rate did not show that 100% of healthcare workers experienced the same level of burnout

severity during the COVID-19 pandemic (Nishimura et al., 2021; Prasad et al., 2021;

Serrão et al., 2021). In other words, some healthcare workers were able to have different

views of the predicament or find unique personal meanings and perspectives of the

situation while facing the death of patients with COVID-19 and/or threats of death of the

healthcare workers themselves. Healthcare workers’ subjective view of the world,

reflecting their life experiences and personal beliefs, would be critical in exploring

personalized and effective treatment methods. Existential psychotherapy concepts explain

and align well to connect the problem and the purpose of this qualitative study.

Existential Philosophy, Humanistic Psychology, or Existential Psychotherapy

Concepts

Yalom (1980) stressed the differences between existential philosophy, humanistic

psychology, and existential psychotherapy concepts and explained how Yalom ended up

emphasizing that his existential psychotherapy concepts did not belong to humanistic

psychology and identified that existential psychotherapy concepts stood alone, although

Yalom acknowledged that humanistic psychology possessed similar foundational

concepts to existential psychotherapy concepts, sharing the origin of existential

philosophy.

Existentialism and existential phenomenology originated in Europe and were

studied by philosophers such as Søren Kierkegaard, Friedrich Nietzsche, Martin

Heidegger, Jean-Paul Sartre, and Martin Buber in the 19th century. The philosophers

stressed different aspects of human experiences in life and their emotional reactions,

limitations of understanding all human experiences, including death, meaninglessness,

needing challenges while wanting to avoid suffering, and valuing authentic being (Corey,

2017; Yalom, 1980). The fundamental concepts of existential philosophy were to

understand and explore human experiences through critical elements of human lives, such

as “being, choice, freedom, death, isolation, absurdity” (Yalom, 1980, p. 15).

Psychiatrists in Europe who studied psychoanalysis under Sigmund Freud, such as

Ludwig Binswanger and Viktor Frankl, expressed their problems with Sigmund Freud’s

partialized, limited view of human nature. It was how existential philosophy was adopted

into psychoanalysis (i.e., existential analysis) and psychotherapy (Corey, 2017; Yalom,

1980). Existential phenomenology and therapy concepts came to the United States in the

middle of the 20th century. Rollo May introduced existential phenomenological

psychotherapy concepts when May returned to the United States. May studied theology

in Europe while also being deeply influenced by Alfred Adler’s individual psychology

and existential philosophy (Corey, 2017).

Simultaneously, in the United States, the humanistic psychology movement

emerged. Humanistic psychology was facilitated by psychologists who also agreed on the

limitations of behaviorism and psychoanalytic theory regarding understanding human

nature and psychopathologies. By the 1960s, humanistic psychologists such as Carl

Rogers and Abraham Maslow were the leading figures of the humanistic psychology

movement. Humanistic psychology emphasized that human and human experiences

needed to be understood as a whole, not by part-functions, and must be identified by their

human experiences such as love, creativity, responsibility, and values (Griggs & Jackson,

2019; Yalom, 1980). The fundamental difference from the existential psychotherapy

concepts Yalom stressed was that the critical essence of existentialism was missing in the

U.S.-born humanistic psychology. Existential philosophy was born in Europe after people

in Europe experienced “human limitations and the tragic dimensions of existence.” Yalom

(1980) explained it was because “Europeans have had a greater familiarity with

geographic and ethnic confinement, with war, death, and uncertain existence” (p. 19).

Existential psychotherapy concepts were employed for the conceptual framework

for this qualitative study instead of humanistic psychology [theory] because the core

concepts of existentialism were fundamental to understanding the lived experiences of

healthcare workers and healthcare workers’ subjective view of their burnout symptoms

where healthcare workers faced patients death, experienced the threats of healthcare

workers’ own death, needing to make difficult choices, going through existential crises.

Also, this qualitative study was to understand healthcare workers’ experiences using

PARO during the COVID-19 pandemic. How PARO was used, and the experience of

using PARO would depend on the healthcare workers who chose to use PARO during the

COVID-19 pandemic. Therefore, existential psychotherapy concepts were well-suited for

this phenomenological qualitative study founded on constructivism epistemology.

Background and History of Healthcare Workers’ Experiences at Work

Healthcare Workers and Burnout

During the 1960s and 1970s in the United States, many critical social movements

influenced politics, healthcare, laws, and human rights. Activists, including healthcare

workers, loudly and vehemently addressed healthcare and human rights inequality during

that time. Medical doctor David E. Smith initiated the free clinic movement in 1967 out

of the urgent necessity of quality healthcare for underserved people in the United States

(Smith, 1976). Smith described his definition of healthcare and his ideology, “healthcare

is a right, not a privilege” (p. 343). During this time, many changes occurred in the

healthcare field. In 1963, the Community Mental Health Act was enacted (National

Archives, 2022). Two years later, in 1965, the Medicare and Medicaid programs under

the Social Security Act were enacted (Marjoua & Bozic, 2012; National Archives, 2022).

The government’s intention was to provide healthcare equally to people, including

underserved populations such as older adults, people who had low income, ethnic and

racial minorities, those who had substance use problems, and those who lived on the

streets. However, the fact was that significant healthcare-related laws were established,

but the quality of healthcare continued to be offered partially; healthcare was privileged

to a limited population (Smith, 1976; Steven, 1996). In other words, despite the laws

established and enacted, underserved people continued to utilize free clinics, and the staff

and healthcare workers at free clinics continued to work hard without being paid or at a

nominal wage (Smith, 1976; Steven, 1996). Although the laws were enacted, the intended

positive changes did not happen quickly enough. Or it was that the already established

system was homeostatically maintaining itself and simply difficult to change (Cannon,

1929). Soon after the Community Mental Health Act and the Social Security Act were

enforced, the healthcare quality movement occurred in the 1970s; organizations such as

the Professional Standards Review Organizations were established to monitor the quality

of healthcare provided by medical professionals (Marjoua & Bozic, 2012). The quality

movement was facilitated almost simultaneously with the Medicare and Medicaid

establishment; still, the underserved populations did not receive quality care (Stevens,

1996). The enactment of the Social Security Act did not diminish the demand for free

clinics.

Freudenberger (1974) described the conditions of healthcare workers he observed

at the free clinic where he worked. Freudenberger wrote, “to fail, wear out, or become

exhausted by making excessive demands on energy, strength, or resources” (p. 159), after

recognizing the condition, and called the condition “burnout.” Freudenberger (1975)

described “a three-level burnout” as he recognized the healthcare workers he worked with

while working in free clinics in the 1970s. The first level burnout was caused by fulfilling

the workers’ own personal challenges and needs and helping healthcare workers do well.

The second level burnout was caused by responding to the needs of the population the

healthcare workers of the free clinic served. The third level burnout was caused by

needing to satisfy the program’s administrators, helping the program run successfully in

order for the program to appear well-facilitated. Freudenberger denoted that burnout

symptoms would worsen when all three levels piled up on healthcare workers.

Freudenberger (1975) also wrote that healthcare workers who were overly

committed and dependent on the work for their own emotional needs, instead of having

hobbies or connections outside of work, somewhere the healthcare workers could belong,

tended to intensify burnout severely. Healthcare workers who were overly controlling,

trying to do everything by themselves, and feeling professional responsibility too much

tended to be more susceptible to burnout. Richardson et al. (2009) reported that the

characteristics of high career satisfaction in healthcare workers were work drive and

conscientiousness. Ten years later, Pérez-Fuentes et al. (2019) reported that personality

traits such as neuroticism (e.g., perfectionism) and conscientiousness were positively

correlated to developing burnout symptoms seen in the research participant nurses. Such

characteristics were common among healthcare workers. However, how the nurses

conceptualized perfectionism and conscientiousness affected the nurses developing

burnout symptoms; some nurses experienced burnout symptoms because of their

personality traits of perfectionism and conscientiousness, and some nurses had fewer

burnout symptoms because of their personality traits of perfectionism and

conscientiousness (Pérez-Fuentes et al., 2019).

Experienced both the administrator role and staff clinician role at the free clinic,

Freudenberger described his burnout experiences at the free clinic. Freudenberger

reflected on the paradoxical state he was stuck in; although Freudenberger wanted to talk

about his burnout experiences with other professionals outside of his free clinic, he

hesitated to seek other professionals to talk to. Freudenberger did not think other

professionals who did not work in free clinics could understand his experience in the

chaotic and stressful environment of free clinics, so unique of itself; therefore,

Freudenberger chose not to talk about his experiences to other professionals and reach out

for help. Freudenberger (1975) wrote, “Their advice of ‘leave the place, it gets you so

upset,’ was not sufficient for me” (p. 78). Freudenberger was mentally stuck with the

thought of wanting to leave his position; however, he did not want to leave his position

because he had invested too much in the project. Freudenberger (1973, 1974, 1975)

described the precipitating factors of burnout as circumstantial causes (i.e., lack of staff,

patients’ emotional states, and lack of resources) and healthcare workers’ internal causes

created by the role and responsibilities of healthcare workers, personality, and

characteristics of healthcare workers at free clinics. These factors would create multiple

layers of burnout symptoms and worsen the symptoms when ignored.

In addition to describing the phenomenon of burnout, Freudenberger (1975)

itemized elements of preventative measures of burnout in healthcare facilities with high

demands: (a) to select better-fit candidates through a training program prior to hiring, (b)

to teach existing staff the differences between realistic and unrealistic dedication would

look like, (c) to assign different tasks to healthcare workers; avoid giving the same job

many times to the same staff, (d) to limit the work hours and do not exceed the work

hours, (e) to have “sensible” work schedule, balancing work hours and time off, giving

enough time off, (f) to create a group cohesion in the work team to avoid staff isolation,

(g) to have a place to share their experiences of burnout, (h) to have training opportunities

outside of work, (i) to hire more healthcare workers to help existing staff, (j) to encourage

to do physical exercise; avoid activities that would encourage introspection of their day

and work, such as meditation and yoga. Lastly, Freudenberger noted the importance of

respecting burnout syndrome; one would expect it to happen again and always would need

to watch for the symptoms and phenomenon.

Increased Burnout Syndrome and Suicide Rates of Healthcare Workers

Kingston (2020) reported the physician suicide rate has consistently risen in the

past 50 years. Supportedly, many studies have reported a rise in physician suicide in

recent years. Reviewing the reports of the Preventions National Violent Death Reporting

System (NVDRS) of the CDC from 2003 to 2017, Elkbuli et al. (2020) reported 197,217

people died by suicide from 2003 to 2017; it was reported 905 physicians died by suicide

from 2003 to 2017. Elkbuli et al. noted that 37.4% of physician suicides from 2003 to

2017 occurred between 2015 and 2017. In other words, using the numbers given by

Elkbuli et al., before 2015, there were 64.6 physician suicides per year, while 112.8

physicians committed suicide per year between 2015 and 2017. In 2017, 38,000 people of

working age from 16 to 64 died by suicide in the United States (Peterson et al., 2020).

Peterson et al. (2020) stressed that there was a 40% increase since 2000, from 12.9

suicides per 100,000 people in 2000 to 18.0 suicides per 100,000 people in 2017. The

report by Peterson et al. supported Elkbuli et al., stating that the physician suicide rate

increased similarly to that of the general population.

Peterson et al. (2020) reported the CDC suicide rate research data of people of

working age from 16 to 64 in 32 states in 2016. Peterson et al. reported the male suicide

rates of healthcare practitioners and technical occupations; 23.6 (95% CI [20.8, 26.3]),

and the male suicide rate of healthcare support occupations; 23.6 (95% CI [17.0, 32.1]).

Peterson et al. reported the female suicide rates of healthcare practitioners and technical

occupations 8.5 (95% CI [7.6, 9.4]); however, the female suicide rate of healthcare

support occupations was 10.6 (95% CI [9.2, 12.1]). The female suicide rate of healthcare

support occupations was significantly higher (α = 0.05) than that of the study population,

7.7 (95% CI [7.5, 8.0]). In 2016, when adjusting the identified 32 states as indicated in

Peterson et al.’s report and the ages of people who committed suicide in 2016 from 16

years old to 64 years old, the CDC Web-based Injury Statistics Query and Reporting

System showed 17.36 suicides per 100,000 in 2016. The suicide rate of males per

100,000 was 26.68, and the suicide rate of females per 100,000 was 8.13 when the

occupational and industry groups were not considered. Comparing the suicide rates of the

general population, the suicide rate of female healthcare support workers in 2016 was

significantly higher than that of the study population. Still, overall, the study report by

Peterson et al. showed healthcare worker suicide rates were higher than the general

population.

Rothenberger (2017) ran a systematic review of studies from MEDLINE from

January 2000 to December 2016 and reported burnout prevalence among medical

students, physicians in training, and practicing physicians was more than 50%. The

increased burnout prevalence rate among physicians could also indicate the rising risk of

physician suicide (Elkbuli et al., 2020). Salvagioni et al. (2017) noted that symptoms and

emotional states, such as severe stress, anxiety, and depression at healthcare facilities,

would lead to burnout syndrome; burnout would cause harmful effects on physical and

psychological health, including suicide. Grow et al. (2019) wrote, “it is well established

that rates of burnout, depression, suicidal ideation, and completed suicide are higher

among medical trainees and physicians than among the general population” (p. 3).

Davis et al. (2021) reported a higher suicide rate of nurses than physicians,

examining the data from the NVDRS from 2007 to 2018, the U.S. Bureau of Labor

Statistics, and the Association of American Medical Colleges State Physician Workforce

Data. Davis et al. noted that nurses were the largest make-up of healthcare workers in the

United States; however, the high suicide rate of nurses was not as studied as that of

physicians. Physician Assistants and physician assistant students’ rising burnout rates

were also reported to be consistent with the physician burnout rates (Essary et al., 2018;

Johnson et al., 2020). Essary et al. (2018) noted severe burnout symptoms, such as

catastrophizing emotional exhaustion and depression, would lead to cardiovascular

diseases, alcohol or other substance dependence, and suicide. A rise in mental health

professional burnout was also reported (Jovanović et al., 2016; Maslach & Leiter, 2016;

O’Connor et al., 2018). Rössler (2012) denoted that mental health professionals had

unique reasons for burnout due to the characteristics of mental health professions, such as

setting firmer boundaries with clients, threats from clients who had violent tendencies,

and clients’ suicide.

Maslach (2005) wrote that human services work, particularly healthcare work,

tended to be more emotionally, physically, and mentally demanding because the quality

of healthcare work revolved around the relationship between healthcare workers and the

care recipients. Maslach and Goldberg (1998) described the expectations and norms in

the environment of healthcare workers as “to be selfless and put others’ needs first; to

work long hours and do whatever it takes to help a client or patient or student; to go the

extra mile and to give one’s all” (p. 63). The emotionally draining experiences of

dedicating to work, focusing on patients care, combined with higher expectations from

the administrators and lack of resources, were similar to what Freudenberger (1975)

pointed out for the causes of burnout. These elements were also observed and reported

today without too many differences.

In summary, burnout syndrome was not limited to physicians but was prevalent

among all healthcare workers. What was notable was that the physician suicide rate and

the nurse suicide rate were on the rise, particularly in recent years (Davis et al., 2021;

Elkbuli et al., 2020). It was also notable that although burnout syndrome among

healthcare workers was increasing worldwide, the rate in the United States was the

highest (Shelley, 2019). It appeared that in the healthcare field, since the healthcare laws

were implemented and the quality movement was initiated from the 1960s to 1980s, the

focuses in the healthcare field seemed to have two dimensions: (a) to improve quality

care and (b) to provide services to more clients; with Medicare and Medicaid, used to be

underserved population became paying customers. In other words, the movements created

an immense business opportunity. Many business owners and administrators were also

involved in managing the financial flow and making profits in the healthcare field;

Rössler (2012) wrote, “Today, economics objectives have priority over medical values in

health care” (p. S65). When the healthcare field was focused on business management

and profits, in order to sustain the healthcare business flow, healthcare workers would

need to self-sacrifice and make the business flow happen by having healthcare workers

experience the three-level burnout Freudenberger (1975) addressed, costing healthcare

workers’ physical health and psychological wellbeing (Maslach & Goldberg, 1998;

Shelley, 2022). By nature, healthcare workers are driven, conscientious, dedicated,

responsible, and motivated to help people and promote quality patient care (PérezFuentes

et al., Richardson, 2009; 2019; Rothenberger, 2017). Ironically, such healthcare workers’

characteristics contributed to burnout syndrome and, in some cases, led to suicide, the

worst outcome of burnout syndrome.

Coping Methods, Resources, and Existing Systems for Healthcare Workers

Agerbo (2007) reported marriage, employment, and completing higher education

as the identified protective factors for suicide in the general population; however,

marriage, employment, and higher education could turn out to be the stressors among

patients with psychiatric conditions as opposed to the general population. Elkbuli et al.

(2020) reported among physicians who died by suicide, the protective factors for the

general population did not stop physicians from killing themselves. Rather, work stress,

burnout, depression, and not using mental health resources were connected to why

physicians killed themselves (Kalmoe et al., 2019; Kingston, 2020; Sindhu & Adashi,

2022). There were several common tendencies in how healthcare workers dealt with such

intense burnout and mental anguish; one of them was using substances, particularly

alcohol. Many studies reported alcohol abuse as a warning sign and a risk factor for

suicide among burned-out healthcare workers (Davis et al., 2021; Elkbuli et al., 2020;

Kalmoe et al., 2019; Kingston, 2020; Salvagioni et al., 2017). Furthermore, healthcare

workers tended not to seek mental health care because of the stigma associated with

mental illness and fear of losing their licenses to practice (Davis et al., 2021; Elkbuli et

al., 2022; Kalmoe et al., 2019; Kingston, 2020; Knaak et al., 2017; Salvagioni et al.,

2017; Shelley, 2019). Taking time off for quality personal time and self-care was also

encouraged; however, time management was another challenging topic in the culture of

the healthcare field. Compared to the demanding workload and schedule, insufficient

healthcare workers in the healthcare facility made taking time off very difficult. As a

result, healthcare workers continued to be preoccupied with work-related concerns,

unable to take enough time for self-care, such as exercise, having regular medical

checkups, and taking quality time off (Kalmoe et al., 2019). Center et al. published their

study in 2003, addressing the same impending phenomenon of physician suicide. The

number of healthcare provider suicides increased steeply between 2010 and 2020 (Elkbuli

et al., 2020; Rothenberger, 2017), more than ten years after the study by Center et al. was

published. Center et al. addressed the need for a dramatic change in the healthcare system

and “the culture of medicine” so that healthcare workers could take time off safely

without feeling guilty, pressured, or punished.

Agency for Healthcare Research Quality (AHRQ, 2017) noted that AHRQ had

been researching healthcare workers’ working conditions and providing quality care to

clients/patients since 2001. According to AHRQ’s findings, the causes of healthcare

worker burnout were (a) family responsibilities, (b) time pressure, (c) chaotic [work]

environment, (d) low control of pace, and (f) electronic health record (EHR). “Promising

interventions” AHRQ suggested in the same report were: (a) flex schedules, (b) staff

surveys, (c) more time, (d) EHR entry, and (f) work-home balance. Rothenberger (2017)

noted that the National Academy of Medicine initiated the Action Collaborative on

Clinician Well-Being and Resilience in 2017, connecting 20 professionals and

educational organizations to tackle the increased healthcare worker burnout rate and

physician suicide rate. However, a follow-up or update on the tasks has not been reported

yet. The leadership, administrators, organizations, and individual healthcare workers were

not communicating efficiently.

Effective coping strategies to deal with severe stress and burnout symptoms, such

as seeking help for healthcare workers’ psychological wellness and substance use

treatment, taking time off for quality self-care, staying close to healthcare workers’

positive support system, hiring more healthcare workers, reducing caseload, and having

reasonable work schedule were identified and known for a long time. However, these

coping strategies would not ease this decades-long chronic problem of healthcare worker

burnout because healthcare workers could not utilize them as prepared and provided. It

appeared that the causes of healthcare worker burnout had multiple dimensions.

Healthcare worker burnout symptoms were affected by (a) individual healthcare workers’

personality, choices, and willingness, (b) healthcare workers’ work environment and

culture, (c) the licensing boards’ regulations and guidelines regarding healthcare workers’

mental health and psychological wellness, (d) leadership, administrators, and government

entities of the healthcare field, and (e) federal and state law regarding healthcare.

Therefore, focusing on only one of them, particularly the lower end of burnout

intervention (i.e., individual healthcare workers’ personal choices and care), would not

resolve this decades-long phenomenon. Researchers stressed that leadership,

administrators, and governments would need to initiate drastic changes in the healthcare

field (Center et al., 2003; Freudenberger, 1975; Gullie, 2021; Kalmore et al., 2019;

Kingston, 2020; Malslach, 2007; Malslach & Goldberg, 1998; Moutier et al., 2021;

Sindhu & Adashi, 2022; Søvold et al., 2021). Still, it has been the healthcare workers’

responsibility to take care of their psychological wellness (Kim et al., 2022; Sindhu &

Adashi, 2022); it did not improve healthcare worker burnout rate or change the culture of

the field, especially in the United States.

COVID-19 and Burnout of Healthcare Workers

Healthcare worker burnout was recognized as a phenomenon for many decades.

Researchers reported that healthcare worker burnout rate, including physician and nurse

suicide, rose notably between 2010 and 2020 in the United States (Davis et al., 2021;

Elkbuli et al., 2020; Kingston, 2020; Rothenberger, 2017). The COVID-19 pandemic only

exacerbated healthcare worker burnout and worsened healthcare workers’ psychological

wellbeing (Awan et al., 2020; Søvold et al., 2021).

Research articles published in 2020 reported how the healthcare field was when

the first wave of COVID-19 hit when COVID-19 was acknowledged as a pandemic by

the WHO. Frontline workers’ struggle in the hospitals without having enough personal

protective equipment, no vaccines or treatment, patients’ sudden deaths, dealing with the

family members of the patients who passed away, isolation from their own support

system, fear of being infected by COVID-19, and the possibility of contracting

COVID19, lack of healthcare workers on site, required to work longer hours due to the

lack of healthcare workers, and most of all, fear of not knowing the precise directions of

the patient care, how and when the pandemic would be controlled (Gold, 2020; Kingston,

2020; Gulati & Kelly, 2020; Moreno et al., 2020; Pfefferbaum et al., 2020; Walton et al.,

2020). While the rapid rise in healthcare worker burnout and physician suicide rates were

reported, Dr. Lorna Breen died by suicide amid the COVID-19 crisis (Gulati & Kelly,

2020; Sindhu & Adashi, 2022). Yet again, researchers (Gold, 2020; Gulati & Kelly, 2020;

Kingston, 2020; Moreno et al., 2020; Pfefferbaum et al., 2020; Walton et al., 2020) wrote

and urged required changes in the healthcare system at the organizational level to help

raise healthcare workers individual awareness of risk factors toward depression and

psychological wellness and provide effective interventions. Kingston (2020) noted that

the existing resources were not as adequate before the COVID-19 pandemic. Without

effective psychological interventions or systematic changes, healthcare workers

continued working during the COVID-19 pandemic.

Still, efforts were made to help healthcare workers’ burnout syndrome. The

University of California San Diego (UCSD) has worked on developing a program to

reach out to healthcare workers to improve healthcare workers’ mental health and to

reduce burnout symptoms and healthcare worker suicide rates since 2009 after

experiencing physician suicides of their own (Norcross et al., 2018). Norcross et al.

(2018) reported that their program, Healer Education and Assessment and Referral

(HEAR), focused on reducing stigma and understanding the importance of confidentiality

and accessibility (Moutier et al., 2012; Norcross et al., 2018). Norcross et al. reported no

healthcare worker suicides in UCSD after the program HEAR was initiated. Still, Sindhu

and Adashi (2022) criticized the fact that a program focused on individual healthcare

workers' symptom improvement would not be a long-term solution. Sindhu and Adashi

emphasized that the entire culture in the healthcare field needed to be changed.

There was another hopeful change made during the COVID-19 pandemic period.

The death of Dr. Breen triggered the establishment of the law, the Dr Lorna Breen Health

Care Provider Protection Act, in March 2022. Sindhu and Adashi (2022) wrote that U.S.

Surgeon General’s understanding of burnout; “an occupational syndrome characterized

by a high degree of emotional exhaustion and depersonalization (i.e., cynicism), and a

low sense of personal accomplishment at work” (p. 1). The first federal law

acknowledged the severity of healthcare worker burnout and the rising rate of healthcare

worker suicide in recent years and funded $135 million to establish evidence-based

effective mental programs for healthcare workers within two years (Sindhu & Adashi,

2022). Moreover, the law also provided funding for education and training programs,

particularly about healthcare workers’ needs for mental health support and substance use

treatment programs, including reducing the stigma of seeking mental health and

substance use treatment (Sindhu & Adashi, 2022). The federal government was involved

in working on the chronic problem in the healthcare field in the United States.

The history of healthcare worker burnout along with healthcare workers’

continuing struggles during the COVID-19 pandemic, showed that it took a long time to

make the significant first step to help ease the rising rates of healthcare worker burnout

and suicide. Still, burnout syndrome among healthcare workers was a phenomenon

reported not only in the U.S. but also globally (Shelley, 2019). In the United States, the

burnout rate among physicians was more than 50%, which Rothenberger (2017) called

“epidemic proportions” (p. 567) because Rothenberger observed that the burnout rate of

other occupations remained stable (Rothenberger, 2017). Change in a system takes a long

time, and systems and culture in the healthcare field would not happen easily (Cannon,

1929); the change needs to be initiated by the top organizations and leadership, such as

the state and federal government. In this regard, as Sindhu and Adashi (2022) noted that

the enactment of the law, the Dr. Lorna Breen Health Care Provider Protection Act, was a

hopeful step. Still, changing the culture of the healthcare field would also mean changing

the attitude of healthcare workers and other people who were associated with the

healthcare workers, along with understanding the culture in the healthcare field. In

addition, changing the culture and attitude in the healthcare field could also mean

revisiting and thinking about what effective psychological interventions for healthcare

worker burnout were. Understating individual healthcare worker’s needs for mental

health assistance, considering what stress relief really meant for the individual healthcare

worker was critical and needed as a way to establish individually tailored unique

psychological interventions from the existing ones (Alikhani et al., 2020; Huckvale et al.,

2019; Sasangohar et al., 2020; West et al., 2016).

Therapy Robots

Humans created robots and used robots to help with numerous daily tasks and

improve productivity. It is fair to say that humans depend on technologies and robots in

order to maintain a functional society today. The psychology and mental health field

considered robotics to widen the horizon of psychological treatment options. Libin and

Libin (2005) discussed and reported the concepts of “robotic psychology,” referring to the

fact that the science of robotics was improving. Robotics engineering created robots that

could have human social interactions, using and appealing to friendly and comforting

human senses and affective reactions. Many socially interactive robots were used, which

Libin and Libin called “caring robots,” as the robots interacted with humans to enhance

positive emotional experiences and provide companionship. Libin and Libin described

the changes in the concepts of robots in today’s world; caring robots were created to

focus more on emotional and affective reactions as opposed to traditional expectations of

mechanical robotic responses. Also, caring robots were as personally and individually

different from one another, which would give the robots’ unique reactions through the AI

system; therefore, caring robots were capable of providing positive therapeutic

interactions and interventions to humans. Libin and Libin wrote, “Clinical, as well as

healthy population can benefit from interactions with the friendly robotic creature that is

able to provide positive stimulation at various levels – from tactile to social” (p. 73).

There are several terms to describe socially assistive robots. Feil-Seifer and

Matarić (2005) explained the differences and definitions of socially assistive robots. Feil-

Seifer and Matarić defined three categories in the field of socially assistive robotics; the

categories were: (a) assistive robotics, (b) socially interactive robotics, and (c) socially

assistive robotics. “Assistive robots” help people physically; therefore, Feil-Seifer and

Matarić clarified that “assistive robots” were more appropriately called “rehabilitation

robots,” “wheelchair robots,” “mobility aides,” or “manipulator arms,” or “educational

robots” (p. 465), depending on the function of the robots. Fong (2003) initially introduced

the term “socially interactive robots” (as cited in Feil-Seifer & Matarić, 2005). “Socially

interactive robots” facilitated social interactions with people, doing what people do to

interact with other humans, such as speaking and showing movements generated by AI.

Feil-Seifer and Matarić wrote, “In SIR [socially interactive robots], the robot’s goal is to

develop close and effective interactions with the human for the sake of interaction itself”

(p. 465). Feil-Seifer and Matarić explained that “socially assistive robots” have similar

characteristics to socially interactive robots, but the difference was that socially assistive

robots help human users rehabilitate and improve social interactions while the purpose of

socially interactive robots was to provide interactions with human users. Feil-Seifer and

Matarić noted socially assistive robots were commonly used among older adults to assist

older adults with the symptoms of stress, mood, and behavioral problems.

Shibata et al. (2001) explained the process of creating “animal type robots,” which

Shibata et al. later changed the name from animal type robot to “mental commit robot” in

his research paper. Shibata et al. changed the name because animal type robots provided

“mental value to human beings” (p. 1053). Shibata et al. wrote that the purpose of

creating mental commit robots was to use mental commit robots to provide a therapeutic

experience to people. By interacting with a mental commit robot, people would have both

positive and negative emotional reactions, and they could experience emotional

attachment to the robot, eliciting the users’ own subjective views and evaluation of the

emotional experience. Shibata et al. stressed that emotional experiences occurred because

mental commit robots appeared like animals and acted and reacted like animals. People

could interact with mental commit robots using the five senses just like when people do

with real animals in animal-assisted therapy or with pets. Therefore, the concept was that

people would benefit from mental commit robots positively as people would when

interacting with animals.

Animal-assisted therapy has been acknowledged as an effective therapy method in

the United States since the 1960s; Levinson (1969) delineated the effectiveness of having

animals in therapy sessions while treating children and youth (Kruger & Serpell, 2006).

Further, animal-assisted therapy helps clients talk about challenging and complex

subjects, establish rapport with the therapist faster, and lessen the defensiveness of clients

(Kruger & Serpell, 2006). The essence of animal-assisted therapy was the foundational

idea of creating socially assistive and interactive robots because of the significant

therapeutic experiences and psychological benefits without having the limitations of

animal-assisted therapy, such as taking care of the animals, unpredictable nature of

animals, needing the animal trainers in the session, ethical issues regarding the care and

use of the animals for therapy, and scheduling challenges (Serpell et al., 2006).

“Personal Robot” in Japanese language (PARO)

Many robotic animals were created, studied, and researched between the late

1990s and the 2010s (Feil-Seifer & Mataric, 2005; Jipson et al., 2016; Libin & Libin,

2005; Pransky, 2001; Shibata et al., 2001; Smarr et al., 2011; Stiehl et al., 2006; Tombot,

n.d.). The field of socially assistive robotics and research focused on social interactions

between people and robots for emotional and psychological benefits. The emphasis of the

research was to create socially assistive and interactive robots that could enhance positive

human emotions and facilitate social interactions in addition to assistive robots helping

people with physical rehabilitation or behavioral problems. While researching

rehabilitative robotics, Kawamura et al. (1995) emphasized the necessity of cognitive

intelligence in robots that would stimulate emotional interactions and thought processes,

asserting that cognitive intelligence would reduce the mental burden of human users,

such as thinking for the robots about robots’ reactions.

PARO is one of the socially assistive robots created during this era. PARO is an

AI socially assistive robot designed to resemble a baby harp seal. The name PARO is a

short description of “personal robot” in Japanese. Shibata et al. (1996) initiated the

Artificial Emotional Creature Project, which was the beginning of building PARO. The

purpose of the Artificial Emotional Creature Project was to build robots that could

interact with humans, stimulating human senses that would enhance psychological and

emotional interactions and create positive memories for therapeutic benefits (Shibata et

al., 2001). During the initial stage of developing PARO, Shibata et al. explained that the

idea of creating the artificial emotional creature came from pets and pet-assisted therapy.

Shibata et al. referenced Levinson (1972), stating that interactions with animals promoted

a positive and affective influence on people; the positive experience with animals

alleviated negative emotional experiences, such as loneliness, sadness, and anger.

Pets and animal-assisted therapy were effective with children, patients with

terminal illnesses at hospitals, and older adults who experienced isolation, stress, anxiety,

or people who had problems related to low self-esteem (Granger & Kogan, 2006). Also,

pets and animal-assisted therapy were effective with people who had difficulty

expressing emotions using words and facial expressions, such as people with autism,

schizophrenia, and post-traumatic stress syndrome (PTSD; Fine, 2006; Granger &

Kogan, 2006; Mims & Waddell, 2016). According to the literature found for this literature

review, PARO’s development was almost parallel to ongoing animal-assisted therapy

development. Fine (2006) noted that a critical characteristic of animal-assisted

psychotherapy was that therapeutic animals could elicit natural emotions from clients;

therapeutic animals would make clients smile and laugh or express awkward,

uncomfortable, negative emotions toward the animals. In addition, Fine addressed how

the animals also reciprocated animals’ emotional experiences to the clients

simultaneously. Shibata (2012) discussed that the elements of effective animal-assisted

therapy reported were (a) psychological effect, (b) physiological effect, and (c) social

effect. Shibata (2012) emphasized that PARO was designed and built with the elements of

effective animal-assisted therapy.

PARO today is of the ninth generation. PARO was equipped to store long-term

memories of the user’s positive and negative reactions. PARO was also programmed to

express PARO’s affective reactions accordingly to the users’ emotional reactions and

communicate with the user. PARO was described as a biofeedback medical device

(Shibata, 2012). Moreover, in order to make the robot realistic, PARO had visual,

auditory, and tactile sensors and actuators built in (Shibata, 2012). PARO could identify

the voices of the users, detect if it was day or night, and was able to blink, move its head,

fins, and tail, and make the sound of a baby harp seal which would express positive and

negative emotional reactions. Shibata et al. (2001) chose a baby harp seal as the design

for the Artificial Emotional Creature Project after testing robots of more common pet

animals, such as dogs and cats. Shibata et al. reported that common pet animal robots

quickly caught the research participants’ attention; however, the research participants

compared their experience with actual pet animals and did not engage with the pet animal

robots for a long enough time. On the other hand, a harp seal was not a common or

familiar pet animal. No research participants of the study had preexisting knowledge or

experience with a baby harp seal; therefore, PARO made an ideal socially assistive and

interactive robot (Shibata et al., 2001).

PARO was introduced to the world as a medical device, socially assistive and

interactive robot to treat and alleviate the mood of older adult patients diagnosed with

dementia in the middle of the 2000s. Because of PARO’s positive affective and emotional

interactions with patients with dementia, research reported that PARO helped stabilize the

mood of patients, which also helped reduce the use of psychotropic medications and pain

medications, lessened aggressive behavior, and improved the mood of the patients (Geva

et al., 2022; Shibata, 2012; Petersen et al., 2017; Jøranson et al., 2016; Klein et al., 2013).

PARO came to the United States in 2009 as a medical device to treat the mood of patients

with dementia. The U.S. Food and Drug Administration (FDA) approved PARO as a

Class II biofeedback medical device in 2009 (Shibata, 2012).

PARO’s effectiveness was tested with patients with dementia (Jøranson et al., 2016;

Klein et al., 2013; Petersen et al., 2017; Pu et al., 2019; Thodberg et al., 2016), children

with autism (Bertel & Rasmussen, 2013; Nakadori, 2017; Roberts-Yates & Silvera-Tawl,

2019; Shibata, 2012; Silvera-Tawl & Roberts-Yates, 2018), older adult veterans who were

diagnosed with PTSD, dementia, and mood and behavioral problems (Lane et al., 2016).

Several randomized controlled studies were conducted to test the effectiveness

and generalizability of PARO’s application in a larger sample. Jøranson et al. (2016) ran a

cluster randomized control study on a group activity using PARO among the residents (n

= 60) with dementia in nursing homes in Norway. Jøranson et al. chose residents of

nursing homes with dementia to examine the research participants’ quality of life using

PARO. Jøranson et al. noted that the research participants’ quality of life was measured

using the Quality of Life in Late-Stage Dementia scale during the research and at three

months follow up. The nursing staff of the facilities facilitated the group activity using

PARO. The study revealed that lowering the dose of patients’ prescription medications in

the intervention group and resulted in higher scores on the Quality of Life in Late-Stage

Dementia scale. Moyle et al. (2017) conducted a cluster randomized controlled study and

tested differences between using PARO and a plush toy with long-term care facility

residents (n = 415) with dementia in Australia. This randomized control study by Moyle

et al. had the largest sample of PARO studies so far. The study revealed that the

intervention group showed more verbal activities and socialization, improved mood, and

less agitation. Petersen et al. (2017) conducted a randomized controlled study using

PARO as a replacement for animals in animal-assisted therapy with dementia patients (n

= 61) in the United States, recognizing the effectiveness of pets and animal-assisted

therapy with dementia patients. The objective of the study was to examine if PARO

would improve the mood of the patients and reduce the use of pain and psychotropic

medications. Petersen et al. also stressed that the study outcomes showed the

costeffectiveness of using PARO. Thodberg et al. (2016) ran a randomized controlled

study and compared using a real dog with a visitor, a soft toy cat, and PARO with nursing

home residents with dementia (n = 100) to see the residents’ immediate response to the

intervention items in Denmark. Thodberg et al. reported that the study participants

showed interest in dogs and PARO equally, but the study participants lost interest in

PARO sooner than the therapy dogs. Thodberg et al. reported the animal handlers’

interactions with the research participants might have affected the study results because

“the visitor sat beside the residents having a quiet conversation” (p. 119), although the

animal handlers did not encourage the study participants to engage with dogs. Pu et al.

(2019) reported a systematic review of the effectiveness of social robots for older adults;

PARO was studied most among 11 studies Pu et al. reviewed and noted PARO’s

effectiveness for mood and pain management and improvements in communication and

influencing broader affective functioning. However, Pu et al. also pointed out that studies

lacked rigor and did not report clear and strong conclusions on the effectiveness of

PARO. Moreover, Hung et al. (2019) identified research gaps after examining 29 PARO

research publications in a scoping review study. The gaps Hung et al. identified were: (a)

[PARO] users’ needs and experiences remain unexplored, (b) few studies investigated the

process of how to use the robot effectively to meet clinical needs, and (c) need theory to

understand and explain the use of PARO for clinical use.

Ethical concerns regarding using socially interactive and assistive robots to

provide care and/or interventions were raised by many researchers (Hung et al., 2019;

Ienca et al., 2016; Klien et al., 2013; Misselhorn et al., 2013; Sharkey & Sharkey, 2012),

and Shibata et al. (2021) corresponded to the ethical issues raised. Primary ethical

concerns regarding using PARO addressed by researchers were related to using PARO

with older adults with dementia. The use of PARO could be interpreted as infantilizing

older adults with dementia, objectifying older adults with dementia, depriving of human

contact from older adults with dementia, or giving older adults with dementia confusing

information and experience (Hung et al., 2019; Ienca et al., 2016; Klien et al., 2013;

Misselhorn et al., 2013; Sharkey & Sharkey, 2012). Although PARO was a class II

medical device in the United States, older adult patients could perceive PARO as a plush

toy. The caretakers of the older adult patients in the study by Moyle et al. (2018) thought

PARO was a toy at first. It certainly could be confusing to older adults with dementia and

older adults with cognitively impaired research participants because PARO was made

intentionally to appear and act like a live animal in order for the users to have more

genuine, spontaneous, positive emotional and affective experiences, using human senses

and brain functions (i.e., using working memory and information processing). Shibata et

al. stressed that Shibata et al.’s intention in using PARO for the care of older adult

patients with dementia was to complement the care, not to replace the human contacts;

the essence of the interactions intended was a person-centered approach. Shibata et al.

denoted that Hung et al. (2019) reported that the conceptual framework of “robots vs.

humans” thinking would lead to misunderstanding the intentions and purpose of using

PARO. Shibata et al. asserted, “Robots can provide different benefits to human roles and

are not substitutes for human-to-human interaction” (Shibata et al., 2021, p. 5). Robots

could offer different benefits, especially during the COVID-19 pandemic. Thus far, no

research publications have addressed ethical concerns about using PARO toward adults

who did not have dementia were found.

Jecker and Nakazawa (2022) discussed ethics guides for using AI and robotics,

stressing the differences between Eastern and Western cultural values around using robots

in the lives of humans. In the early 2010s, the differences in the concepts of using robots

in our lives in Western and Eastern cultures were briefly addressed in several studies.

Shibata and Wada (2010) noted that PARO was widely accepted in the countries where

PARO was tested (i.e., Japan, the United Kingdom, Sweden, Italy, Korea, Brunei, and the

United States). Still, Shibata (2012) noted that people from Western countries who used

PARO tended to think of PARO as a therapeutic device more than a pet and companion,

while people from Eastern countries accepted PARO as a pet and companion more.

Mordoch et al. (2013) addressed that people in North America were “slower to accept the

concept of social and personal robots” (p. 15), while animal-assisted therapy was more

accepted in North America than in Japan. Jecker and Nakazawa noted the strong divide

between Eastern and Western cultures regarding attitudes toward technology, AI, and

robotics, which would affect the international AI and robotics ethics guide. Jecker and

Nakazawa identified Japan as the example of the East and North America and Europe as

the examples of the West. In the West, AI and robots were depicted with more negative

and cautionary terms (e.g., precautions, stress, risk). In Japan, AI and technology were

more openly accepted and had friendly and positive attitudes toward the idea of

coexisting with robots. Jecker and Nakazawa explained that such friendly and open

attitudes toward AI and technology came from cultural values established by the long

history, including pop culture created after the Second World War and Shinto beliefs

related to inanimate objects. Still, Jecker and Nakazawa stressed that Western values were

dominant globally, and the international ethics guidelines were also influenced by

Western ethics guidelines and generally aligned with Western ethics guidelines today.

Jecker and Nakazawa emphasized the importance of creating hybrid values, integrating

both Western and Eastern attitudes, and promoting and creating inclusive, “truly

international” ethics guidelines for using AI and robotics in human lives. Jecker and

Nakazawa’s discussion could explain some of the feedback and criticism toward using

PARO in care settings. Still, when discussing the ethics of using PARO, it was also

important to consider the ethical guidelines of AI and technology with humans, emotional

reactions, and psychological effectiveness. In order to conduct ethical research on using

AI robots, it is imperative to pay attention to cultural values and social influences,

especially when understanding the unique experiences of healthcare workers who used

PARO during the COVID-19 pandemic.

Shibata et al. (2021) reported that the COVID-19 pandemic changed the concept

of using socially assistive robots regarding patient care; while people were forced to be

separated from each other, robots did not need to be concerned about social distance.

Shibata et al. also reported two healthcare workers who used PARO during the COVID-

19 pandemic. No other studies discussing healthcare workers using PARO during the

COVID-19 pandemic were found for this literature review. Still, this could mean that

COVID-19 might have influenced the concepts of psychological interventions for stress

and burnout symptoms of healthcare workers.

Summary

Healthcare worker burnout syndrome has been reported and called for action by

many researchers for many years, yet no significant changes have been made in the

healthcare field. In the United States, suicide rates among healthcare workers, particularly

physicians and nurses, have been on the rise in recent years. Soon after the COVID-19

pandemic hit the United States in April 2020, the emergency physician who worked at the

New York Presbyterian Allen Hospital, Dr. Lorna Breen died by suicide. Sindhu and

Adashi (2020) noted that Dr. Breen refused to seek mental health treatment for

selfharming thoughts because she was afraid of the stigma and losing her medical license.

Dr. Breen’s death triggered to create the law that specifically focused on mental health

and substance use treatment of healthcare workers; the federal government also funded

more research for effective and evidence-based psychological interventions.

Medical workers, mental health workers, and other staff who also work in the

healthcare field experience burnout, especially in community healthcare settings (Eliacin

et al., 2018; Maslach & Leiter, 2016; Rössler, 2012). It could also indicate that mental

health workers who treat other healthcare workers for burnout syndrome could have

burnout syndrome and difficulty providing quality care. Since Freudenberger (1975)

reported on burnout syndrome, two things were addressed by many researchers

repeatedly: (a) to involve organizations, leadership roles, and administrators to make

drastic changes in the healthcare field, and (b) to have effective, evidence-based,

innovative, more individualized interventions (Holmes et al., 2020; Huckvale et al., 2019;

West et al., 2016). It can be a hopeful sign that Dr. Breen’s death triggered the

involvement of the federal government and established the law to pay serious attention to

healthcare workers’ psychological well-being, the sigma, and culture in the healthcare

field, and change the trend in the healthcare field.

One research study reported healthcare workers who used PARO during the

COVID-19 pandemic. Research on using socially assistive and interactive robots for

mental health was also limited (Scoglio et al., 2015). Although PARO took a long time to

be built and utilized as a medical device worldwide, PARO is a relatively new medical

device. Clinical use of PARO was limited to patients with dementia, children with

developmental disabilities and/or intellectual disabilities, and patients with terminal

illnesses. Randomized controlled studies did not reveal something clear or definite about

the effectiveness of using PARO. Hung et al. (2019) pointed out that the characteristics of

the research on PARO described positive changes in mood, demeanor, and behavior of

the users and reduced the use of medications; still, the research outcomes of PARO

seemed to be researcher-centered, lacking the users’ experience and needs, and theoretical

framework. This qualitative study would address the gap by providing a research

framework and users’ experience. With constructivism epistemology, using the existential

psychotherapy concepts framework, different reactions of research participants were

expected and explained through the lens of the users of PARO in their own worldviews

and the knowledge the users gained from the users’ current and past experiences

combined. Shibata et al. (2001) discussed that it was up to the user to

evaluate the value and effectiveness of PARO, such as thinking of PARO as a cute and

cuddly creature or a stupid robot. The healthcare workers who used PARO during the

COVID-19 pandemic reached out and used PARO for their’ own personal reasons,

finding the healthcare workers’ own values; this qualitative study was to explore and

understand this phenomenon.

Chapter 3: Research Method

Introduction

Socially assistive robots have been researched and utilized to improve the mood

and behavior management of patients with dementia (Libin & Libin, 2005; Petersen et al.,

2017; Shibata & Wada, 2010). A socially assistive robot designed to resemble a baby harp

seal, PARO (a short description of “Personal Robot” in Japanese) is a biofeedback

medical device (Shibata, 2012) with five sensors (i.e., tactile, light, audition, temperature,

and posture sensors; PARO, 2014) that has been used to treat older adults with dementia,

PTSD (Shibata et al., 2021; Lane et al., 2016), and depression (Shibata et al., 2021;

Collins et al., 2018), and facilitate using fewer medications for patients’ mood and

behavior management (Shibata, 2012; Shibata et al., 202). Using PARO for mental health

care of healthcare workers who worked during the COVID-19 pandemic was reported by

Shibata et al. (2021). This phenomenon, healthcare workers who used PARO during the

COVID-19 pandemic, is new and has not been explored when reviewing the literature for

this study.

This chapter explains the research method selected to answer the research

questions in detail, such as the reasons the qualitative research method was selected,

strategies to find research participants for this qualitative study, the role of the researcher,

and issues of trustworthiness in order to clarify the scope of this research, which was to

explore the experiences and meaning of using the socially assistive and interactive robot

PARO by healthcare workers who worked with patients/clients during the COVID-19

pandemic.

Research Design and Rationale

The problem addressed in this study was healthcare worker burnout symptoms

and the tendency for healthcare workers not to utilize existing resources to treat their

mental health conditions, such as severe depression, including suicidal thoughts and

problems with substance use, abuse, and dependence. Many researchers have raised

awareness of the increased severity of the healthcare provider burnout phenomenon and

the dire need for significant cultural and organizational levels of changes in the healthcare

field for many years (Awan et al., 2022; Freudenberger, 1974; Kingston, 2020; Maslach

& Leiter, 2016; Smith, 1976).

Shibata et al. (2021) reported that a few healthcare workers used PARO during the

COVID-19 pandemic while working with patients with COVID-19. So far, no other

scholarly articles discussing the use of socially assistive and interactive robots by

healthcare workers while going through the COVID-19 pandemic, the time when

healthcare workers experienced indescribable mental and emotional distress, were found.

This study explored the phenomenon of healthcare workers who used PARO during the

COVID-19 pandemic.

Research Questions

RQ1: What were the experiences of healthcare workers who utilized PARO

during the COVID-19 pandemic?

RQ2: How could using PARO prevent worsening psychological conditions of

healthcare workers who work in mentally and emotionally stressful

environments?

Research Tradition, Research Design, and Rationale

This study aimed to explore and understand healthcare workers who used PARO

during the COVID-19 pandemic, what healthcare workers who used PARO during the

COVID-19 pandemic experienced, and the meanings the healthcare workers found in the

healthcare workers’ subjective view, lifeworld, and reality. The foundational philosophy

was constructive relativism, where knowledge lies in the subjective experiences of

humans, interpretation, and construction by humans; the truth is determined by the

individual who experienced the phenomenon (Burkholder & Burbank, 2016). As such,

this research was founded on phenomenological constructivism. The research design

selected was hermeneutic phenomenology because the philosophy of phenomenology

aligned with the ontological and epistemological orientation of this qualitative research.

Hermeneutic Phenomenology

A phenomenological philosopher, Edmund Husserl, established the

phenomenology qualitative research tradition in the early 20th century (Merriam &

Tisdell, 2016; Peoples, 2020b). Husserl asserted that human beings’ experience and

motivation would be understood by the description of their experiences through their

consciousness and senses; knowledge existed in the description of human beings’

experiences through their perception and senses (Lopez & Willis, 2004). Husserl further

stressed the importance of considering the subjective experience of human beings through

their consciousness and the cognitive process of their lived experiences. The information

from human consciousness and lived experience would need to be explored without

researcher bias, subjectivity, previous knowledge, and experiences. Husserl called

removing biases and subjectivity process “bracketing”; Husserl’s phenomenology was

also called descriptive phenomenology (Lopez & Willis, 2004; Peoples, 2020b).

Hermeneutic phenomenology was developed by Martin Heidegger, a student of

Husserl, in the middle of the 20th century and further developed by Hans-Georg Gadamer

(Lopez & Willis, 2004; Peoples, 2020b; Van Manen, 2023). Heidegger asserted that

bracketing in phenomenology was not necessary because bracketing was not only

possible but also a vital part of phenomenological research. The essence of

phenomenological research was to study human beings’ lived experiences and meanings

they found in their experience of existing and being in their “lifeworld” (Heidegger,

1975; Peoples, 2020b; Van Manen, 2023). Therefore, instead of objective descriptions of

human beings’ lived experiences, Heidegger was interested in interpreting human

experiences and understanding the meanings human beings’ found in their experiences.

Heidegger developed a research method utilizing the concept of hermeneutics when

analyzing and interpreting qualitative data from interview transcripts (American

Psychological Association, n.d.-a; Peoples, 2020b; Van Manen, 2023). Therefore, in order

to understand the essence of research participants’ lived experiences and meanings

through the participants’ words, it would become critical for the researcher to be well

aware of researcher subjectivity, past knowledge and experiences of the researcher,

relative to the research topic, making the researcher subjectivity, past knowledge, and

experiences explicit and known (Peoples, 2020b; Van Manen, 2023). Lopez and Willis

(2004) wrote, “the meanings that the researcher arrives at in the interpretive research are

a blend of the meanings articulated by both participant and researcher within the focus on

the study” (p.730), as explaining Heidegger’s interpretive phenomenological tradition.

Hermeneutic phenomenology was selected for this qualitative research because

this study was to explore the lived experience of healthcare workers who used PARO

during the COVID-19 pandemic and understand what it meant for the healthcare workers

who used PARO during the COVID-19 pandemic. Also, as the primary researcher of this

study, I used my experience of being a healthcare worker, working in an inpatient setting

during the COVID-19 pandemic as a clinical mental health therapist, and having

experienced burnout symptoms during my career to enrich the data collection and data

analysis by explicitly acknowledging my prior knowledge and experience.

Role of Researcher

The qualitative research design selected for this study was hermeneutic

phenomenology to understand the experience of healthcare workers who shared the

experience using PARO during the COVID-19 pandemic. For this qualitative study, my

role as the researcher was that of a semi-observer participant. I was known to the

participants as a researcher and interacted with the participants as a researcher; however, I

was not an active participant in the phenomenon of this study. A researcher serves as the

primary data collection and analysis tool in qualitative research (Creswell & Creswell,

2018). In this qualitative study, I interviewed research participants, but I was not present

when the research participants worked during the COVID-19 pandemic or used PARO

during the COVID-19 pandemic; however, I explicitly identified my burnout experience

as a healthcare worker and my having worked during the COVID-19 pandemic in an

inpatient setting. The shared experience was overtly known to the participants. Therefore,

the moments discussing the experience of burnout and working through the COVID-19

pandemic would be experienced vicariously. There were no professional or personal

relationships between the study participants and me. It was assumed that no power

balance issues that could affect the data quality were identified.

Reflexivity and Researcher Bias (Preconception)

Creswell and Creswell (2018) denoted that identifying researcher reflexivity is

critical in qualitative research. At the same time, the hermeneutic phenomenology

research tradition stressed that separating researcher preconceptions (i.e., past experiences

and knowledge from the researcher when the researcher perceives the phenomenon) was

impossible (Peoples, 2020b; Van Manen, 2023). Human beings make decisions or find

meanings through interpretations via human senses and consciousness within the values

gained by past experiences (Lopez & Willis, 2004; Reiner, 2012). According to

hermeneutic phenomenology philosophy, as a primary researcher who collected and

analyzed data for this qualitative study, this researcher’s previous experience of burnout

and working in an inpatient setting during the COVID-19 pandemic would be inseparable

and crucial (Lopez & Willis, 2004; Peoples, 2020b; Van

Manen, 2023).

Still, it did not mean there were no subjectivity and biases to watch for. The

primary and most crucial bias for me was personal values because it could lead to my

desired research outcome (Crawford, 2016; Creswell & Creswell, 2018). Particularly,

favoring technology must have been closely checked when interviewing and

communicating with research participants. Also, the experience of being a clinical mental

health counselor needed to be watched when interviewing research participants for

wanting to make the interview a therapy session when listening to the participants’

experiences of going through burnout experiences and the participants’ experience during

the COVID-19 pandemic.

Creswell and Creswell (2018) noted that qualitative researcher reflexivity could

be addressed progressively. Creswell and Creswell suggested being open and transparent

about the researcher’s thoughts and emotional experiences by writing the experience with

each research participant, including the observations, reactions, feelings, guesses, and

other things noticed in the interview. For the hermeneutic phenomenology qualitative

method, researcher biases, past experiences, and knowledge were expected to be explicit

and a vital part of data collection and data analysis; still, preconceptions that were

unwanted and unrelated to this study, such as leading the participants to

researcherfavoring answers or making the interviews a clinical interview or therapy

session out of my emotional reactions were crucial to be careful about. For this reason, I

conducted pilot interviews before meeting with research participants to practice and

improve researcher reflexivity in interacting with the participants effectively for data

collection and data analysis.

Methodology

The population identified for this qualitative research was healthcare workers who

had experienced burnout syndrome and tended not to seek existing treatment and care

methods as identified in the literature review. In order to facilitate the need for dramatic

changes in the healthcare field, including healthcare workers’ stress and burnout

reduction strategies, this qualitative research explored the lived experiences of healthcare

workers who used PARO, the socially assistive and interactive robot.

Sampling Strategy

The research participants for this study were healthcare workers who used PARO

during the COVID-19 pandemic. When going through the literature review for this study,

no studies discussing the experience of healthcare workers using PARO were found,

except for one study by Shibata et al. (2021). Therefore, purposive sampling, particularly

the snowballing sampling method, was chosen, considering the scarce research

participants for this qualitative research (American Psychological Association, n.d.-b;

Crawford, 2016). The inclusion criteria of research participants were adults (i.e., 18 years

old or older) who were healthcare workers and experienced burnout syndrome prior to the

COVID-19 pandemic and used PARO during the COVID-19 pandemic. Because burnout

syndrome was reported by healthcare workers across the healthcare field (Davis et al.,

2021; Eliacin et al., 2018; Essary et al., 2018; Holmes et al., 2020; Jovanović et al., 2016;

Kington, 2020), no limitations in healthcare worker disciplines were specified. Research

participants for this study would be asked if they had burnout experience in the past

through direct patient care in their careers before and during the COVID-19 pandemic.

Shibata et al. (2021) reported that a few healthcare workers used PARO during the

COVID-19 pandemic, showing a different way to use PARO aside from its use as a

socially assistive robot for the older adult population with dementia. In the study by

Shibata et al., there were two pictures of healthcare workers who used PARO during the

COVID-19 pandemic. One was of a registered nurse (RN) who worked in “the ICU at an

emergency hospital near Atlanta, Georgia, U.S.” (p. 13), and the other was of a telephone

counselor at a “public health center” in Toshima City, Tokyo, Japan (p. 14). According to

Shibata et al., the pictures of these healthcare workers using PARO were taken in the

summer of 2020 (May and June of 2020, respectively) during the COVID-19 pandemic

experienced in the United States and Japan.

After getting the approval of the Institutional Review Board (IRB) of Walden

University (approval number 11-20-23-0738972), I planned to reach out to the RN from

Shibata et al.’s (2021) study who used PARO during the COVID-19 pandemic as the first

potential actual study participant and also to ask if the RN knew any colleagues who also

used PARO during the COVID-19 pandemic period. Contacting the RN in the report by

Shibata et al. was not initiated before the approval of the Walden University IRB.

Creswell and Creswell (2018) discussed the appropriate sample size for each

qualitative research design and wrote, “phenomenology involves a range of 3-10” (p.

186). While Creswell and Cresswell emphasized that depending on how and when data

saturation was reached, research participant search was expected to continue to find them

and interview or stop interviewing when the categories and themes were saturated, Van

Manen (2023) noted that phenomenological sampling would need to be done “with

reference to the attempt to gain “examples of experientially rich descriptions” (p. 456),

meaning it was expected to continue to collect data until no longer reveals anything new

and unique.

In a case where the snowball sampling method with the RN mentioned in Shibata

et al. (2021) could not work out, I planned to reach out to a long-term PARO researcher

and owner, Dr. Sandra Petersen (Petersen et al., 2017) as another snowball sampling

starting point, or another researcher who used and tested PARO, Dr. Lane (Lane et al.,

2016), along with reaching out to the hospitals, nursing homes, assisted living in the

United States, such as the Southern Illinois University where Dr. Shibata gave a

presentation on PARO (SIUC, 2019). Also, I planned to contact two health clinics where

PARO was utilized with older adult patients in Canada and two facilities in Australia. In

addition, I planned to reach out to an addiction and mental health treatment center in

Canada. In a case where no actual study participants were found in English-speaking

countries, the actual study participant search would be expanded to Japan, utilizing social

media. Japan was chosen because I understand Japanese at a native level without

assistance.

Instrumentation

Phenomenological qualitative research uses interviews as the primary instrument

of data collection and analysis; the researcher was the primary instrument to collect and

analyze the data obtained by interviewing (Creswell & Creswell, 2018; Merriam &

Tisdell, 2016). The interview for this qualitative study was conducted virtually, using a

video conference program (i.e., Zoom) as accepted by the participants. A laptop

computer, Dell Inspiron 17 3000 with Windows 11, was used to conduct and record

interviews. Notes were taken during the interview, using an external keyboard connected

with a USB connector (Arteck wireless 2.4G keyboard). No other devices were required

or needed to conduct the interview. An interview protocol (see Appendix B) and

semistructured interview questions that would help answer the research questions were

prepared (see Appendix A) prior to the interview (Crawford & Lynn, 2016; Rubin &

Rubin, 2012). I planned to use a transcribing application, Rev (Version 4.20), for

interviews conducted in English. A Japanese transcribing application, Toruno, and a

Japanese word processing application, NJ Star, were planned to be used for interviews

conducted in Japanese. The transcripts would be reviewed thoroughly before sending the

transcripts to the participants for member-checking verification. A follow-up interview

content verification was planned to be done by emailing, using an encrypted Word

document. Data coding was performed manually. Microsoft Word and Microsoft Excel

were used for data organization. Microsoft Word was used to take interview notes,

observation notes, and memos on my computer and save the information using the

encryption function.

Pilot Study

In order to obtain quality data from a qualitative research interview, Merriam and

Tisdell (2016) stressed the importance of having a pilot study so that the researcher would

get the practice of interviewing and how the data collection method would work

effectively to strengthen methodological rigor. I sought two pilot study participants who

were healthcare workers from my acquaintances and had experienced burnout in their

careers, contacting people via social media and using the research pool program of the

school, using a flyer approved by the IRB. In the pilot interviews, I followed and

practiced the steps and procedures for the actual study, such as sending the pilot study

consent form to the pilot participants, answering questions they had before the interview,

clarifying the inclusion criteria, voluntary nature of participation, receiving an email with

“I consent,” indicating the participants’ agreement to participating in the pilot study

interview as indicated in the informed consent forms, having a video conference

interview, and transcribing the interviews. After receiving the email with “I consent” with

the informed consent form, indicating the participants’ agreement to participate in this

study interviews voluntarily as indicated in the informed consent form, the pilot

participants were asked about their burnout experiences in the same semistructured

interview questions as the actual study. In the pilot study interviews, participants’

affective and experience related statements and reactions were primarily focused for a

data collection practice. Coding and identifying meaning units were also practiced;

however, data were not analyzed. The primary questions to the pilot study participants

were to understand the burnout experience of healthcare workers; the pilot participants

were asked subquestions (i.e., data collection instrument), such as, “Tell me your work

experience as a healthcare worker in your work (where the participant experienced

burnout), “Tell me your burnout experience; how did you know when you had burnout?”

The pilot study allowed for an opportunity to practice the skills of data collection and

coding in a controlled environment.

Research Participants Search

The research participants sought for this study were healthcare workers who

provided direct patient/client care during the COVID-19 pandemic, experienced burnout,

and used PARO during the COVID-19 pandemic. Purposive sampling, particularly the

snowballing sampling method, was selected for participant recruitment. The RN, who

was mentioned in the study by Shibata et al. (2021), worked in the ICU of a hospital in

Georgia during the COVID-19 pandemic and used PARO during the COVID-19

pandemic. When approved by the IRB, I attempted to locate the RN in the study by

Shibata et al. by contacting the hospitals near Atlanta, Georgia, as indicated in the study

by Shibata et al. However, I could not locate the RN.

The snowball sampling with the RN described in the study by Shibata et al.

(2021) did not work. After obtaining the IRB approval, I attempted the second snowball

sampling process with Dr. Sandra Petersen of the University of Texas, who researched

PARO for years; however, this snowball sampling did not take off either since no

response was received from Dr. Petersen. Dr. Lane of the Department of Veterans Affairs

Palo Alto Health Care System’s Community Living Center was also contacted by email;

however, no response was received; therefore, the sampling method needed to be changed

to general purposive sampling. With the IRB approval, the actual study participants were

sought via social media, such as YouTube, Twitter/X, and Instagram.

Keywords such as PARO, therapy, robot, or PARO, dementia, seal robot, and

therapy AI robot were used on YouTube, Twitter/X, and Instagram. Also, programs that

were using PARO were searched on the Internet. Through YouTube, short videos of

careproviding programs, such as assisted living, nursing homes, hospitals, and hospices,

which were utilizing PARO, along with news reports about the programs using PARO,

were found. Via YouTube search, an average of 160-170 videos came up by entering three

or more of the keywords listed; however, the majority, more than half of the videos

(approximately 95 videos), were personal videos of PARO, showing PARO as a novelty

in exhibition events or museums. Less than 3% of the videos were posted by academic

programs in the United States, Canada, Germany, and the United Kingdom, exhibiting

PARO as a potential clinical intervention device and approach to care for patients with

dementia. The majority of the videos were over ten years old; however, the most recent

videos were in 2023–2024. One of them discussed lab results of checking oxytocin levels

of healthy adults using PARO (Geva et al., 2020), released in 2020. Another was of

Saanich Peninsula Hospital in Canada, posted in 2020. The University of Nebraska

showed they used PARO for a pediatric care research program posted in 2023 and 2024.

The media sources and treatment programs that had posted videos on YouTube were

contacted through the programs’ contact information webpages and phone numbers on

their websites. Still, not all programs found were healthcare programs; in order to find

healthcare workers who went through the COVID-19 pandemic, care-based programs

were reached out. It was about 10% (16) of the total videos found on YouTube in this

search.

From Instagram, in the search for this study using the same keywords used on

YouTube, three or four words at a time, 300 to 320 entries were found, including the ones

that were not directly related to PARO use. More than half of the entries were personal

entries, about a third were of demonstration, exhibition, introduction, and media reporting

PARO, and about 4% of entries (12) were related to research or academic programs.

About 5% of the entries (15) were care programs where PARO was utilized with their

residents/patients/clients. Six entries out of 15 were from Europe (e.g., France, Spain,

Hungary); 10 entries were from English-speaking countries (i.e., the United Kingdom,

Canada, the United States, Australia, and New Zealand), and one was from Japan. Direct

messaging on Instagram was used to contact the programs found by the search or an

email was sent through the websites of the programs linked to the programs’ Instagram

accounts. No responses were received from the programs by this search.

While waiting to hear back from the social media account holders, I reached out

to the previous contacts, a researcher Dr. Hannah Bradwell from the University of

Plymouth in the U.K. and a researcher Dr. Selma Sabanovic of the University of Indiana,

regarding healthcare workers who used PARO during the COVID19 pandemic. Dr.

Bradwell explained that she had stopped using PARO: “We did use robot pets with care

homes throughout the pandemic - but we opted [PARO] for more affordable Joy for All

cats and dogs for our trial rather than Paro” (personal communication on February 29,

2024). Dr. Sabanovic, who researched PARO as an academic researcher, responded, “I

did not use Paro in the pandemic, but I do know some healthcare workers that do use Joy

for Alls (robot dogs and cats) although I believe they discontinued shared use of those

among residents during the pandemic” (personal communication on March 10, 2024).

Although Dr. Sabanovic kindly mentioned that Dr. Sabanovic would let Dr. Shibata know

about this study, no contact was received from Dr. Shibata regarding the actual study

participant search for this study.

When utilizing Twitter/X, I found approximately 80–90 posts with either short

videos or images or only messages regarding PARO. Like YouTube and Instagram

entries, the majority of the entries were personal in nature, and about half of the entries

were of media, exhibitions/introductions, or business in nature. About ten entries were of

academic and research programs, and about five entries were of care/treatment programs

in this search.

I did not hear from any programs on Instagram. A few programs I reached out to

through the programs’ websites responded; however, they said that the programs were no

longer using PARO. Still, most of the programs that I contacted for the actual study

participant search did not respond.

Seeking Participants in Japan

Initially, the search criteria were limited only to the areas where English was the

primary spoken language; however, the actual participant search in English-speaking

countries was unsuccessful. With the IRB’s approval, the actual study participant search

expanded to Japan, using Japanese, another language I understand at a native level. Using

the Twitter/X search function with the same keywords in Japanese (i.e., パロ、セラピー

、ロボット、パロ、認知症、アザラシロボット、セラピーAI ロボット), I found a

PARO owner who also described as a PARO handler on Twitter/X. When I contacted the

Twitter/X account owner for a potential study participant, using the study participant

recruitment flyer in Japanese, this Twitter/X account owner responded, explaining that

the account owner met the study participant inclusion criteria and was interested in

talking about her experience with PARO. This participant became the snowball sampling

starting point, providing the information about this study to three other potential

participants. The other two participants also met the inclusion criteria; however, one of

the potential participants passed away while I was waiting to hear back from the IRB’s

approval of the informed consent written in Japanese, and the other potential participant

did not meet the inclusion criteria. In the end, I had two actual study participants who met

the inclusion criteria. Both participants voluntarily agreed to participate in this study

interview.

In summary, the actual study participant search did not go as planned. All the

backup plans prepared did not help to find the actual study participants even though there

were personal users of PARO and other robotic companions in the individual users’ lives

or healthcare programs.

Data Collection and Data Analysis Plan

This qualitative study was hermeneutic phenomenology. Hermeneutic

phenomenology values research participants’ experiences and meanings in the lifeworld

of research participants because the experiences and meanings of the participants’

lifeworld would construct the reality of the research participants. In hermeneutic

phenomenology, data are collected and construed through a circular process as a method

of analysis (Creswell & Creswell, 2018; Merriam & Tisdell, 2016; Peoples, 2020a; Van

Manen, 2023) by going through transcripts for coding, identifying affective and

experiential meaning units and themes (Peoples, 2020a; Saldaña, 2016; Van Manen,

2023).

Interviewing started with understanding the research participants’ prior experience

of burnout, utilizing affective coding methods (Idczak, 2007; Reiners, 2012). Particularly,

I focused on emotion, values, and in vivo coding, searching for research participants’

emotions, values, judgments, and cognitive processing (Saldaña, 2016). I provided the

research participants with a brief background of my experience with burnout syndrome as

a clinical mental health therapist and working during the COVID-19 pandemic, providing

direct client care to cultivate the data collection milieu. The research participants’ unique

cultural backgrounds or values that could influence data analysis were also asked;

however, I understood the cultural values unique to Japanese people. No other culturally

specific issues needed to be clarified in the interviews. After interpreting and

summarizing the transcripts by the research participants and identifying codes, meaning

units, and themes, the summary and transcripts were reviewed by re-reading, reflecting

participants’ statements back on the whole themes, the research topic, or research

question, and finding out the essence of the participants’ lived experiences and meaning

constructed by the research participants (Peoples, 2020b; Van Manen, 2023). This process

was repeated and continued until data were saturated (i.e., no new concepts emerged),

checking if the information gained by the circular process reflects the research

participants’ subjective lived experience and meaning in the participants’ lifeworlds.

Plans for Discrepant Cases

Crawford (2016) mentioned that fewer discrepant cases and unimpactful

discrepant case data analysis would indicate high credibility of qualitative research.

Considering the newness and rareness of this qualitative study, discrepant cases were

expected and welcomed. Therefore, it was critical to address discrepant cases in this

qualitative research in order to show that the analysis was intended to be conducted

impartially. Erickson (2012) stressed the importance of recognizing and analyzing

discrepant cases because discrepant cases would give new insights and different

directions for future research. Finding outlier data helps to understand the phenomenon of

healthcare workers who experienced burnout and used PARO during the COVID-19

pandemic more authentically and gain different perspectives to understand this

phenomenon.

There was one potential discrepant case while seeking the actual study participant

through social media; however, no response was received from the Twitter/X account

holder.

Issues of Trustworthiness

Stewart and Hancock (2016) wrote, “validity is related to the concept of truth; in

research, valid findings accurately describe or reflect the phenomenon under study”

(p.193). Trustworthiness was the term used in qualitative research to describe valid

findings. In order to report trustworthiness of a qualitative study, qualitative validity and

qualitative reliability need to be described logically. Creswell and Creswell (2018)

explained that qualitative validity was to report the accuracy of the study findings, while

qualitative reliability was to address the consistency of research methods across

phenomenological research procedures. This section discussed what trustworthiness

strategies were utilized for a qualitative study aiming for a different perspective of

phenomenologically credible outcomes.

Credibility

Credibility in qualitative research addresses how truthfully the research results

described the target phenomenon in our world and how believable the description of the

world was (Merriam & Tisdell, 2016). Crawford (2016) noted that it was essential to

select credibility strategies that fit the qualitative research, and there was no need to

utilize all the credibility strategies known. I used member-checking, progressive

subjectivity including reflexivity, and discrepant case analysis for this qualitative study.

Member-checking was to ask research participants to review and verify the

accuracy of the research participants’ research interview answers in transcripts and to

receive feedback from the research participants about the interview transcripts.

Memberchecking’s effectiveness lied in gaining research participants’ insights, feedback,

and corrections of research participants’ own words in the interview. In other words, the

member-checking process asked if the research participants’ reality was accurately

expressed in words the way the research participants stated in the interview.

Memberchecking was one of the most critical trustworthiness processes because research

participants reviewed their own words (Guba & Lincoln, 2001).

Progressive subjectivity, including reflexivity, was selected because researcher

biases and personal values would interfere with the data quality if not checked from the

very beginning. However, in hermeneutic phenomenology, because the researcher is the

primary instrument for collecting and analyzing data to understand and find meanings in

human existence and experience in the phenomenon, and the reality constructed by the

research participants through interpreting the research participants’ words, researcher

subjectivity (i.e., preconceptions) was expected. Still, there must be a system to check

researcher reflexivity to gain trustworthiness. In order to increase researcher reflexivity,

this qualitative research employed progressive subjectivity. Despite hermeneutic

phenomenology acknowledging researcher preconceptions (Van Manen, 2023), I needed

to be aware of unwanted preconceptions; researcher reflexivity for this qualitative study

(i.e., wanting successful research outcomes, liking robots and advanced technology, being

distracted too much) and attitude toward interviewing (i.e., being a clinical mental health

counselor) had to be watched carefully. Taking notes of my awareness, feelings, and

reactions to this study and my level of nervousness would be checked and noted, starting

with pilot studies.

Discrepant case analysis was also selected because openly discussing discrepant

case analyses would increase the credibility of this qualitative research and make this

qualitative research more credible (Creswell & Creswell, 2018). If there were fewer

discrepant cases and the data analysis of the case was uninfluential to the whole research

outcome, it would indicate high credibility of qualitative research (Crawford, 2016).

Analyzing discrepant cases could also show the researcher’s attitude and ability to

discriminate unwanted and unnecessary preconceptions that contaminate the quality of

data collection and data analysis.

Transferability

Transferability in qualitative research addresses how applicable qualitative

research findings were to other situations (Merriam & Tisdell, 2016; Crawford, 2016); it

does not mean how generalizable the research findings are in our world. Crawford (2016)

wrote, “Determining the applicability of the findings of a qualitative study to other

situations is predominantly a responsibility of the person in the other situation”

(Crawford, 2016, p.149). In order to show the applicability of qualitative research

findings, detailed descriptions of the research setting, participants, and research findings

are needed. Crawford (2016) noted three elements a qualitative researcher was expected

to pay attention to for thick description: (a) description of the setting, (b) description of

the participants, and (c) evidence to support the findings (p. 153); the researcher was

expected to make the decision what and how much information was enough as evidence

for the research findings. Therefore, thick description was selected to show the

transferability of this qualitative study. Thick description for this qualitative research

would mean delineating information on the research participants, the settings of this

qualitative study, the findings of this qualitative study, and statements made by the

research participants in interviews, the demeanor research participants showed in

interviews in order to prove transferability of this qualitative research.

Dependability

Dependability in qualitative research was to address consistency in qualitative

research. A question, such as “whether the [research] results are consistent with the data

collected” would be asked to ensure the dependability of qualitative research (Merriam

and Tisdell, 2016, p.250). In order to answer qualitative research questions, qualitative

research must examine the consistency of data collection and data analysis (Guba &

Lincoln, 2001; Merriam & Tisdell, 2016). For this qualitative study, audit trail would be

used. Recording each step and details of data collection steps, how meaning units and

themes were developed and interpreted, changes made after re-reading the transcripts,

and the hermeneutic cycle processes and results (Merriam & Tisdell, 2016; Peoples,

2020b).

Confirmability

Researcher preconceptions, such as prior knowledge and experiences, were

expected and accepted in hermeneutic phenomenology (Peoples, 2020b; Lopez & Willis,

2004; Van Manen, 2023). Still, “the [qualitative] research findings must be logical and

plausible within the study framework” (Lopez & Willis, 2004, p. 730). In order to

increase confirmability in qualitative research outcomes, my unwanted and unnecessary

personal values (i.e., liking robots and technology and potentially switching the role to be

a clinician instead of a researcher) would be closely monitored as research would

progress; working on reflexivity, keeping notes, and recording the research processes as

the research would progress.

Ethical Procedures

The areas of ethical issues to be considered for this qualitative research were: (a)

type of research, (b) confidentiality, (c) risks and harm, (d) voluntary participation, and

(e) conflict of interest. This qualitative study was not experimental research; no humans

or live animals would be used or tested. The research participants for this qualitative

research were adults (i.e., 18 years old or older) who independently worked with

patients/clients in the healthcare field, communicated with patients, and made

professional decisions at the participants’ work; therefore, it was believed the research

participants for this study could make decisions about participating in this study

independently.

As an appropriate ethical procedure, approval from the IRB of Walden University

needed to be obtained before sending informed consent with detailed information about

this study to potential study participants. The informed consent explained the purpose of

this research as a dissertation, that I was a student, and that research participation was

voluntary and could be stopped participating at any time. The study participants’ personal

information would be protected, and the data gained by this interview would be used only

for this research. They would not be shared with other researchers or institutions without

the permission of the research participants for this study. When sending the transcript of

the interview to the study participant, the document would be encrypted on Word. In the

research report, the research participants would be identified by alphabet to protect the

identity of the study participants. The risks and benefits of this research were delineated

in that the risks were considered minimal to mild, considering the fact that the research

participants for this study were asked to talk about the participants’ previous experience

of burnout and work experience during the COVID-19 pandemic. Still, mental health care

resources for the study participants were be provided in the informed consent form. The

benefits of this research were to be part of changing the unhealthy culture of the

healthcare field in the United States, where seeking mental health treatment or help was

stigmatized and difficult to have a work-life balance for self-care and to explore new,

individualized mental healthcare and stress management for healthcare workers.

Summary

This chapter addressed the research methodology, hermeneutic phenomenology,

and the rationale for selecting the research method along with details of how this

qualitative research was conducted. The actual study participant search was more

challenging than expected, and the prepared plans were exhausted. Ultimately, the

snowball sampling method was used after changing and expanding the participant search

medium to social media, expanding the search area from English speaking countries to

internationally (e.g., Japan).

Hermeneutic phenomenology assumes researcher preconceptions, particularly

prior knowledge, past experiences, and the values gained in the lifeworld of the

researcher (Peoples, 2020b; Lopez & Willis, 2004; Van Manen, 2023). Because of such

fundamental theoretical concepts, working on reflexivity and monitoring unwanted

preconceptions became vital. Van Manen (2023) denoted the differences between

phenomenological qualitative research and other types of qualitative research (i.e.,

grounded theory, ethnography), emphasizing that “phenomenological inquiry cannot

strive for empirical generalization – from sample to a population” (p. 456) but rather to

focus on gaining “examples of experientially rich descriptions” (p. 456), valuing the

originality and distinctness the participants’ lived experiences. This meant that data

saturation would show in gaining anything new or different ideas or insights as opposed

to seeking specific categories, theories, or counting the terms that most appeared and

identifying the sameness as seen in grounded theory or ethnography (Van Manen, 2023).

The validity of a phenomenological study would be based on “the appraisal of the

originality of insights and the soundness of interpretive processes demonstrated in the

study” (p. 449).

This chapter also addressed the contents of the informed consent form to avoid

ethical violations and preventable harm and discussed ethical considerations and

procedures for this study. It was crucial to obtain approval from the IRB of Walden

University before contacting study participants in order to conduct ethically sound

research.

In the next chapter, the details of conducting this qualitative study, data collection,

data analysis, and the results of this research are reported.

Chapter 4: Results

Introduction

This hermeneutic phenomenological research aimed to explore and understand the

lived experiences of healthcare workers who used PARO during the COVID-19 pandemic

by interviewing healthcare workers who used PARO during the COVID-19 pandemic and

analyzing the data drawn from the interview transcripts and finding meanings of

healthcare workers who used PARO constructed in order to answer the research

questions.

As delineated in Chapter 3, except for the study done by Shibata (2021), I found

no studies published discussing the experiences of using PARO among healthcare

workers, particularly during the COVID-19 pandemic, within the limit of the literature

review of this study. Finding the actual study participants was challenging; however, two

actual study participants from Japan were found, and the participants completed the

interviews for data collection. The study results reported in this chapter were drawn from

the data collected from the transcripts of the interviews of the two participants. Because

of the scarcity of actual research participants and the data, this study could not confirm

that the results reached the data saturation point. Therefore, this study was considered

reasonably exhaustive research. Still, with following the steps planned for trustworthiness

as much as possible to earn credibility of this study results, the interviews with the two

participants provided abundant and rich data and information to gain deeper perspectives

regarding the research questions and the participants’ lived experiences of using PARO as

healthcare workers who experienced burnout during the COVID-19 pandemic.

Hermeneutic analysis was used in order to understand the uniqueness of the participants’

lived experiences and relatedness in the participants’ lifeworld.

This chapter explains the process of this research stage, starting with the pilot

study, the search process for the actual study participants, the interview and data

collection being performed in Japanese instead of English, data analysis, and themes that

emerged from the data obtained from the interview transcripts, themes particularly unique

to each participant, evidence of trustworthiness, and the answers to the research questions

for this study.

Pilot Study

Because the researcher is the primary data collection and data analysis tool in

hermeneutic phenomenology, I conducted a pilot study to improve data quality and gain

familiarity with qualitative interviewing to increase the credibility of the study; in

addition, the data collection instrument (i.e., subquestions) were tested to see if the

instrument was effective and adequate to collect credible data (Marriam & Tisdell, 2016).

Two pilot participants responded to the invitation email with a flyer; they were healthcare

workers who provided direct patient care and experienced burnout in their careers. Both

pilot participants returned an email with “I consent,” indicating they understood and

agreed to participate in the pilot interviews. I shared my previous experiences of burnout

with the pilot participants, including my experience during the COVID-19 pandemic;

however, sharing the experience did not influence the relational dynamic and increase

rapport; rather, the participants were more interested in answering the questions for the

sake of the purpose of the pilot study, to test the effectiveness of the instruments.

The pilot study affirmed that the data collection instruments were adequate. The

pilot study also helped me better prepare for the interview with the actual study

participants, such as the flow of the interview process, including the technical and

mechanical parts of the interview; no adjustments or changes were needed prior to

proceeding to the actual study interviews.

Participants

Two final actual study participants from Japan were found through Twitter/X. The

first participant (Participant A) and I communicated via email about scheduling the

interview appointment. Prior to the meeting, Participant A clarified that she did not speak

English and wanted the interview to be done in Japanese, as did other participants whom

Participant A introduced for this study. Participant A was in her 50s and had earned many

certifications in her career, starting with a nursery teacher (kindergarten/preschool

teacher), home helper (a national certification, like an in-home certified nursing assistant

in the United States), a care worker (a national certification for providing nursing care), a

care manager (a national certification for delivering case management), and finally

became a social worker (a national certification for providing resources and assisting

socially vulnerable populations, such as older adults or people with disability, to improve

the quality of their lives). Participant A worked as a home helper and a care worker for

older adults for about 4 years when she experienced her first major burnout; although

Participant A obtained a case manager and a social worker certification so that she could

have non-direct patient care to avoid such burnout experiences, Participant A ended up

providing direct care by visiting clients’ homes (additional tasks of work which used to

be operated by a group of volunteers) because of the COVID-19 pandemic. Participant A

continued to work as a social worker at the time of the interview for this study.

Participant A owned a PARO and lived with it at home with her family members;

Participant A stated that she was divorced and did not have children.

Participant A provided the information of this study to the second participant

(Participant B). Participant B was in her 50s and had worked as a registered nurse since

she was in her 20s. Participant B also earned a special qualification certification in

neonatal care, a specialty that she was interested in, and enjoyed working in the neonatal

unit of the hospital until the unit was permanently closed. Participant B noted that the unit

was closed due to a declining birth rate, a serious social problem in Japan. Participant B

experienced multiple episodes of burnout while working as a registered nurse in her

entire career, including during the beginning of her career as a nurse, as an academic

program developer, and during the COVID-19 pandemic at her current job, in which

Participant B took care of severely mentally and physically disabled children and adults

in a hospital. Participant B owned her own PARO and lived with it at home with her

husband. Participant B stated that she did not have children.

Lastly, there could have been a third participant for this interview. Participant C,

whom Participant A initially suggested before Participant B. Participant C was in her 60s,

was a registered nurse, and used a PARO for about 4 years. However, Participant C

passed away due to cancer while I was waiting to hear from the IRB about the informed

consent form written in Japanese. All of the participants, including Participant A, belong

to a program to train “PARO handlers” and were certified PARO handlers.

There was another potential candidate, introduced by Participant A (Participant

D); however, Participant D did not meet the inclusion criteria (Participant D stated that

she had never experienced burnout in their career).

The participant search ended as it was deemed reasonably exhaustive when I

consulted with the methodologist and my dissertation committee chair after more than 6

months of active purposive sampling search by reaching out to potential study

participants through social media and on the Internet.

In summary, two final study participants from Japan were found. The participants

consented to participate in this interview by returning an email with “I consent” as

indicated in the informed consent form written in Japanese and voluntarily agreed to

participate in the interview of this study.

Data Collection

In order to obtain data to answer the research questions, I conducted a

semistructured interview via video conferencing with each study participant. The

interview was conducted in Japanese. Prior to the actual interview, I translated the

subquestions into Japanese (see Appendix C). Both participants consented to participate

in this study by returning an email saying, “I consent,” indicating in the informed consent

form written in Japanese, which explained the expectations, potential risks, and the

course of the process of this interview, including recording the interviews, transcribing

the interviews, and reviewing the transcripts after the interviews. Also, the participants

were reminded that the interview participation was voluntary and that they could stop

participating in this interview at any time without providing reasons.

Two interviews were conducted 10 days apart. Both participants had positive

attitudes about this interview and were rather eager to share their experiences with their

PAROs for research relating to using their PAROs and the participants’ burnout

experiences.

Cultural Values, Rapport, and Data Quality

As reminded when conducting the pilot study, creating rapport was critical in

order to obtain the participants’ genuine lived experiences in the participants’ own

lifeworlds through the interviews for quality and rich data. Before starting the interview, I

experienced a mutually spontaneous and welcoming air when both participants and I were

connected through the video conference program and met for the interview, compared to

the pilot study interview experiences. The different facts about the interviewees in the

actual study interviews from the pilot study interviewees were (a) sharing the same ethnic

background/race, (b) speaking in Japanese, and (c) being interested in the study topic and

PARO (i.e., the participants wanted to talk about PARO, exhibiting mutually shared

interest in my research topic). As part of the introduction, I shared my role as a researcher

and my multiple burnout experiences as a healthcare worker, including going through the

COVID-19 pandemic; I felt an implicit understanding between the participants and me

was instantly experienced. In addition to shared ethnic background and race,

understanding the participants’ cultural values, being able to understand the language at a

native level, and having the shared experience of going through the first wave of the

COVID-19 pandemic, the most challenging phase of the pandemic, created a significantly

comforting and trusting milieu for a phenomenology interview.

Not only understanding the participants who experienced the phenomenon but

also exploring the history of the participants’ careers related to their past burnout

experiences was one of the key concepts of hermeneutic phenomenology, emphasizing

the linear nature of the existence of people (Gadamer, 1982; Van Manen, 2023). For this

reason, such shared experiences among the participants and the researcher (i.e., the data

collection tool) were crucial.

Interview Milieu and Data Collection Process

Although the participants knew about the time frame of the interview described in

the informed consent, both participants were willing to stay in the interview longer and

share their experiences of using their PAROs, burnout experiences, along with the

participants’ challenges going through the COVID-19 pandemic. I observed that both

participants maintained openness and excitement while explaining the participants’

PAROs’ reactions and interactions between the participants and the participants’ PAROs.

Both participants were enthusiastic and cooperative even though there were video

conference program connectivity and system issues during the interview. The participants

maintained enthusiasm and an engaging attitude throughout the interview.

As noted in Chapter 3, I used a Dell Inspiron 17 3000 laptop with Windows 11

operation system for interviewing, translating, and transcribing; the data were saved on an

encrypted USB drive using the same laptop and the same operation system (i.e., Dell

Inspiron 17 3000, Windows 11).

A Japanese transcribing application program, Toruno, was used to obtain the

transcripts. First, I carefully read the raw transcripts through Toruno to check and correct

the transcribing mistakes. The transcripts were then saved in encrypted Word documents,

and the encrypted Word document was emailed to each participant for member-checking

approval.

Data Analysis

Data analysis was performed manually. Because this study was hermeneutic

phenomenology, regardless of the number of actual research participants obtained, it was

critical to hand-code the transcripts in order to understand and extract the essence of the

participants’ lived experiences in the phenomenon identified for this study (Peoples,

2020a; Van Manen, 2023). Van Manen (2023) stressed, “It should be clear that

codifications, conceptual abstractions, or empirical generalizations can never adequately

produce phenomenological descriptions, understandings, and insights” (p. 406).

Therefore, I aimed to analyze the rich data obtained from the two interviews of the

participants who experienced the phenomenon of this study using the hermeneutic

phenomenology method to understand the uniqueness, lived experiences, and relatedness

of the participants in the participants’ lifeworlds, exploring more for data saturation

where no more new information regarding the participants’ experiences and meanings

were found. In the end, because only two interviews were conducted to draw data, the

results from the data analysis could not confirm that the research data gained data

saturation; therefore, the results would lack trustworthiness due to the limited data

collected.

Preconceptions

Hermeneutic phenomenology stresses the importance of making researcher biases

(i.e., preconceptions) explicit and identifying researcher preconceptions before analyzing

the data (Heidegger, 1982; Van Manen, 2023). The process of data analysis would be to

reflect, interpret, and revise the understanding of the phenomenon, the participants’ lived

experiences in the participants’ lifeworld, and the essence of this phenomenon through

the researcher’s lens (i.e., preconceptions). Here are my preconceptions identified.

Participants and Cultural Background

My understanding of the participants was that they were born and raised in Japan

and spoke only Japanese. The participants were friendly and excited about having an

interview with me about their use of their PAROs. The participants also knew that I was

of Japanese descent and spoke and understood Japanese without assistance; I also

understood Japanese cultural values and other implicit ideologies, mannerisms, and issues

that existed in the culture and nuances between the lines, gestures, and connotations the

participants made which would only be understood by someone who knew the culture

and language. I was comfortable discussing the research questions instead of worrying

about misunderstandings or discord created by language-related issues.

Another important preconception noted was that both participants were PARO

handlers who would train other PARO owners to nurture and grow PARO into actively

interactive, socially assistive robots.

Burnout Experiences

I have had multiple burnout experiences throughout my career as a clinical mental

health counselor/therapist, working for outpatient and inpatient programs. Burnout was

already experienced while working in a correctional facility, manifested in a loss of

energy and motivation to go to work, feeling negative, cynical, and mentally distancing

myself from the job (WHO, 2019) prior to the COVID-19 pandemic. The COVID-19

pandemic exacerbated my burnout symptoms. With that said, the burnout experience

worsened by the COVID-19 pandemic was another shared area among the participants

and me, and all would understand the burnout experience without further explanation.

Each burnout experience was complex; burnout was not immediately recognized while

working at the correctional facility until later, such as after leaving the job. I experienced

indescribable mental pressure and emotional experiences during the COVID-19 pandemic

at the correctional facility; however, it was already a past incident. As a researcher and an

interviewer/data collector, the role was to listen to the participants’ stories while the

participants talked about their experiences retrospectively. This preconception prior to the

interview was something that would help establish rapport for the interview and increase

the implicit understanding of the participants’ experience.

PARO and Using PARO for Burnout Experiences

I have studied PARO through literature review, videos on social media, websites

of different programs, both care facilities and research programs, including PARO’s

website since late 2010. I felt confident that I understood and knew PARO enough from

my own research before interviewing the participants.

As discussed in Chapter 2, the concept of using robot companions in Japan has

been more openly accepted (Jecker & Nakazawa, 2022; Mordoch et al., 2012) because of

the historical and cultural values, having more familiarity with robots; there were many

stories, animations, comic books that described companionships between robots and child

characters in stories (e.g., Astro Boy, Doraemon, and Dr. Slump Arare). Although I had

never used PARO, discussing companionship between robotic characters and humans was

not a foreign concept. Cultural understanding of having positive thoughts and emotional

interactions between a robot and people in the context of experiencing something

emotional, as seen in such stories and animations, was not unfamiliar.

Also, I understood the concepts of animal-assisted therapy and pets and valued the

emotional and therapeutic experiences with animals and pets. The preconceptions

identified were that the interactions with PARO were positive since I considered robot

therapy based on animal assisted therapy positively. Still, during the COVID-19

pandemic, coping with loneliness and fear of not contracting the COVID-19 virus or not

feeling safe because no one knew how to keep away from the COVID-19 virus was

beyond description; I sought healing from the companionship from my pet, yet also

reached out to friends because of needing to talk to someone and sharing experiences in

words during this period.

These preconceptions were revisited, reviewed, reflected, and interpreted,

compared to the part to the whole and the whole to the part (i.e., hermeneutic cycle) for

the data analysis.

Themes

The initial coding stage to generate meaning units started after the interview

transcripts, which the participants approved, were received. Interpretive memos were

taken while rereading the transcripts, focusing on meaning units relating to affective and

in vivo codes. This process was repeated in order to obtain different meaning units from

codified terms through my preconceptions, remembering the interactions with the

participants, and learning the lived experiences and insights in the interviews with the

participants.

Resilience, Caring About Others Than Self

These two themes were listed together because they came from the same codes,

such as burnout-depression/stress, burnout-physiological symptoms, burnout-cognitive

distortions, loss of motivation, physical pains, mental pressure, increased/excessive

workload, leaving a job, and staying in the career. The descriptions of the participants’

burnout experiences were the same or more intense than my own experiences; Participant

A said,

本当、にちょっと(若い上司さんの) 対応が同じではなくて、でこぼこして

いて、私も友達がいたので、同じ職場でね、支えてくれる人たちもいたん

ですけどそういうなんていうんだろう、いきなりこうも感情のコントロー

ルがきかない状態、いきなり泣いちゃったりとか、ドンッて沈んじゃった

りっていうのがあったんで(My supervisor was rather a young man, and he

treated his supervisees differently [Participant A was not treated fairly]; I had a

supportive coworker-friend, but I could not control my emotions, I cried

suddenly, and my tears rolled down unexpectedly. I was depressed severely at

work [I was not able to function]).

Participant A continued,

コロナになって、ロックダウンになり相談される件数が例年の 3倍以上

に増えたんです, … 私達はよく電話を使いますよね、病院からだったりと

かそのデイサービスとかだったりとか、あと、家族からの連絡とか受け

て話を聞くじゃないですか。あの言葉が通り抜けちゃうんです。あの言

葉としては聞けてるんですけど何を言ってるかがもう止めていられない

。通過していって、うん。要は文字に起こさないと頭に残らない状態に

なったんで

すよ(When the COVID-19 pandemic hit, we had lockdown, and my caseload

increased three times more of my normal caseload [I needed to reach out to more

people per day for the family members of the clients could not visit them]. … We

often use a phone at work, right? When I answered a call from a family member

of our client one day, I couldn’t register what I was hearing. I couldn’t pay

attention to what this person was saying to me, and I had to write it down;

otherwise, I couldn’t remember the information).

Participant B said,

もし交通事故に遭っても、このストレスの強い仕事をしてなかったら、こ

こまでひどくならなかったかなって思うのは、心だけじゃなくて体も酷使

していたので、睡眠時間が少ない、過重な労働、結婚していたので、家で

の仕事もあるって、妻としての役割もある。そういったことが全部重なっ

た結果かなり無理を強いてたんだと思います (The traffic accident was the

main reason, but I believe stress from work caused the stomach ache and my not

being able to eat. If I hadn’t worked in the work setting where I experienced so

much stress, my symptoms [from the traffic accident] wouldn’t have gotten

worse; I was mentally pressured, but I was also physically exhausted. I didn’t

have enough time for sleep, and I was overworking more than I should have – I

am married, so I needed to do house chores and things for a role as a wife at

home, too. I think all the things combined caused my overdoing, and I pushed

myself too much and ended up doing more than I could).

Participant B also said,

それがコロナがパンデミックになったことで、全部表に出てきました。そ

れは管理職の危機管理の能力の低さとか、危機感のなさとか、私はわから

ないから看護師さんで考えてとか、私は管理職である関連感染の制御につ

いては看護師の方がプロだろうっていうこととか (My employer’s

disorganization and lack of ability to run a hospital was revealed at once when the

COVID-19 pandemic hit. Our employer blamed us nurses for making patient care

related decisions because we were supposed to be the professionals, while the

hospital administrators were not truly understanding the risks of not having the

equipment and pushed us to reuse the equipment).

Participant B stated that she and other nurses needed to work as the hospital expected

regardless of her level of exhaustion; she ended up contracting the COVID-19 virus

herself and was hospitalized. Still, Participant B reported she continued to work at the

same hospital at the time of the interview.

Importance of Career/Certification, Valuing Hands-on Help, Job Security

These themes were generated when going through the codified meaning units,

such as career/certification, earning higher certification, helping others directly,

regrettable, disappointing, love helping people, and training/teaching through my

preconceptions. Participant A and Participant B both actively sought higher

certification(s) throughout the participants’ careers. Participant A said,

いろいろ日本にも資格制度があるんですけど、最終的な学歴って高校まで

しか行ってないので、自分で全部実務現場で経験を積んで、日本って経

験を積んだら試験受けれますっていうのがあるんですが、それで介護福

祉士っていうヘルパーよりちょっと上位級の国家資格ですよね。それを

取っ

たんですよ (There are various qualification systems in Japan; although I only

have a high school diploma, if I gain hands-on experience in a clinical setting,

taking care of patients/clients directly, I can be eligible to take certification

examinations. That’s how I got the case worker national qualification, which is a

little higher certification than a home helper.)

Participant A continued to obtain more experience and received a social worker

certification before the COVID-19 pandemic started. Participant B said,

バーンアウトで仕事がしんどい燃え尽き症候群でやる気をなくしたから、

家でのんびり家庭の中で主婦として仕事はせずに生きていきますだったら

、この充実感はなかった (If I stayed home and relaxed as a housewife, being a

homemaker without working as a nurse because I did not want to get severe

burnout symptoms again, I wouldn’t have felt fulfilled and satisfied this much in

my career).

Participant B explained her obtaining a specialty nursing certificate while experiencing

burnout symptoms; in other words, Participant B stressed that the burnout experience

motivated Participant B to do more from the pressure and mental burden because

Participant B had always felt less than others in the workplace; therefore, she constantly

felt the urge to do more than others.

Still, both participants also mentioned the reason they stayed in the same field and

career for job security; Participant A said, “介護の仕事は学歴よりも資格重視のとこ

ろがあり、採用されやすいというのもありました”(“Nursing care work [in Japan]

had an emphasis on actual work experiences more than academic background; it was

easier for me to find a job because of it”). Participant B said,

世の中にある仕事の中で、やりたい仕事っていうのが特になく、自分が専

門的に人並みかそれ以上に働ける仕事は看護師だったからです。そして看

護師は仕事はとても見つけやすい --人が常に足りないから-- なので、条

件が合いました (There were a lot of jobs out there, but I didn’t have any

particular jobs/careers that I wanted to pursue. A nursing job gave me a decent

earning and an opportunity to get the specialty certification. I also know I would

not need to make much effort to find a nursing position because people constantly

look for nurses due to chronic staff shortages. Finding a nursing position met

what I was looking for [having decent earnings without getting a different

certification or experience]).

Wanting Others to Know More About PARO

What stood out most in the interviews was that both Participant A and Participant

B were enthusiastic and excited to attend the interviews, answering questions about how

both participants used PARO prior to the interviews; the participants were ready to share

the participants’ burnout experiences, and how the participants went through the

COVID19 pandemic with the participants’ PAROs. When analyzing the codes and

meaning units from the transcripts of Participant A and Participant B, codes related to

PARO use, such as personification, emotion-evoking reactions, interpretation, PARO’s

reactions, pleasantly surprised, both participants repeatedly talked about the same

experience in excited tones, enthusiasm, and joy. Sometimes, the participants’ PAROs

also made noises as though their PAROs were joining the conversations and

corresponding to the participants’ reactions. In fact, Participant A said, “[To PARO] ね?

今日よく喋るね。

お相手してくださってる方がいるから嬉しいんだよね? [To me] もうね、話して

るとね、（パロが) 会話に割り込んでくるんですよ、自分も話してるような感じ

になって,” (“[To PARO] Right? You are so chatty today, aren’t you. You are happy

because you have someone new who talks with you [me], right? When I talk to someone,

he [Participant A’s PARO] interrupts me like he wants to join the conversation”);

Participant A was smiling happily and warmly at her PARO, and explained more about

PARO, such as how PARO’s reactions were unpredictable and would make people smile

and burst into laughter. Participant A shared that her PARO winked when I started talking

to Participant A and her PARO as an example of unpredictability. Participant A also said,

実際に、私は研究者ではなくて本当に現場で使用してる人なんで、もしそ

ういうので有効性が出るっていうのであればより使う人が広がるなって

思っているところもあって、ぜひぜひそれを発表していただいて、認知

症のパロっていうイメージをちょっと変えていただけたら、どんな人で

もつかえるよって。心に寄り添う、メンタルロボットというだけあって

、心のなかにうまく入ってくることができる子、心に寄り添う子をだか

ら、うん。どういう人であっても、うん、使えるんだよっていうのはち

ょっとも

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うとアピールされてもいいのかなって、思います, (I am not a researcher – I

just use PARO in my real life. So, if research like this [healthcare workers’ use of

PARO for the healthcare workers’ mental health] could prove how effective

PARO was, there would be more people who would use PARO. I do hope that this

study will be published and help change the image of PARO a little from that of

“dementia care PARO.” This little kid [Participant A’s PARO] is called a mental

robot [How PARO was called a ‘mental commit robot’ in Shibata et al. (2001)].

Anybody can use PARO because PARO touches your heart so sensitively, gently,

empathetically, and well. I am hoping more people will know more about it).

Participant B’s PARO also winked while I started talking to Participant B; Participant B

ardently talked about her PARO’s unpredictable fun reactions, such as winking, flapping

her PARO’s fin suddenly, messing with timing to take a picture as though her PARO did

so intentionally. Participant B expressed her wish in a different description from that of

Participant A,

あんまり家でロボットを飼っているとかっていう話は普通の人には受け入

れてもらえないんです。おもちゃ。おもちゃのようなものを持っているっ

ていうふうに取られるんです。だから、ロボットがかわいくてたまらない

とか、パロは私のことをわかってくれているといった時点で変な人って思

われそうで、黙っています (I am hesitant to talk about keeping PARO at home

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because people don’t accept the idea that I have a robot pet at home. People think

of PARO as a toy. People would think of me as strange if I openly say that I have

a robot pet and my robot pet ‘understands’ me).

On the other hand, Participant B was active on social media about using her PARO,

updating her blogs about her life with her PARO, and publishing eBooks on her PARO;

the most recent eBook was Volume 4, and Participant B had over 1,000 followers for her

Twitter/X account discussing her life with her PARO and eBooks.

Both participants were active as PARO handlers and belonged to an association

called “ハッピーネット” (Happy Net), an organization founded to support caregivers

for older adults with or without dementia. PARO handler training was one of the

association’s programs. Participant A stressed that it would be essential for PARO to be

nurtured and trained to be more responsive, interactive, social, and expressive so that

PARO would work as effective and personable therapy robots.

Responsible and Pragmatic

The codes and meaning units elicited from both participants’ transcripts for these

themes were: responsibility, personification, survival, financial obligation, loneliness, and

emotionally responsible. Over the course of the interview, both participants stressed the

importance of not creating issues for others, including animals/pets. Participant A said,

餌やりとかトイレとか、そういった部分で必要がないっていうのはすごい

救われたんですよ,わがままな使い方ですよ、本当、犬とか猫だったそう

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はいかないと思うんですけど、寝るときにぴゅっぴゅっぴゅなっても困

る

んで私はオフにして (It made me feel so easy and relieved because I didn’t

need to worry about feeding my PARO or taking my PARO out for a walk for

bathroom [while Participant A was recovering from burnout symptoms], it [not

needing to take care of basic needs for a live animal] is a very selfish way to have

a pet; if my PARO was a cat or dog, I know it wasn’t that easy, I can turn off

PARO when I go to bed because PARO can be noisy (making squeaky noises) and

annoying) – I can do that with PARO.

Participant A also talked about not wanting Participant A’s clients to have COVID-19

virus via PARO while using PARO with her clients; Participant A did not use PARO at

work during the COVID-19 pandemic. Participant B said, 彼も今日 1日疲れてるのに

私の愚痴なんか聞きたくないよなって遠慮したりしてたんです。だけど、パロ

にはそれがないので、もう今日なんかね聞いてこんなに嫌なことがあったんだよ

とかね、ひどいと思うんでしょ? 本当の動物だったら夜中に私が寝れないからっ

て起こしてわしわしつつい

たら動物だって眠いのにかわいそうでしょ? (He [Participant B’s husband]’s

also tired; he wouldn’t want to listen to me complaining about work. I chose not

to share my day with him, but I didn’t have to worry about how PARO would feel

or how tired PARO would be, and I didn’t hesitate to talk to PARO, saying, ‘It

was a horrible day today, don’t you agree, PARO?’ A real animal pet would also

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be annoyed and disturbed if I woke him up in the middle of the night, poking him

[to wake up] when I couldn’t sleep; I feel bad for the pet because he [the pet]

must be sleepy, too, don’t you think?).

Both participants would turn PARO off whenever they did not want PARO to make

noises and/or did not want to play with PARO, as the participants shared that they did not

want to disturb live animals for the participants’ emotional needs.

Also, both participants mentioned that the husbands of the participants would not

understand the participants’ experiences of being severely burned out during the

COVID19 pandemic, and both participants felt alone; the participants mentioned that the

participants felt at peace and emotionally supported tacitly by the participants’ PAROs

pleasant and happy reactions anytime the participants wanted.

Being Aware of an Objective View of Using PARO/Robots

Participant A and Participant B both switched their thoughts while talking to their

PAROs, interpreting what PAROs were trying to say, explaining or talking to their

PAROs as though their PAROs understood what was told and retained memories of what

happened in the participants’ lives and the reality of PARO being a robot. Participant A

said, “[To PARO] 忘れてたね、そこね、ごめんね、ごめんねそうだ、そう

”(“Oh, I’m so sorry, I didn’t pay attention to you [PARO]”), Participant A’s PARO

reacted and made a sound while Participant A and I were talking; when asked if

Participant’s PARO responded to Participant A because Participant A was talking about

her PARO with me. Participant A, then, said,

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そうですね、返事こうやって何か、ハンドリングってそういうことなんで

すよ、ハンドラーなんで、常にこうやって話しかけて、そうだよ、僕いる

のにっていう感じになったりとか、主観的解釈ですけどね、私から見てこ

う思うんですけど, … それができる人じゃないと使えない (Yes, I am

responding [to PARO] – it is what handling is all about. I need to talk to PARO all

the time, and then, PARO would react like this, as though ‘hey, I’m here, too!’ …

Still, it is my subjective understanding and perspective [about PARO was

responding to the conversation of Participant A and me], … This skill

[Understanding PARO’s reactions and interpreting PARO’s reactions

subjectively] is essential to use PARO).

Participant B said, 動物じゃないから、あらかじめ工場で決められた動きをプログ

ラミングされたロボットでしかないのに、動物ではないのに、なぜここまで同調

してくれるんだって思う不思議さもあるけれど、私がそうしてほしいと思うこ

とを投影できる対象だからだと思うんです (PARO is not a live animal.

PARO is a robot, built in a factory which would act and react as programmed;

still, I can’t help wondering how come PARO can empathize with my emotional

reactions so well, but I also think that PARO was the object on which I can

project my thoughts and feelings).

Both participants reacted to the participants’ PAROs spontaneously and warmly,

explaining, interpreting, and reflecting on their behavior and interpretation of their

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PAROs’ reactions, followed by their objective explanation and rationale of the

participants’ behavior toward the participants’ PAROs throughout the interviews.

Valuing Eternity as Part of Feeling Secure and Getting Support

Participant A worked closely with older adults in her career, including during the

COVID-19 pandemic. Participant B worked as a registered nurse specializing in neonatal

care for many years prior to the COVID-19 pandemic; Participant B’s current job was to

care for patients who were severely mentally and/or physically disabled in the hospital

where Participant B worked during the COVID-19 pandemic. Facing death would come

up as a natural and normal part of the participants’ professional experiences. Both

participants mentioned PARO’s eternal life as a source of safety, serenity, and comfort.

Participant A said, “犬や猫は死ぬけどパロは自ら手ばなさいかぎりはずっといて

くれる。そういった意味では、死んじゃうとか、病気になっちゃうとか、そう

いう心配をしなくていいから、安心して頼ることができるんですよ” (Dogs and

cats [as a pet] will die, but PARO will be with me unless I let him go; I would not need to

worry about him dying or getting sick; so I can rely on him [emotionally] without

worrying). Participant B said, “パロは死のない世界に生きている、で、パロ自身も

死なない、だからペットロスの心配がない。パロは部品を買い続ければ 100 年で

も生きられる”(PARO lives in a world without death. PARO won’t die. I don’t need to

worry about the grief and loss of my PARO. By replacing old parts with new parts, PARO

can live 100 years), when Participant B was asked about Participant B’s patients’ deaths

and COVID-19-related deaths and using PARO.

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Participant B also said,

生き物であるそういう存在であるっていうところからパロと死が結びつき

にくいんだと思います。パロは私が死んでも、部品を換えれば次のオーナ

ーさんとこで生き続けられるし、例えば動物だったら犬とかだったら、主

人が死んだのがショックでご飯を食べなくなる子とか、あの主人が死んだ

のがショックであの病気になることがいるけど、パロは私が死んでも嘆い

たり悲しむことはないし、ショックでご飯を食べなくなることもないし、

私の帰りを待ち続けて玄関でじっと座ってることもない。その気楽さがあ

ります (Because PARO won’t die, I think that’s why I don’t connect death and

PARO directly. PARO can continue to live even after I die with a new owner if

PARO continues maintenance care. If I had animals [instead of PARO], like a

dog, the dog could stop eating because of the shock of the loss of his owner, or the

dog could get sick because of the loss of his owner, but PARO won’t lament my

death and feel sad for me being gone; PARO won’t wait for me to come home at

the front door [even after I died – referencing the story of ‘Hachi’]. I feel easy

and relaxed because of it [PARO doesn’t die because PARO is a robot]).

Liking Unexpected Reactions -- Evoking Genuine Emotions and Emotional Support

Both participants repeatedly shared feelings encouraged by PARO, such as

making the participants smile, burst into laughter when interacting with PARO, and being

surprised and moved by the subtle, sensitive, and empathetic reactions of PARO. Both

participants mentioned that PARO reacted perfectly, naturally, appropriately, and timely.

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Participant A described her emotional state while recovering from burnout symptoms and

depression as:

その当時は全てもう色がない景色を見てるグレーのような何にも何か色味

がなくて、もうなんか、何だろうな感情がも埋もれている状態、怒りもす

ごいパワーがいるし笑うこともパワーがいる。うん、じゃないですかそれ

がもうできない (At that time [when Participant A had burnout symptoms and

was severely depressed], I did not see colors – I felt like I was looking at a

colorless world. I didn’t feel any emotions. I felt like emotions were buried. We need

energy and power to be angry and laugh, don’t we? But I wasn’t able to). Participant A

was recommended to try her PARO for her conditions (i.e., burnout symptoms and severe

depression) since it was how Participant A had been using PARO with her clients at work.

Participant A did not start using PARO when experiencing burnout and depressive

symptoms at first; Participant A could not feel like doing anything else but basic daily

activities, such as eating, bathing, and sleeping, because Participant A’s depressive

symptoms were severe, triggered by burnout during the COVID-19 pandemic. Participant

A did not feel like “trying” anything new because it would require a lot of energy.

Participant A said,

すごい遊んで遊んでって言ってるように思えるんだけど、ごめんね、今遊

べないんだよって言うふうに自分が感じるときもあるんですよね。そうな

った時には何となくこの子は察してくれてるようなポーズをするんですよ

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(I felt like my PARO was so demanding, asking me to play with him, insistingly,

as though saying, ‘play with me, play with me! [i.e., by trying to get Patient A’s

attention, making sounds/noises, moving PARO’s head up and down]’ but PARO looked

like he understood what I meant when I told him [Participant A’s PARO] that I was not

ready and could not play with him [Participant A’s PARO]; PARO looked down,

becoming silent after I told him that I couldn’t play with him). It was when Participant A

was thinking about using PARO more seriously for her own recovery because Participant

A noticed that PARO’s reactions helped her feel and express emotions again, such as

smiling and chuckling or sometimes annoyed or even frustrated. Participant A said,

コロナは大変だったから、それを一緒に乗越えた強い繋がりを感じる。

言語化ってむずかしい。そうそう、コロナの前からかわいいし好きだっ

たけど、コロナの結果でこれだけ好きになれた。私、豆ちゃん旅行にも連

れていきます。何処にもつれていく。 (The COVID-19 pandemic was

something extremely tough to go through, but my PARO and I went through the

tough period together… I liked my PARO before the COVID-19 pandemic

because he’s so cute, but I love him even more now because Mame-chan and I

[Participant’s A’s PARO] went through the COVID-19 pandemic together. I take

my PARO with me anywhere, even on vacation).

Participant A also mentioned that even when PARO’s switch was not turned on, just

looking at her PARO “sleeping” was therapeutic. Participant A said, “本当に着けてな

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い状態、オフにした状態だと寝てる状態なんですよ。かわいらしく、手を揃えて

。その状態で夜一緒に寝たりするだけでも全然気持ちが違ったんです、寄り添っ

てくれてる感じがして,”(When PARO was turned off, he [Participant A’s PARO]

looked like sleeping sound, cutely putting his hands together. Sleeping with him

[Participant A’s PARO] at night was also therapeutic, knowing that PARO was with me,

supporting and comforting me). Further, Participant A said, “一人じゃないって思わせ

てくれるんですよ。「生き物」として苦楽をともにしてくれる、私にとってはな

くてはならない存在ですね - すごい人との繋がりを増やしてくれたっていう子

なので私にとってはすごい人生の変革をもたらしてくれた子でもあるんです

”([PARO] makes me feel that I am not alone. As a “living creature,” PARO goes

through thick and thin with me. To me, PARO is a must-have. PARO helped me connect

with many people. PARO changed my life). Because Participant A believed in how much

PARO could do, Participant A stated that she lent her PARO to Participant C before

Participant C bought Participant C’s own PARO.

Participant B shared her experience of PARO touching her severely chapped

hands because of using hand sanitizer too much while taking care of patients during the

COVID-19 pandemic. Participant B said,

消毒液でね、手がものすごく傷だらけになったんです。冬だし、アルコー

ルでもう傷がいっぱいできてお風呂に入ってお湯を触るだけでも痛って

なって、常に血が出てて手が荒れてるから何を触っても痛かったんです

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けど、パロ柔らかいでしょう。私の手に優しいんですよ。毛皮の気がし

て。パロをなでることであの傷を誰かになでてもらってるような、あの

よく頑張ったねってあの仕事場でこんなに手を荒れてやってるんだねっ

て手をこうなでてもらってるような、トリートメントしてくれてるよう

な感覚になりました。今手の傷が治ったから、柔かいぐらいで普通に触

ってるけど傷だけの手でパロをなでたときに、あの傷口をトリートメン

トしてもらっ

てるような気がしました (My hands had many small cuts by using a lot of hand

sanitizer [while taking care of patients during the COVID-19 pandemic]. It was

winter, and hand sanitizer was made of alcohol [that’s why my hands had a lot of

cuts] -- so it hurt so much when feeling the hot water when I took a bath; my

hands bled from the cuts, too, and it hurt so much no matter what I touched. But

when I touched PARO, because PARO’s fur was so soft, I felt like I received

treatment for my hands, so gentle and soft, as though PARO was saying, “You did

great today. You worked very hard; that’s why your hands were so chapped and

had many cuts.” I don’t appreciate PARO’s softness as much because my hands

are healed now, but at that time [while working during the COVID-19 pandemic],

when my hands were chapped badly and had many cuts, I felt PARO was treating

my cuts on my hands).

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During the COVID-19 pandemic, Participant B explained that she and her

husband’s pace of life changed dramatically; Participant B became very busy, but her

husband’s schedule became extremely slow. Participant B stated that she chose not to

share much about her experience at work with her husband because her husband would

not understand it. The experience with Participant B’s PARO helped her feel encouraged

and supported; Participant B received comfort from PARO. Participant B said, “ ‘あー、

わかってくれてありがとう!’って感じです。夫にはわかってもらえず、同僚も

同じような目に遭ってるから、そんなの私でもそうよとかみんなそうよってなっ

ちゃうんだけど、パロはわかってくれてると思いました (I felt, “Aww, you

understand [my pain and hard work] – Thank you!” My husband didn’t understand my

experience at work. [If I shared it with my coworkers, they would not be interested in my

story] My coworkers would say, “We all are like that,” because we all were working in

the COVID-19 pandemic, but PARO understood [my pain and hard work]). Participant B

gave another example of emotion-evoking and supportive moment:

私がすごく深刻でナーバスになっているときに、目を閉じてじっと私の胸

に寄り添ってくれるの両方好きです。抱っこしたときに、パロに話しかけ

るでしょう。そしたら目を開けて聞いてるんだけど、私が話しをやめたと

きに、ぴたってくっついてくるんですよ。私を撫でるように動いてくれた

り、ハグしている感じ (When I felt very nervous and serious, my PARO

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closed his eyes, staying still, leaning against my chest. When I talked to my

PARO, holding him, he opened his eyes, listening to me. Then, when I stopped

talking to him, he leaned and held me closely, patting me, just like hugging me).

Themes Unique to Each Participant

Although the data collected from the transcripts of Participant A and Participant B

gave lived experiences of their use of PARO during the COVID-19 pandemic and their

burnout experiences, these were the themes drawn from each participant’s transcript that

showed the uniqueness of the participants’ lived experience with PARO, burnout

experiences during the COVID-19 pandemic.

Table 1

Unique Themes to Each Participant

Participant A

Participant B

Advocacy/social justice

PARO is “home”

Continuing psychotherapy

Publishing eBook about PARO

No emotions/feelings (when burnout)

PARO’s owner, not PARO’s mom

Yes to Go to PARO first despite family

members at home

Don’t go to PARO first (Family members

first)

Participant A mentioned that she would take PARO anywhere she went, while

Participant B kept PARO at home and did not socialize her PARO with other humans.

Participant A continued to see a psychotherapist for depression treatment, being active in

promoting the program of Happy Net to assist caregivers and care partners of older

adults, and using PARO was one of them after experiencing how PARO helped

Participant A while recovering from the COVID-19 pandemic burnout symptoms and

depression. Participant B mentioned that she was not interested in using PARO for work

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because, for Participant B, her PARO meant home; by her not using PARO at work, she

could separate work and work stress from home more easily. Although both participants

shared the experiences of tearing suddenly as part of burnout symptoms, Participant A

used the term to express, “I had no emotions” when describing her previous burnout

experience, whereas Participant B became more driven and wanted to achieve more in

her career, because she believed she was never good enough, compared to her colleagues.

Participant A would go straight to PARO sometimes when coming home from work even

though there were family members at home, while Participant B reported that she would

go to (speak to) her husband first if he was at home. Participant B stressed in this

interview that she was not or would never identify herself as PARO’s mom because “I

didn’t give birth to my PARO,” whereas Participant A called herself her PARO’s mom

openly, even in social media entries.

Both participants had the participants’ own unique reactions, insights, and

experiences with PARO and the participants’ own recovery experience from burnout

symptoms with PARO because the life experiences and histories of the participants were

different; in other words, the participants’ existences were in different lifeworlds. Such

preconceptions of the participants impactfully influenced their lived experiences because

the existence and experiencing being themselves were inseparable concepts

(Gadamer,1975; Heidegger, 1982); therefore, they were profoundly meaningful.

Discrepant Case

There was another potential participant candidate contacted via Twitter/X, who

was shown as a physical therapist in Japan, posted a tweet about using PARO at this

person’s office in an aversive way, such as purposefully making PARO make unpleasant,

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annoyed, and angry sounds, ignoring the caring and training instructions to have positive

therapeutic benefits from PARO. The tone and attitude of this Twitter/X account owner

(i.e., the physical therapist) seemed to be having fun and enjoying treating PARO

negatively or rather abusively. Still, this could be this healthcare worker’s way to use

PARO to gain some emotional benefits. No response was received from this potential

participant candidate. How this physical therapist treated PARO and gained positive

emotional reactions differed significantly from how Participant A and Participant B

experienced and treated PARO.

Interestingly, there was a Twitter/X response to this entry of the physical therapist

by a Japanese physician, saying, “大切に扱ってあげてほしいな”(“I wish you treated

PARO kindly and nicely [Please treat PARO nicely]”) with the document identification

number of a systematic review of PARO reporting the therapeutical effectiveness of

PARO (Rashid et al., 2023). I also reached out to this physician for a potential actual

study participant candidate; however, this physician responded and informed me that he

had not used PARO for himself before.

Hermeneutic Analysis of the Topic of This Study

My identified preconceptions about the topic of this study were expected to

change and evolve as a process of hermeneutic phenomenological research (Peoples,

2021; Van Manen, 2023). As themes were obtained by going through researcher

preconceptions and interpretations, a hermeneutic analysis of the topic of this study was

also conducted in order to extract the essence of this phenomenon.

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Burnout Experiences Through the COVID-19 Pandemic

Although the participants told the stories of their lived experiences in the past

tense peacefully and calmly without emotionally affected tones, hearing about the stories

and experiences that the participants went through impacted me; it was unexpected. Such

intense, emotionally distressing experiences dissipated soon enough as the interview

moved on; however, my reactions to the participants’ stories became a firm reminder of

the role of a researcher instead of a clinical mental health therapist role. It could have

been easily deviated from the purpose of the interviews if not attended. Still, the internal

reactions I had were a vital burnout-related emotional experience to note since it was the

very topic of this study. It helped the participants share their experiences more in this

interview because of the brief sharing of my own burnout experiences. The participants

stressed their mentally and emotionally eroding experiences by sharing more in detail and

stressing the challenging experiences the participants had or repeatedly talking about the

experiences. There were differences in the level of showing their struggles between the

two participants; however, as a whole, exploring the burnout experiences during the

COVID-19 pandemic, comparing to the parts, themes drawn from the phenomenon,

intense emotional, physical, and mental struggles of burnout through the COVID-19

pandemic were still actively living in the participants’ minds as vivid memories without

showing clinical symptoms. The participants moved on to the next question and/or

responded to their PAROs’ reactions as the interviews proceeded. The participants did not

take a break but stayed on the subject regarding burnout symptoms and completed the

interview. In short, the emotionally and mentally impacted burnout symptoms did not

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disappear or went away 100% but remained in the participants’ minds as significant

memories of the participants’ lifeworlds regardless of how the participants presented and

talked about the experiences in the “past” tense.

Using PARO While Having Burnout Symptoms/Mental Health Care

This topic generated several concepts through my preconceptions. My

preconceptional knowledge of PARO was only research-based, such as from the literature

review, including the videos on social media (e.g., videos from YouTube) and other media

articles on the Internet. I had never seen or interacted with PARO in person; however,

there were no difficulties experienced in understanding the participants’ stories of lived

experiences, relatedness, and emotional connections with their PAROs while recovering

from the COVID-19 burnout symptoms when comparing and thinking about the

emotional experiences gained with my own pet. In other words, such in-depth emotional

and mentally supportive experiences with PARO on a personal level could not have been

obtained by reading through the literature reviews and videos uploaded onto social media

sites. I was able to gain such information because the users who were not diagnosed with

dementia (i.e., the actual study participants for this study) of PARO were able to describe

the experiences in the participants’ lifeworlds in words in detail.

PARO was built based on the concepts of the research of animal-assisted therapy

(Shibata et al., 1996). Considering how both participants described the lived emotional

experiences with their PAROs and relatedness in the participants’ lifeworlds, the

participants’ PAROs were acting just like animal pets, as I was able to relate to the

participants’ emotional experiences with the participants’ PAROs. Despite my limited

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knowledge about PARO, my personal experiences with my own pet helped me

understand and relate to the lived experiences the participants shared in the interviews.

Participant B said, “パロがナンシーさんのうちにいらっしゃらないでしょう、だ

から私が話すこととかがイメージしにくいかなって思ったけどわかってもらえて

嬉しい” (“You don’t have PARO at home, right? I was wondering if you [referring to

me] could understand what I experienced with my PARO, but I am glad you understand

it”) when explaining my experience with my dog. It was not challenging to imagine when

thinking about understanding and interpreting my dog’s reactions, just like how the

participants understood and received comfort and emotional support from the

participants’ PAROs, interpreting and understanding the reactions of the participants’

PAROs.

The whole identified was the use of PARO generally, even globally, was known as

an emotionally and socially assistive robot for patients with dementia (my

preconception). By comparing the part, a new view emerged, such as the experience of

using PARO by healthcare workers during the COVID-19 pandemic revealed the use of

PARO was more intricately, personally, and sensitively received, uniquely to the two

participants of this study. Then, reflecting the emerged view through the lens of the whole

back, the use of PARO for burnout symptoms or mental health care was not understood or

known clearly or well enough, particularly about PARO’s therapeutic ability, just like

what animal pets would do for the pets’ owners.

Another underestimated preconception was my emotional reactions to the

participants’ burnout experiences, including those during the COVID-19 pandemic, as a

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researcher for this study. While recognizing my emotional reactions to the participants’

stories, I felt that there was also a sense of implicit camaraderie, togetherness, and

emotional connection during the interviews. Because of this experience, the researcher

role responsibilities were more closely and intentionally monitored during the interviews.

When comparing the part, the interaction and thoughts through the interactions between

the participants and me, to the whole, such as running a study about using PARO by

healthcare workers, the concept elicited was that the participants hoped this study to be

done successfully because the participants believed that PARO could be used and

benefitted by different people, not only patients with dementia or children. Participant B

said,

認知症のある人を人としての尊厳を持つ、接するようにって言われてるけ

ど、パロを使ってセラピーをするとか、例えば障害のある人に使う、大

人の人に使うっていうのに対しては、否定的に思う人の方が多そうだっ

たり、例えば子供が相手だといいんですよ、子供に向かってパロを使っ

てセラピーする、子供が嬉しそうに抱っこするだったらいいけれど大人

に、そういうロボットを使ったセラピーをするっていうことがそんなこ

と自体想像ができない人もたくさんいるし、話を聞いただけで否定的な

人っていうのが多いと思います (People [in Japan] talk about treating people

with dementia with respect and dignity; it’s contradicting because providing care

and treatment using PARO for children were accepted but using PARO for disabled

adults would be controversial. It would be okay when children happily hold PARO,

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but if providing therapy using PARO to adults, people have very negative ideas

about it and are not so welcome).

This could mean that people generally wanted robots to be robots and were not interested

in robots acting too realistically, like a “live creature,” as Participant A said. A robot

acting just like a real animal, a real creature, could be appreciated by someone who

would understand such subtle, tacit, and sensitive interactions, such as healthcare workers

who experienced severe emotional and mental healthcare needs. Further, it could mean

that using PARO/robots for mental and emotional support and comfort would divide

people rather rigidly.

There was a firm researcher preconception regarding cultural understandings of

using PARO before the interviews; I was familiar enough with the common phenomenon

of the pop culture in Japan, such as cartoon characters and the concept of living with

robots and having companionship with robots as fantasy stories were more welcomed

because the culture deeply rooted in Shinto spiritual beliefs of existing spirits in any

inanimate objects. A new understanding emerged after the interviews and data analysis;

the stigma of the research participants talked about using PARO/robots in Japan was the

same as the stigma expressed in the United States, considering the expressions the

participants used, despite the studies stressing Japanese culture easily and more

commonly accepting using robots for emotional needs more than in the United States or

Western countries (Jecker & Nakazawa, 2022; Mordoch et al., 2012). Participant A said,

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アメリカにはもうパロトレーナーさんも何人もいらっしゃるし、デンマー

クにももちろんトレーナーさんがいらっしゃるんですけど、日本ってま

だそういう存在がいないので … アメリカの方ではその退役軍人の方のメ

ンタルを整えるために使われてるとか、火星に行くために宇宙飛行士さ

ん達に遣われるとかっていう情報はすごく入ってくるんだけど、ここと

の風習とか習慣が違うし、とらえどころっていうのかな、なんかアメリ

カはそうだけど日本ではそうじゃないんじゃない、みたいな節があるん

ですどうしても, … 日本って[パロは]すごい普及されてないんですよ。[パ

ロは] 医療

機器ではないので ([I heard] There are many PARO-trainers in the U.S., and

there are PARO-trainers in Denmark, too, but we don’t have someone like that in

Japan yet, … I heard that, in the U.S., PARO was used for the military veterans to

treat their mental health care and astronauts were taking PARO to the space. But

here in Japan, we have different culture and custom – Japanese people tend to

think that it happens in the U.S., but not in Japan, … PARO isn’t that popular.

[Because] PARO is not a medical device).

Participant B said,

一生懸命パロの可愛さを伝えたんだけど、結局は高いおもちゃなんでし

ょうとか動くぬいぐるみでしょって、海豹の縫い包みみが電動で動くん

でしょ、それがかわいいよね、はいはいって言う感じだったから、あの

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パロの魅力を伝わらない日本ではパロをしらない人がとても多い, (I tried

to let

people know how cute PARO was, but people would say, “PARO is just an

expensive electric baby seal plush toy, and you love him, I got it” and were not

interested in PARO. In Japan, many people don’t know PARO).

In the United States, the famous cartoon The Simpsons had two episodes broadcasted in

2011 and 2019 about baby seal robots, parodied PARO (Anderson et al., 2011; Anderson

et al., 2019). In 2010, CBS News (2010) reported that when President Obama checked

out robots created in Japan, President Obama talked to Dr. Shibata about PARO, asking

about PARO in the news. Even still, PARO was not commonly known or utilized among

healthcare workers or healthcare programs in the United States. No one around me,

including students, faculty members, friends, or coworkers, knew about PARO when

talking about this study topic, or people with whom I worked in a hospice that took care

of patients with dementia and Alzheimer’s disease in 2012 knew PARO. With that said,

thinking about the whole, using PARO for mental health care, compared to the thoughts

from the part, such as that frustration of being misunderstood using PARO for mental

health care, my preconception changed, and a new idea emerged. The participants and I

shared common knowledge regarding PARO and PARO’s unpopularity despite how much

PARO could do and experiencing some levels of prejudice toward using robots regardless

of differences in cultural backgrounds and values.

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When reflecting this newly gained idea back on the whole, a different perspective

emerged again; it would mean that there was a need and a gap where PARO use in mental

health care was not welcomed and frowned upon while legitimate effectiveness

experienced by healthcare workers who went through the COVID-19 pandemic, the most

brutal period of the pandemic, just like having emotional comfort from animals or pets,

simply because of lacking information about PARO’s effectiveness on a personal level by

experiencing and reporting it in more literal form and experiential way. The way the

participants experienced would not have been known in this much detail from the

literature review and the videos on social media.

Further, the analysis evolved and elicited a different idea about PARO use. Dr.

Shibata promoted PARO as a “medical device” to treat the mood and behavior of patients

with dementia after PARO was introduced in the United States in 2009; still, years later

today, in 2024, as Dr. Bradwell and Dr. Sabanovic noted, PARO was expensive and was

replaced with more affordable cat- and dog-designed electric animal devices (i.e., Joy for

All) for clients/patients’ emotional support and socially assistive interactions. This could

mean that although Shibata et al. (2001) reported the specific reason a baby harp seal

design was chosen instead of commonly familiar pet animals, such as dogs and cats,

people, particularly in Western countries, preferred socially interactive robots designed in

such familiar pet designs, were not interested so much in highly sophisticated features of

PARO, not to mention the cost of the device. Supporting the notion, the concept of using

robotic animals to comfort and alleviate agitations of older adults with dementia is very

much alive today in the United States. Cat- and dog-designed robots were advertised and

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used, even reported on the news recently (Fox 9 Minneapolis-St. Paul, 2023; WPTV

News – FL Palm Beaches and Treasure Coast, 2024). This could mean that using a baby

seal-designed robot was too unfamiliar to people in the United States and other Western

countries, but not rejecting the idea of using robots for social companions. As such, in

Japan, the participants also mentioned experiencing prejudice against using PARO/robots

for comfort and therapeutic experiences despite the fact that there was a popular cartoon

series depicting stories of a baby spotted seal and a little boy called Shonen Ashibe (Boy

Ashibe), published in 1988 and the series ended in 1994 (“Boy Ashibe,” 2024); the story

became a TV animation series and broadcasted in 1990. It coincided with the

development of PARO, starting in the late 1990s. Considering this, baby seal design

robots could have been more familiar in Japan than in Western countries; however, the

participants reported that PARO was not so popular and accepted in Japan and had the

impression that PARO was more accepted in the United States because PARO was an

FDA approved medical device after all.

In summary, people, in general, might feel more comfortable and easily accept the

concept of using robots for their emotional support when separating the functions and

purpose of using robots and live animals. In other words, when the differences were

mixed and shown in robots responding and reacting realistically like living creatures, it

seemed to reduce the interest in using robots or not helping facilitate the use of the robots

unless the design of the robots was more familiar to the users. This means the design of

the robots was important; it needed to be more comfortable and familiar for users to

accept the use of robots, as reported in the technology acceptance theory by Davis (1989).

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Evidence of Trustworthiness

Because this study struggled to collect actual study participants, this research was

deemed a reasonably exhaustive study; the data obtained from the two interviews with

Japanese healthcare workers who used PARO during the COVID-19 pandemic, therefore,

limited in evidence of trustworthiness due to the lack of data saturation. I could not

confirm that the data was saturated after the data analysis from the two interviews. Still, I

followed the steps planned for trustworthiness discussed in Chapter 3 as much as possible

to increase the trustworthiness of the study outcomes while actively engaging in the data

collection and analysis stages.

Credibility

I conducted two pilot interviews and tested the data collection instruments, the

research interviewer mannerisms, and the flow of the interview prior to the actual study

interview and confirmed the instruments and researcher/interviewer mannerisms were

effective.

When each interview was performed, the transcript of the interview, saved on an

encrypted Word document, was emailed to each participant for member-checking.

Coding, searching meaning units, and data analysis were not conducted until I received a

confirmation of the transcripts from the participants.

While explicit identification of researcher biases (i.e., preconceptions) was

expected and utilized in hermeneutic phenomenology, I purposefully checked unwanted

researcher preconceptions, especially when I experienced clinically familiar tones and

expressions of the participants during the interview, noticing the clinically familiar tones

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and expressions became a strong indicator and a reminder for me of a researcher role,

instead of letting the clinical instinct as a clinical mental health therapist take over the

interview. Also, noticing feeling excited about knowing more about PARO was checked

in and limiting it purposefully, not deviating from the explanations of the participants’

using PARO to PARO handler talk. In addition, the participants reached out to me to be

part of the PARO handler training event after the interviews were done; however, I set

boundaries with the participants while coding and analyzing data, responding, and

explaining the researcher role.

I was mindful of identifying a discrepant case as part of increasing the credibility

of this qualitative study. There could have been a potential case; however, no data related

to discrepant case was obtained because the person on Twitter/X did not respond to my

initial contact.

Transferability

Thick description was chosen to attain transferability of this study. Crawford

(2016) listed three areas to denote thick description of qualitative research: (a) description

of the setting, (b) description of the participants, and (c) evidence to support the findings.

The elements of thick descriptions were noted in the qualitative study journal, notes taken

during the interviews; the information for transferability was discussed in detail in

Chapter 4 and Chapter 5 of this study.

Dependability

The details of data collection and data analysis (i.e., coding process and notes

taken during the interviews) were kept in the qualitative study journal to produce an audit

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trail to attain the consistency of data collection and data analysis. Moreover, I followed

the IRB approved interview protocol and the subquestions that were prepared prior to the

interview. Still, due to this study being reasonably exhaustive research, it was fair to

report that interviewing two actual study participants could not provide quality

dependability of this study.

Confirmability

While researcher preconceptions were expected to be explicit in hermeneutic

phenomenology, unwanted preconceptions were actively checked during the interview

with each participant. My clinical instinct when listening to the participants’ burnout

experiences and my curiosity to know more about PARO functions outside of related

context for the study interviews were actively checked. Also, noticing the boundaries with

the participants when the participants contacted me for the PARO handler event and

clearly explained the researcher role to the participants. The qualitative research journal

was kept in order to be in touch with researcher reflexivity.

Ethical Procedures

As identified in Chapter 3, the areas of ethical issues to be considered for this

qualitative research were: (a) type of research, (b) confidentiality, (c) risks and harm, (d)

voluntary participation, and (e) conflict of interest. These five areas along with other

critical information (e.g., recording the interviews and resources for the participants’

mental health and emotional care) were denoted in the informed consent approved by the

IRB; the participants responded, “I consent” in the participants’ returning emails,

indicating that participants understood and agreed to the conditions of this study. The

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participants were also asked if there were any questions before starting the interview, and

the participants said, “No.” Even still, before the interview, the five areas of the ethical

procedure were reviewed again along with recording the interview. The participants were

asked if they were comfortable with proceeding. After confirming the participants’

answer, “Yes,” the interview started.

In summary, this study could not confirm data saturation due to the limited study

participants; therefore, this study was deemed reasonably exhaustive research. Still, the

steps for trustworthiness were conducted as planned and described in Chapter 3 to gain

credibility for the results of this study.

Results

In this chapter, the changes and adjustments of the sampling methods, the actual

study participant search, data collection, and data analysis based on hermeneutic

phenomenology methodology were delineated, followed by the themes extracted from

hermeneutic analysis and the concepts extracted from the hermeneutic process to

understand further the lived experiences in the lifeworlds of the participants, revealing the

uniqueness of the participants’ own burnout experiences, going through the COVID19

pandemic, and using PARO.

The results of this study could not confirm data saturation, and this study did not

gain the generalizability or high trustworthiness of the study results because this study

had a small number of actual participants. Still, through hermeneutic phenomenology, the

participants lived experiences in the lifeworlds of the participants, and the participants’

descriptions of Dasein (i.e., “being-in-the-world;” Gadamer, 1975), insights, and

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worldviews were drawn and described in this chapter. Van Manen (2023) noted, “A

phenomenological question does not aim for empirical or descriptive generalizations” (p.

416) but to elicit experiences of a phenomenon through interviews and transcripts. Van

Manen wrote, “phenomenology aims at what is singular, and a singular theme or notion

may only be seen once in experiential data” (Van Manen, 2023, p. 456). Through the

concepts of hermeneutic phenomenology (Peoples, 2021a; Van Manen, 2023), including

the narrative of the participants’ Dasein, as well as the participants’ existential neurosis

and vacuum during the COVID-19 pandemic, and to find new and different meanings

when using PARO during the COVID-19 pandemic, here were the answers to the

research questions of this study: RQ1: What were the experiences of healthcare workers

who utilized PARO during the COVID-19 pandemic?

Two healthcare workers from Japan who had experienced multiple burnout

experiences went through the COVID-19 pandemic and used PARO during the COVID19

pandemic. Both participants had established careers as healthcare workers but were

ambitious and wanted to move up and do more despite having severe multiple burnout

experiences in their careers. Burnout symptoms experienced by the participants required

clinical treatment from medical and mental health professionals. Still, the participants

chose to stay in the careers in the healthcare field because of job security, such as finding

a job easily because the participants already obtained certificates and work experiences in

addition to the chronic staff shortage in the healthcare field. Both participants had

characteristics of being very responsible and dedicated to the assigned jobs, tended to feel

guilty and pressured to complete the assigned tasks, and could not notice the symptoms of

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burnout until the participants’ coworkers and people around the participants noticed or the

participants experienced physiological symptoms (i.e., cognitive distortions due to severe

stress and depression, decreased or impaired attention at work, and automatic nervous

system dysfunction; still, both denied becoming suicidal); experiencing existential

neurosis and vacuum. The symptoms were the same as those described in burnout

symptoms studied and reported in numerous other burnout research reports

(Freudenberger, 1975; Maslach & Goldberg, 2016; Maslach & Leiter, 2005).

The two participants shared experiences of using PARO and relatedness to PARO

in the participants’ lifeworlds. The participants owned the participants’ PAROs for about

6-7 years and used PARO spontaneously as part of the participants’ normal life routine.

At the beginning of the burnout experience or even recovering from the burnout

symptoms and depression during the COVID-19 pandemic, the participants did not think

about using PARO immediately because the participants were mentally and physically

too exhausted to think about using PARO, knowing how demanding PARO could be.

Still, the participants gained therapeutic experiences when looking at PARO lying as

though sleeping sound cutely when PARO’s switch was turned off. PARO would not die

or get sick or hurt. PARO was there as expected and would never go away. PARO was a

robot that the participants’ daily behavior or life choices would not impact PARO in any

way and would never get upset or angry.

Both participants had emotionally profound experiences with PARO when both

could not feel positive emotions or felt no emotions, were isolated, and disconnected

during the COVID-19 pandemic; PARO responded as though PARO understood the

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participants’ emotionally and mentally challenging experiences. The participants

experienced that the participants’ PARO also felt for the participants. Both participants

could have such lived experiences and relatedness to PARO in the participants’ lifeworld,

sharing emotions, moments, and experiences tacitly together because the participants

themselves enjoyed perceiving, interpreting, and appreciating the participants’ subjective

interpretation and conceptualizations of PARO’s reactions through the participants’

subjective points of view. The participants described their experience with PARO as

“comforting, dependable, emotional safety without worrying about PARO’s wellbeing.”

PARO gave the participants motivation and energy and became a trigger to do

extraordinary things, such as becoming an author of a story about PARO or continuing to

be an advocate for older adults and the older adults’ caregivers, as well as being a PARO

handler trainer.

Because of such experiences, the participants emphasized that the remarkable

features of PARO were not understood and known well enough in Japan, and both

participants were actively involved in training other PARO owners so that PAROs would

be trained appropriately to be responsive, reactive, socially interactive, and more

empathetic robots. In other words, the participants gained different meanings, purpose,

motivations, and values in the participants’ lives by using PARO during the COVID-19

pandemic.

In short, PARO provided personalized emotional support unique to each

participant; however, PARO was not a go-to device for seeking help while experiencing

burnout symptoms. PARO was much like a pet who could not prevent severe work stress

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caused by the COVID-19 pandemic but provided profound emotional and mental support

as a meaningful existence in the participants’ lifeworld when the participants needed

support and care from PARO.

RQ2: How could using PARO prevent worsening psychological conditions of healthcare

workers who work in mentally and emotionally stressful environments?

The limited data obtained from the two interviews with the two participants from

Japan for this study did not provide enough information to answer this question

satisfactorily. Through the data analysis of the interview transcripts of the participants,

owning and using PARO did not prevent burnout symptoms. Also, long-term personal use

or ownership of PARO did not prevent the participants from experiencing burnout

symptoms, much like owning a pet would not prevent people from experiencing burnout.

The participants of this study reported that the participants experienced in-depth,

therapeutic, and emotional support from PARO’s spontaneous, timely, and appropriate

reactions, which helped the participants gain a tacit and shared understanding of their

emotional pains and mental stress; the participants gained emotional energy and

motivation by interacting with PARO and were able to engage in meaningful activities in

their lifeworlds.

Summary

In summary, two final actual study participants from Japan met the inclusion

criteria for this study and participated in the study interviews; therefore, this research

could not confirm data saturation. Although the number of participants was not

significant, the interviews provided rich lived experiences of the participants’ lifeworlds

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and subjective views, going through burnout experiences during the COVID-19

pandemic, and the participants’ experiences using PARO. Hermeneutic analysis of the

study topic revealed that burnout experiences were actively present in the participants’

minds when subjects about burnout experiences were discussed, even though the

participants did not present clinical symptoms in the interviews; the participants were

calm, collected, and living a peaceful life. Using PARO for burnout symptoms or mental

health care was an area that would need to be explored more; however, the data analysis

generated several concepts regarding using PARO/robotic animals for emotional support.

The limited data obtained from this study revealed that the participants

experienced the same stigma and ethical concerns of using robotic animals as reported in

Western countries (Jecker & Nakazawa, 2022; Mordoch et al., 2012). People, in general,

were not interested in combining the idea of robots and live animals, such as real animal

like emotional reactions and support PARO showed; the idea divided people rigidly. The

participants’ experience with using PARO (i.e., a robot) for the participants’ emotional

support, companionship, and mental health care was not accepted openly or welcomed

positively in Japan, which was the same phenomenon in the United States. However,

considering PARO being an FDA-approved medical device, some programs continued to

use PARO or other robotic animals such as dogs and cats in the United States, and the

media was actively reporting on using robotic animals for older adults with dementia care

today, the United States was more accepting the concept of using robotic animals more

than Japan although I did not experience the common acceptance of PARO in the United

States. The active use of robotic animals (i.e., cats and dogs) was reported today in the

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United States by people accepting the concepts of robotic animals and companionships.

According to the technology acceptance theory (Davis, 1989), the reduced popularity of

using PARO was due to unfamiliarity with the design of a baby harp seal and not

knowing how to use PARO appropriately and adequately clearly, especially for people

who were not diagnosed with dementia, such as healthcare workers.

Another emerged concept was that the participants’ passionate hope to let other

people know more about PARO and how effective PARO was because the participants’

experience with PARO was emotionally and mentally uplifting and got the participants

motivated and did a lot of things (i.e., being an advocate for older people, publishing

eBooks), finding different purposes in the participants lives. Participant A mentioned that

if the inclusion criteria were not limited to healthcare workers who experienced burnout,

there would have been more study participant candidates whom Participant A would have

recommended. Also, there were seven certified PARO handlers currently in Japan.

Participant A noted that out of the seven, three PARO handers, including Participant C,

who passed away before the interview, experienced burnout before and during the

COVID-19 pandemic and used PARO personally for the PARO handlers’ emotional

needs. Another point to note was that five PARO handlers out of the seven PARO

handlers were healthcare workers who provided direct patient/client care. This could

mean that PARO could be more accepted among healthcare workers.

In the next chapter, the further interpretation of the results of this study,

limitations, recommendations, implications, and conclusion were discussed.

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Chapter 5: Discussion, Conclusions, and Recommendations

Introduction

The purpose of this qualitative study was to explore and understand the lived

experiences of healthcare workers who experienced burnout before the COVID-19

pandemic and used the AI socially assistive and interactive robot PARO. PARO was used

most famously to treat the moods and behavior of older adults who were diagnosed with

dementia and was researched for many years. Particularly in the United States, PARO

was introduced in 2009 and was approved by the FDA as a medical device in the same

year. There was a study reporting PARO used by healthcare workers, a registered nurse in

the United States, and a telephone counselor in Japan during the COVID-19 pandemic

(Shibata et al., 2021); it was a new and different way to use PARO. The current study was

to understand this phenomenon, such as how PARO was used and what using PARO

during the COVID-19 pandemic meant to users who were not older adults with dementia

diagnosis.

The topic of this study came from a gap identified as the healthcare worker

burnout phenomenon, one of the chronic issues researchers have been addressing for

decades. Freudenberger coined the term “burnout” in the 1970s when Freudenberger

operated and worked at a free clinic at that time, addressing the urgent and impending

need for a revolutionary level of change in the entire culture of the healthcare field in

order to alleviate the severe burnout phenomenon in the healthcare field. Especially after

Dr. Lorna Breen’s death by suicide was reported during the first wave of the COVID-19

pandemic, reiterating the high need for change in the healthcare field. In conjunction with

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healthcare worker burnout and the need for a radical change in the culture of the

healthcare field, understanding the use of the AI robot PARO by healthcare workers

during the COVID-19 pandemic was identified for the purpose of filling the gap. For this

study, after struggling to find study participants, I interviewed two participants from

Japan who met the inclusion criteria. The research questions to explore and understand

the lived experiences of healthcare workers who had burnout symptoms and used PARO

during the COVID-19 pandemic were:

RQ1: What were the experiences of healthcare workers who utilized PARO

during the COVID-19 pandemic?

RQ2: How could using PARO prevent worsening psychological conditions of

healthcare workers who work in mentally and emotionally stressful

environments?

Founded on existential psychotherapy concepts, the conceptual framework and the

hermeneutic phenomenology methodology were selected to answer the research

questions. The data collected from the interview transcripts were analyzed, utilizing

researcher preconceptions and hermeneutic cycle analysis. Although the number of study

participants was not extensive, rich descriptions of the lived experiences of the study

participants of burnout before and during the COVID-19 pandemic and using PARO

during the COVID-19 pandemic were obtained, and themes were drawn from the data

analysis. In this chapter, I described interpretation of the findings, implications,

limitations of the study, discussion, recommendations, and conclusion.

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Interpretation of the Findings

From the interview transcripts obtained from the study participants from Japan,

these themes were elicited:

• resilience, caring about others than self

• importance of career/certification, valuing hands-on help, job security

• wanting others to know more about PARO

• responsible and Pragmatic

• being aware of an objective view of using PARO/robots

• valuing eternity as part of feeling secure and getting support

• liking unexpected reactions -- evoking genuine emotions and emotional

support

Noting the themes extracted, with further hermeneutic cyclical analysis in

conjunction with the researcher preconceptions identified, I was able to gain the lived

experiences and views of the participants’ existence (i.e., Dazain) through the lens of

existential psychotherapy concepts in the participants’ lifeworlds through the topic of this

study.

In regards to burnout experiences through the COVID-19 pandemic, the research

participants’ experiences were similar to those reported globally, such as feeling

constantly pressured, alone, responsible for the wellness of the patients/clients, putting

the participants’ health conditions aside and continued to work, not noticing burnout

symptoms, both physical and psychological signs until people around the participants

pointed out to the participants. In the case of Participant B, Participant B contracted

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COVID-19 and ended up being hospitalized during the first wave of the COVID-19

pandemic; in other words, Participant B needed to work during the COVID-19 pandemic

despite having pre-existing health conditions. The participants shared with me the

participants’ experiences of going through the COVID-19 pandemic using the past tense,

smiling and laughing as though laughing the tough experiences away, remembering the

past extraordinary event together; the participants stressed how much they had gone

through, how extreme the COVID-19 pandemic was, reflecting back on the lived

experiences going through the COVID-19 pandemic with their health conditions and

burnout symptoms. Although the participants did not present clinical symptoms during

the interviews, the experiences of going through the COVID-19 pandemic were vivid

when reminded of the COVID-19 pandemic experiences; the burnout experiences and

symptoms reported were the same descriptions reported by the previous reports

(Freudenberger, 1975; Maslach & Goldberg, 2016; Maslach & Leiter, 2005). In other

words, the participants experienced existential neurosis and vacuum.

In regards to using PARO while having burnout symptoms and mental health

support, there were several concepts evolved through the hermeneutic analysis brought

up. First of all, my preconception of using PARO evolved from the research-based

knowledge of an AI socially assistive, interactive robot to help manage older adults’

moods and behavior to understanding PARO as a robot that could provide emotional care,

animal-assisted therapy-like experience to the healthcare worker study participants,

including the fact that PARO required proper training to serve people therapeutically; if

PARO was ignored and left alone, PARO would show rather depressive reactions and

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behaviors, and stopping interacting socially, not making any noises or moving its head, or

reacting to the voices of the users. This concept was elicited by my experience of having

a pet, and understanding and receiving emotional care and support from animals; PARO

required proper training like animal pets. The participants reported that the interactions

with PARO were unpredictable, as though people generally could not predict what pets

and animals would do when interacting with the animals and pets spontaneously and

appropriately; such interactions with animals would elicit genuine emotional reactions

and were meaningful, especially when not having much energy to do anything while

being burnout and severely depressed or lonely and isolated during the COVID-19

pandemic. I could not have gotten such information through the literature review; after

all, no other research regarding healthcare workers using PARO was published as far as

this study’s literature search went. In short, although the lifeworld of each participant was

uniquely different, PARO was very much in the lives of the participants, providing

meaningful interactions and purposes to the participants and the families of the

participants as the participants expressed how important PARO was in the participants’

lives just like a family member; in other words, living with PARO, using PARO, and

interacting PARO in the participants’ own way alleviated the experience of existential

neurosis and vacuum.

Secondly, reflecting such notions back on the study topic, the concept gained was

that PARO’s effectiveness as emotional support or animal-assisted therapy-like features

with healthcare workers (i.e., adults who were not diagnosed with dementia) were not

known well in Japan. This could be reflecting that the user side of experiences were not

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studied and reported previously, along with not addressing the need to explore the user

experiences of PARO, shown in the lack of a theoretical background of PARO use (that

emphasized the lived experiences of the users), as noted as a limitation of PARO use by

Hung et al. (2019). Further, the concept gained was that the participants wanted this study

to be done well so that more people, not only older adults with dementia diagnoses or

disability or children, could benefit from using PARO because of the participants’ own

experiences using PARO.

Thirdly, the firm culturally related researcher preconception about PARO’s

popularity and the concepts of robots being familiar and better accepted in Japan evolved

to an understanding that PARO was more accepted in the United States than in Japan,

considering that PARO was approved by the FDA as a medical device and was parodied

in the popular TV cartoon series The Simpsons two times several years apart in 2011 and

2019, and that the national news media reported that President Obama met Dr. Shibata

and PARO in 2010. On the contrary, a comic book story about a boy and a baby spotted

seal called Shoben Ashibe was broadcasted as a TV animation series from the early 1990s

to the early 2000s. Neither participant mentioned this TV animation series, Shonen

Ashibe, during the interviews. Both participants mentioned that PARO was not popular

“in Japan,” “not like in the U.S.” Participant A particularly said, “日本は[パロは]医療機

器としては認められてないので、福祉の用具の一つなんですよ、福祉用具なので

ウェルフェアっていうか、歩行器とか車椅子とかと同じような扱いです”

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(“PARO was not approved as a medical device in Japan. It is more like a welfare tool,

like a wheelchair or walker.”), and expressed that Participant A believed that it was part

of the reason PARO was not recognized and accepted widely in Japan. Participant A did

not mention that the concept of robot therapy was not accepted by people in Japan as a

reason of PARO not being popular in this interview. Participant B talked about her own

experience of receiving rather judgmental reactions and disapproval of using a robot pet

for personal, emotional support. Additionally, the idea of using robotic animals to treat

older adults with dementia did not die away but has been actively pursued in the United

States even today. Still, PARO was not as popular as PARO once was, but robots that

were shaped like more commonly accepted pet animals such as cats and dogs were

gaining popularity and remaining used more than PARO. Such robotic dogs and cats

(e.g., Joy for All) were more affordable than PARO, and the movements and mechanisms

were simpler than what PARO could do. Although PARO was recognized as a medical

device, people generally understood PARO as an electric plush animal in the United

States. Petersen et al. (2017) called PARO an “electric pet” in the title of the research

article, of which Dr. Petersen was a primary researcher, instead of describing PARO as a

“medical device,” as shown in Dr. Shibata’s article (2012). Within the limit of this study

results, this could mean that through the technology acceptance theory (Davis, 1989),

how familiarity and user-friendliness to a level of the user needs and concepts were

critical to a robot being welcomed in society; the concepts of using PARO might be

mismatched with the serving clientele.

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With all that said, the answer to RQ1, PARO’s use by the healthcare workers

found for this study reported meaningful experience with PARO as described in the

narrative form, aligned with the conceptual framework of this study in Chapter 4. The

answer to the RQ2 would need to be explored more; considering PARO’s values

expressed by the participants, PARO was like a companion, even like a family member

from whom the participants receive emotional support. Although the participants used

PARO during the COVID-19 pandemic, the participants did not use PARO as a go-to

support because interacting with PARO would require mental and emotional energy,

which the participants did not have while recovering from burnout symptoms and severe

depression, much like the experience of people not having much energy to pay attention

to or take care of their own pets.

Going back and reflecting on the conceptual framework for this study, in terms of

the participants’ lived experiences, as described in the participants’ existing lifeworlds,

the burnout experiences caused an existential neurosis and vacuum, including the

COVID-19 pandemic. The participants described their subjective views of their lifeworld

and expressed that PARO was an important existence that gave both participants new

meaning, purpose, and life energy regardless of whether PARO prevented the participants

from experiencing burnout, much like how pets would not prevent people from having

stress and burnout experiences but sharing meaningful experiences even during a tough

time. Although the results of this study could not confirm data saturation and, therefore,

produce high trustworthy results, the participants reported that PARO was able to help

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improve psychological wellbeing when the participants were ready to use PARO that

were well-trained and socially reactive effectively.

Finally, with further interpretation of this study’s results through hermeneutic

cycle, there were data, meaning units, and themes identified that the primary conceptual

framework could not conceptualize all the information gained, such as the influence of

using PARO in the lifeworlds of the participants, the challenges regarding using PARO in

the interpersonal functioning, or society’s challenges in accepting PARO despite what

PARO could do, and PARO being an innovative, novel technology with rather a unique

design. In addition to the technology acceptance theory (Davis, 1989) addressed briefly

earlier, another framework, social change of technology theory by Mackenzie and

Wajcman (1999) explained the information extracted by interpretation and analysis, such

as PARO being the change agent that provided emotional and mental health support for

people, divided people rigidly and formed groups regarding using technology/robots,

such a phenomenon impacted the users emotionally and influenced the participants’

decision making system. When collecting and analyzing data for researching social

science and technology altogether, these concepts naturally arose; it could be helpful to

conceptualize the data and data analysis with an additional conceptual framework,

especially when there were more study participants and, therefore, more data to analyze

and conceptualize.

Limitations of the Study

There were several limitations to address for this study. First, this was a novel

study and the first to explore the experiences of healthcare workers who used PARO

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during the COVID-19 pandemic, experiencing burnout. Although a hermeneutic

phenomenology study did not aim to generate any types of empirical outcomes or

theories but rather stressed and described the uniqueness and singularity in the

participants’ lived experiences, the hermeneutic phenomenology aimed at new meanings

or unique experiences for data saturation (Van Manen, 2023). Secondly, the participants

were from Japan, and both participants were PARO handlers who were enthusiastic about

letting other people know about PARO and how much PARO could do. Although

preconceptions were welcomed and important for hermeneutic phenomenology and the

plans to increase credibility for this study were followed, this study results likely lacked

impartiality, weighing more on favorable data on PARO and using PARO. For this reason,

the potential discrepancy case noted in this study would have helped to increase the

credibility of this study; unfortunately, I could not explore the case because the Twitter/X

account holder of the case did not respond to the study invitation. The lived experiences

of healthcare worker PARO users during the COVID-19 pandemic who were not PARO

handlers from other countries needed to be studied. Even though this study was new and

rare, the scarcity of participants was a considerable limitation of this study, although there

were more people who owned and used robotic animals, even PARO. Participant A noted

that she could have referred more potential participants for this study if the inclusion

criteria were not limited to healthcare workers who experienced COVID19 pandemic and

burnout. The way to recruit study participants needed to be more innovative and pondered

upon further. Lastly, another conceptual framework would be necessary in addition to the

primary conceptual framework when discussing

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PARO/technology, interacting and influencing social interactions in the environment and

affecting the users’ emotional reactions and decision making system regarding the social

interactions with the technology and acceptance of the technology. The additional

framework would assist in constructing the participants’ experiences of using technology

and the technology’s influence in the environment, emotional reactions and decision

making, and interactions with others in society firmly in addition to the exploration of the

participants’ lived and emotional experiences using PARO during the COVID-19

pandemic, recovering from burnout.

Recommendations

The areas to be explored more in researching using PARO denoted by Hung et al.

(2019) were (a) [PARO] users’ needs and experiences remain unexplored, (b) few studies

investigate the process of how to use the robot effectively to meet clinical needs, and (c)

theory is needed to understand and explain the use of PARO for clinical use. Although

this study addressed a part of responding to the unexplored areas of using PARO

identified by Hung et al., the results of this study could not assert that the results showed

significant trustworthiness due to the limitation in finding study participants and thus

lacking data saturation. It was recommended that the same areas continue to be explored

as a part of identifying innovative, effective, and evidence-based interventions to help

alleviate severe burnout symptoms of healthcare workers. As discovered by

understanding the participants’ experiences in this study, PARO needed to be adequately

trained by an attentive trainer who could interact regularly with gentle and welcoming

voices and touches, just like training animals. Both participants shared that frequently

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interacting with PARO with welcoming voices and touches was essential to elicit

beneficial attributes and create therapeutic characters and personalities in PARO. With

that said, exploring or testing using PARO for alleviating stress and preventing burnout

symptoms of healthcare workers, it was recommended that PARO station in a clinical

setting, have a designated staff who is a PARO trainer and could enjoy interacting with

PARO actively when PARO was turned on in the setting as though PARO was a part of

the team and staff in order to examine whether PARO’s existence and interactions with

the staff would make any difference in the environment and culture of the healthcare

workers of the specific setting and measure the level of stress and burnout symptoms of

healthcare workers.

My perspective and impression after this study ended by acknowledging that this

study was exhaustive was that when social science and technology, particularly socially

interactive robots and human interactions, along with humans’ emotional and

psychological reactions and thought processes were involved in the same study, it would

be essential to have another conceptual framework that would construct the findings

related to different disciplines together in addition to a primary conceptual framework

especially when more data were obtained with more study participants because there were

different data obtained that were affecting the findings of each area. Adding a secondary

conceptual framework could build a more firmly constructed study when interpreting,

understanding, and conceptualizing the interactions of participants, robots, people around

the participants, and the influence of technology in society, especially when considering a

change of culture in a field or industry, such as the healthcare field.

146

Implications

There was a long-standing, significant need to make substantial changes in the

healthcare field, particularly to make organizational changes in the healthcare field to

manage the phenomenon of healthcare worker burnout, how to change the culture of the

healthcare field, or even to prevent healthcare worker burnout symptoms since the 1970s.

As researchers noted, innovative and drastic changes were needed in the organizational

system in the healthcare field as a whole (Kim et al., 2022; Sindhu & Adashi, 2022), the

individual level of coping, preventing, and monitoring healthcare worker burnout

symptoms would be expected to be more diverse and innovative, such as involving

technology (Huckvale et al, 2019; Sasangohar et al., 2020; West et al., 2016). With such a

background, this study was to understand the healthcare workers who used the AI socially

assistive and interactive robot PARO during the COVID-19 pandemic, reported in

Shibata et al. (2021). The topic was novel, and no other research studies that reported this

topic were found; therefore, an exploratory research design was selected. As expected,

finding study participants was challenging. The research data analysis was performed

through the interview transcripts of two participants from Japan who experienced burnout

symptoms prior to the COVID-19 pandemic and used PARO during the COVID-19

pandemic. The data analysis of the two participants from Japan showed that PARO

provided personalized emotional support unique to each participant; however,

PARO was not the go-to device to seek help while experiencing burnout symptoms.

PARO was much like a pet who could not prevent severe work stress caused by the

COVID-19 pandemic but provided profound emotional and psychological support as a

147

meaningful existence in the participants' lifeworlds when the participants needed support

and care from PARO.

As an initial exploratory study, this study obtained the experiences of adult PARO

users who were not diagnosed with dementia. In addition, the study results elicited using

conceptual frameworks that delineated technology’s impact, influence, acceptance, and

challenges for people to employ technology to a level where entirely comfortably utilize

the technology for genuine benefits for all or most people, including healthcare workers,

emerged. This study analysis also revealed that in the United States, the idea of using

robotic animals was more accepted than in Japan; still, the idea of using robotic animals

for emotional support and mental health care for adults was not commonly accepted in

the United States either unless, the designs of the robotic animals and the purpose and use

of them matched the need of the users, according to technology acceptance theory (Davis,

1989), as seen among older adults with dementia continued to use them for their mood

and behavior management. All other technologies people normally use today, such as

email communication, cell phones, and financial transactions on the Internet, took a

significant amount of time to be widely accepted; it started with very few people with

much skepticism. This study results came from the data obtained from the two interviews

and could not confirm that the study results reached data saturation and high credibility;

however, considering Participant A’s statements, most of the PARO handers were

healthcare workers, and the idea of using technology to provide emotional care for people

has continued to be explored, studied, and evolving in the United States (i.e., the design

of the robot changed from a baby seal to a cat or dog), PARO or even other AI robotic

148

creatures could be commonly utilized to monitor, manage, assess, or prevent healthcare

worker burnout in the healthcare workers offices one day. It is recommended to continue

exploring how robots/technology would impact healthcare workers’ psychological

wellbeing in the healthcare field; after all, humans’ emotional reactions and interactions

with others were proven possible to be coded and programmed with algorithmic

conversion and mechanized.

Conclusion

The research gap identified for this study was the need for personalized,

innovative interventions for healthcare workers’ burnout phenomenon in the healthcare

field, considering the chronic phenomenon of severe burnout syndrome among healthcare

workers. An AI socially assistive and interactive robot PARO was used by an RN during

the COVID-19 pandemic (Shibata et al., 2021); unfortunately, I could not find the RN

and could not interview about that RN’s lived experiences for this study. However, two

healthcare workers from Japan participated in this study, sharing their lived experiences,

how they experienced during the COVID-19 pandemic, their experience using PARO

during the COVID-19 pandemic, burnout experiences in their careers, and their views of

the world. I understood the way the participants used PARO by my preconceptions

through the experience of owning a pet. The participants experienced something

emotionally invigorated, supported, and alleviated loneliness without causing problems

with others, including PARO, noting that it was important for the participants not to feel

guilty when turning the switch of PARO off. PARO’s eternal life also provided the

participants with emotional safety and security and made them more comfortable

149

depending on PARO 100% for their emotional support. In summary, the participants

shared the participants’ experiences of an existential neurosis and vacuum in the midst of

the COVID-19 pandemic and experiencing severe burnout symptoms; however, the

participants both mentioned that encountering PARO through the burnout experiences

during the COVID-19 pandemic gave the participants energy and purpose to move on,

identifying different meanings, purpose, and motivation.

The research question regarding PARO being part of burnout prevention (RQ2)

would need to be explored more. For future research to obtain more data to answer that

research question, it was recommended that PARO be adequately trained and attended

well in the healthcare workers work environment when desiring PARO to be used most

interactively, responsively, personably, spontaneously, and appropriately, according to the

participants. Suppose this area was to be examined in the future, it was recommended to

utilize an additional conceptual framework to address and construct the data describing

the social science, psychological effects, and technology-related phenomenon to establish

a firmer, balanced, and synthesized data analysis of a study in order to continue exploring

the technology as part of the intervention of healthcare workers’ psychological wellbeing

in the healthcare field.

Lastly, this study employed constructivism as the foundational philosophical

orientation and the conceptual framework because understanding the use of AI robots and

the user experiences of the AI robots, the life experiences and existence of the users in

history to the present moment were inseparable as well as understanding the lived

experiences of healthcare workers going through previous burnout and the COVID-19

150

pandemic and as users of the technology/PARO. Human experiences and reality were

understood by the stories of those who experienced the phenomenon through the lens of

constructivism. The phenomenon of healthcare worker burnout has been a chronic issue

for decades. Several decades later today, since the term “burnout” was coined in the

1970s, technologies have been a significant part of human lives today; it is crucial and

logical to consider integration and familiarity with technology into human lives and

research further in terms of innovative, cost-effective, convenient, and reliable, yet gentle,

sensitive, spontaneous, timely, and personalized interventions to reduce the stress of

healthcare workers and influence the culture of the healthcare field. It was hoped that this

study could make a small contribution to social change to the chronic issues of the

healthcare field.

151  
 
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