This research was approved by the Institutional Review Board at the university (IRB #1807587226). Informed consent was obtained from each participant. The participant population included members of the intraoperative surgical team at the patient bedside: surgical nurses, residents, and attending surgeons. Surgical nurses are at the bedside with the attending surgeon to ensure that surgical instruments are available and handed to the surgeons (Yu et al., 2016). Residents are trainees who complete the role of the assisting surgeon; they perform segments of the procedure under the guidance of the attending surgeon or assist to the procedure by holding instruments for visualization.

Multiple strategies were utilized to recruit participants with intraoperative experience from different surgical roles for the focus group study. A convenience sample of surgeon and resident participants was recruited. Surgical nurses were recruited through a hospital-wide showcase event, where a table was set up with the exoskeleton near the OR front desk at a satellite hospital of a larger health system. The exoskeleton display drew the attention of staff passing by. The snowball sampling technique was used to recruit participants for each surgical role. After obtaining at least one interview from each surgical role to ensure diversity in sampling, a stopping criterion was set as when no new themes emerged. The point of data saturation was defined when this criterion was met (Francis et al., 2010; Saunders et al., 2018). Sampling was stratified to ensure diversity of roles; however, we included all interested participants during the 6-month study period. After providing informed consent, participants completed a two-part study in the following order: (1) individual or multiperson interviews, and (2) a simulated laparoscopic skills task while wearing a passive arm-support exoskeleton (Levitate AIRFRAME^™; Figure 1a).

All focus group sessions were audio recorded. Recordings were deidentified, and a professional service was used for transcription. The raw transcript data are accessible in a data repository (https://purr.purdue.edu/projects/hf196191). NVivo 12 (QSR International, Melbourne, Victoria, Australia) was used to complete a content analysis through inductive and deductive processes to identify relevant themes from participants’ responses (Hsieh & Shannon, 2005; Krippendorff, 1989). Three study team members independently completed the thematic analysis of the first three participants. They then came together to resolve coding discrepancies and identify subthemes. All remaining transcripts were double-coded; a minimum of two independent raters completed every transcript. A team of qualitative methods and clinical subject matter experts were consulted throughout theme development. Data saturation was reached with the 14 participants, as responses by the last focus group were anticipated by the researchers and no new themes emerged (Onwuegbuzie, Dickinson, Leech, & Zoran, 2009; Saunders et al., 2018).

Thirteen participants (93%) reported experiencing MS symptoms within the last year. The one participant who did not report MS symptoms was a surgical resident who spent the entire past year on research (i.e., protected time from clinical duties to dedicate to research). Aching, stiffness, and fatigue at the neck, shoulder, and back were listed as common symptoms. To alleviate their MS symptoms and fatigue outside the OR, participants indicated that they complete stretches inside and outside the OR and exercise (72%). Inside the OR, all participants noted doing small stretches and changing positions to not disturb the surgical instruments. Participants of shorter (less than 160 cm; n = 2) and taller (more than 188 cm; n = 2) stature noted challenges in managing their MS symptoms due to the height differences among the surgical team. One resident noted, “I’m short so [I] have to use step stools often, and often stacked several high—it become unstable and difficult to use pedals for cautery or shift positions,” whereas a taller resident stated, “I am constantly tempted to have horrible posture due to shorter attending [surgeons].” When asked what would help overcome managing MS symptoms, two participants noted a need for interventions that can help maintain posture, whereas others (n = 4) highlighted gaining knowledge on ergonomic strains and more personal exercise and strength training.

Four main themes were identified related to the adoption of exoskeletons in the OR: characteristics of individuals, benefits, environmental/societal factors, and intervention characteristics (see Table 2). These themes were organized considering the Consolidated Framework for Implementation Research (CFIR) by Damschroder et al. (2009). The subtheme of usability was included within intervention characteristics.

After completing the simulation tasks, the mean SUS score for the exoskeleton tested was 81.3 out of 100 (SD = 8.1) (see Table 3). The system was thus considered usable, falling between the “good” and “excellent” scores and within the acceptable range of usability (Bangor, Kortum, & Miller, 2009). Two attending surgeons provided the lowest SUS score (72.5), which is at the cutoff between “OK” and “good” ranges. Two-thirds of the participants indicated that they agree/strongly agree they would use the system frequently and disagree/strongly disagree that the system was unnecessarily complex. One participant reported a strong agreement that the exoskeleton was very cumbersome to use. Participants provided additional comments, such as the need for a stronger focus on back and neck support, rather than arm support. In addition, an attending surgeon noted that the exoskeleton was not necessary “as elbows were at my side so did not require upper body support.”

Our study identified themes for the adoption of exoskeletons in the OR and furthered understanding of facilitators and barriers to stakeholders using this technology. This evidence can be used to build strategies for more widespread implementation for all worker roles in the OR, as well as inform requirements of future exoskeleton design and selection criteria for exoskeletons to be used by surgical team members. For example, regarding concerns of maintenance (Theme 4), it is well known that nursing staff have limited time, especially during OR turnover, so incorporating additional equipment may add to the already high workload. However, exoskeletons can be easily wiped down and arm cuffs easily replaced, thus enabling them to be sterilized en masse. Furthermore, we believe that existing sterility protocols for shared equipment (e.g., lead vests to wear during X-rays) could be adopted to address concerns for the risk of infection and sterility between operations (Theme 3). Adopting the strategies used in other industries, such as assigning an exoskeleton to specific workers or groups of workers and having personnel responsible for only their own fabric components, can also be incorporated into strategies for widespread adoption.

The showcase event used in this study can be a strategy for addressing the identified barrier of familiarity. The event allowed members of the OR team to become aware of the technology, and participants mentioned awareness as a key influence on receptiveness toward the use of the technology. Coordinating this event helped increase communication with OR management and workers about the study. Furthermore, the need for champions (Theme 1), particularly from the attending surgeon and surgical nurse roles, that were enthusiastic of the intervention and dedicated themselves to supporting the exoskeleton to other team members was identified from our focus groups. This resource within the organization is critical to obtain buy-in for new innovations (Wisdom, Chor, Hoagwood, & Horwitz, 2014). For other OR interventions, the traditional process of implementing a new medical device into surgical practice involves an attending surgeon who advocates for the use of a new device and a company representative that is present in the surgical procedures using this device to facilitate smooth adoption. Because ergonomic risk affects the entire bedside surgical team, we found that champions from both surgeons and nurses can better facilitate translation.

Several characteristics of the OR environment may help address noted barriers regarding the logistics of independently donning the exoskeleton. Surgical teams typically have a circulating nurse (who remains nonsterile) who helps put gowns on those who need to be in the sterile field, and this individual could assist in donning an exoskeleton (Theme 4). In addition, it should be noted that although participants needed help here donning the exoskeleton, they were able to independently take off the exoskeleton after the simulation. Having exoskeletons stored in the surgical core, where it is easily accessible to workers, or including it on a specific case cart for specific procedures can also help address logistic barriers (Theme 3).

Worker role and specific operation were key factors identified for successful implementation. Although the attending surgeon was a team member identified as benefiting from this technology (Liu et al., 2018), the exoskeleton may not provide the most value in this role due to the constant movement required to perform an operation. This limitation was further reflected in the usability comments and SUS scores from attending surgeons, who noted that they have been trained to keep their elbows close to their bodies when possible, especially for minimally invasive surgeries. With the exoskeleton, they stated that there was a lack of support and stabilization near the forearms, and this would be more beneficial than support on the upper arms. However, it would be challenging to have forearm support in the OR due to the need for sterility. This remains a challenge for current exoskeletons to make an impact for surgeon workers and should be a critical design requirement for future exoskeletons created for surgical teams. Surgical trainees (e.g., residents or medical students) and nurses may receive the most benefit (Theme 2), because individuals in this role must often maintain static posture, such as when holding instruments (e.g., scopes or retractors). Compared with operative nurses, who take routine breaks, trainees may receive more benefit from this intervention due to the requirement that they remain during the entire surgery. An exoskeleton may thus help address the high perceived physical workload among residents (Yu et al., 2016). Regardless of the OR worker role, the surgical team had similar perceptions of the usability (Theme 4) of the exoskeleton, confirming that this technology can be relevant to the team, despite different tasks and roles. This may be an indication of the need for an intervention due to the entire team experiencing ergonomic risks (Theme 1). In addition, although the overall SUS score was not designed to predict whether users would frequently use exoskeletons, there was a positive response (between neutral and agree) from participants on the SUS item asking whether they would be frequently using this device.

The perception of a need for an intervention and the impact and value of exoskeletons to surgical users likely depend on the number of cases in the surgical day and duration of each procedure (Theme 1). Specifically, there is a trade-off between a reduction in biomechanical load and usability stemming from the time needed for donning/doffing the exoskeleton. The surgical specialty members participating in this study averaged 17 hr per week in an academic hospital, and this likely influenced their comments and usability ratings of the exoskeleton. Other surgical specialties may have longer case durations, and other institutions may have different expectations on operative hours per week; thus, the surgeons’ comments here may reflect experiences of other general surgeons at an academic institution and may not reflect other work cultures or surgical specialties. Regarding usability needs for different roles, surgeons interact with patients between cases, where exoskeletons must be removed. This may not be as much of a concern for surgical nurses who do not provide patient/family consultations, but it may explain some of the variation in usability ratings among the various participating roles. Thus, conversations between ergonomists and surgical team members are still needed to develop guidelines that are specific to each institution for use of exoskeletons in the OR.

Our thematic findings of exoskeletons for the OR workplace parallel those found in the construction and agriculture workplaces (Kim et al., 2019; Upasani, Franco, Niewolny, & Srinivasan, 2019). The expected benefits of using exoskeletons and usability were identified in all three domains. Particularly, all three studies highlighted an expected reduction in pain and the need for this technology to be integrated into existing work practices. Having familiarity with both MS symptoms and the exoskeleton appears critical to obtaining buy-in to use this as an intervention for all domains. This reflects the CFIR construct of implementation climate (e.g., relative priority), as well as identified barriers for innovations such as a lack of knowledge and training and resistance to change to prevent MS disorders (Yazdani & Wells, 2018). Although parallels existed across these three domains, key differences were identified between health care and the other domains. For the agriculture domain, back and knee exoskeletons were reported to be the most beneficial for workers, whereas the construction and health care domains focused on back- and arm-support exoskeletons (Kim et al., 2019; Liu et al., 2018; Upasani et al., 2019). Differences in organizational structures were also present in earlier studies in different industries. Participants in agriculture were those performing physical work in their own small-to-medium farms. Those in construction were, however, part of small- to large-sized companies with stakeholders from multiple organization levels (e.g., managers and carpenters); this study focused on workers in one single large institution. The resonating themes drawn from implementation science and in the different industries reflect that exoskeletons can be a feasible intervention for many domains.

Although any inquiries regarding exoskeletons were initially answered, participants often noted that it was difficult to address its expected impact on surgical workers without trying the exoskeletons first. If the simulation portion of our study was completed prior to the focus group, participants may have answered differently. Moreover, the limited (10-min) time frame over which participants wore the exoskeleton is too brief to mimic the effects of MS symptoms and fatigue experienced in live surgical operations. Although the optimal task would have been to hold an object (e.g., scope) for a prolonged period of time to simulate actual task demands during an operation, we chose the FLS task for its validity in minimally invasive procedures, the time availability of the participants, and for the consistency of task where the positioning reflects upper-arm demands for both attendings and assistants (i.e., surgical residents or nurses) when they manipulate the long-handled laparoscopic tools. Thus, for usability ratings, participants used their operative experience to predict how the intervention would affect actual procedures, and further assessments of tasks performed with and without the exoskeleton in actual work environments are needed to generate biomechanical evidence about the effects of exoskeletons during surgical work. Furthermore, shifts in the exoskeleton were observed (i.e., the arm support moved superiorly during lateral bending), which may have caused nonoptimal force distribution and hence lower usability ratings. Without developing MS symptoms during the simulation, users may not have felt the need for the exoskeleton. Actual use in the workplace will allow for the identification of potential in-task barriers and evidence of effectiveness centered around individual users. However, the simulation was informative to gather participants’ perceptions of usability of the technology.

Future work is ongoing to pilot exoskeleton implementation in the OR to gather comparative evidence that this technology is a feasible and effective intervention for reducing surgical team members’ MS symptoms. Although briefly discussed in this study, future work can explore synthesizing qualitative data cross-domains to identify domain-agnostic themes regarding exoskeletons in workplaces.

In conclusion, four themes were identified encompassing facilitators of and obstacles to surgical team members using exoskeletons. Specially, this study focused on gaining perspectives from all stakeholders in the OR, especially the surgical team members who are also exposed to ergonomic injury risks yet received less attention than surgeons. Exoskeleton use in simulation suggests acceptable usability for surgical tasks that may translate to the OR. Exoskeletons as an intervention received positive comments, especially from individuals in the nursing role. Thus, exoskeleton technology has the potential in this work environment to improve workforce retention and decrease MS symptoms for all team members. Although adoption of arm-support exoskeletons can be valuable, a key contribution of this initial work is the identification of unique aspects of the surgical environment and barriers and facilitators such as cost and team member buy-in that need to be addressed to help guide future translation of exoskeletons into practice.