Developing bespoke theory-informed implementation strategies.

The findings from the interviews were used to develop a RAS implementation plan to address the key barriers identified at each phase. To do this, core themes raised by the interviewees were reviewed and the actions repeatedly observed by interviewees to improve implementation were summarised. Additionally, we summarised the barriers and enablers identified in the interviews and matched evidence-based strategies to identified behavioural influences, a systematic method proposed by Michie and colleagues [18] shown to be highly effective in other clinical applications [9–12]. This approach makes use of a taxonomy of strategies that have been theoretically and experimentally proven to change specific behavioural targets (tailored to the context in hand, i.e. implementation of RAS). We have included more detail about the methodological steps involved in the design of the implementation plan in a supporting file (S1 File).

The suggested implementation strategies were collectively reviewed and refined by the research team. A RAS Surgeon reviewed the implementation plan to establish the feasibility of our proposals.

Cost & culture (CFIR cost, culture).

Cost analysis issues are contained within all three phases of the study findings and are described in detail in the section on Outcomes of RAS & Influence on Adoption below.

The culture of a hospital and/or the NHS, having an appetite (or not) for innovation and a level of openness to the incorporation of new interventions were also identified as opportunities and challenges to implementing RAS. A lack of appetite and agility to respond to innovation was problematic:

“Well what didn’t help was the scepticism and the lack of agility….and vision of big administrative structures and managerial structures in the NHS, where innovation and change is not really adopted very easily.” P01S, Specialty Lead.

The transition of an innovation with pedigree and genesis seated in a more commercial or private healthcare delivery sector into a public medicine domain was further framed as a barrier according to some interviewees:

“Trying to roll that process into a public healthcare system–and it’s not the UK specifically, this is a Europe-wide experience–is where we seem to hit friction. As a company, we really struggle to work out what it is that means that that model doesn’t necessarily translate to a public healthcare system.” P03I, Industry stakeholder.

Opportunity to network with external organisations/industry (CFIR cosmopolitanism and industry enabled opportunities).

For initial adoption, many interviewees cited positive experiences with industry in the process of procurement, namely in terms of effective collaboration with the sales team and establishing international and national links with external organisations. Exposure to other institutions around the world and observing the demonstrable effects of RAS created a favourable impression for one Service Manager:

“My understanding of the benefit of delivery of that was certainly going to [country] and seeing the system …there. . . . . It’s a conveyor belt of surgery….using robotics.” P2M9, Service Manager.

Social and professional roles: Impact on adoption (Dominant domains: Social influences, social professional role & identity).

Some Service Managers interviewed had a clinical background and/or worked in prior services where technology and innovation had been at the forefront: this was reported to contribute to their positive impression of RAS. Other interviewees acknowledged that their own established international, national and/or local status facilitated the adoption of RAS, sometimes with reference to their academic credentials. One industry representative considered the interplay between, and influence of academia and clinical Key Opinion Leaders (KOLs) on the slow change in perception into the more general workforce. On the one hand clinical KOLs, without necessarily utilising academic or research based arguments, had driven implementation by providing a positive impression. However, those from more research-based academic backgrounds were also influential during pre-adoption, but in a more balanced and dispassionate way (offering arguments for and against implementation). Both of these types of individuals were considered to influence the next level of the RAS user workforce:

“…But when you get into the next realm, when you get into that earlier doctor group who come out of academic institutions who are good surgeons and they start to say, “This we think is good”, that’s massively influential.” P2I13, Industry stakeholder.

As a further nod to the relationship between academia and social/professional status, a few interviewees recognised that innovation in surgery, including RAS, generally tends to be ‘eminence driven’ as opposed to ‘evidence driven’.

Perceived peer/patient influence and group conformity (Dominant domain: Social influences).

Group conformity, peer and patient influences were also noted as drivers of RAS implementation. Observing the conduct of RAS in other hospitals was sometimes reported to drive local decisions to implement. Perceived patient pressure was also reported to influence procurement, especially in Urology where robotic prostate procedures are well-established:

“…I think particularly with urology, you would see it with the prostate operation, that suddenly these centres appeared and every patient went where there was a robot.” P2I26, Industry stakeholder.

While many interviewees reported a general enthusiasm about RAS among peers in the surgical community, some level of resistance and/or disengagement about adoption was commonplace. According to one stakeholder, competitiveness amongst clinicians from multiple disciplines within the same hospital could act as a barrier to initial RAS implementation; this was thought to be fuelled by the desire to incorporate other innovative technologies. Furthermore, while many interviewees reported a general enthusiasm about RAS among peers in the surgical community, it was acknowledged that there had been some level of resistance and/or disengagement about adoption:

“…there is a lot of resistance I think to robotic surgery and I know because it’s a very young specialty because it’s only twenty years old, unlike laparoscopic surgery ten years prior to that…people I work with that are very resistant to it…..” P12N, Scrub Nurse.

Managerial, hospital level executives and commissioner influences (Dominant domain: Social influences, related to knowledge).

Many interviewees reported difficulties in explaining the perceived benefits of RAS to management, hospital level executives and commissioners, especially in the absence of strong evidence and considering the up-front cost of the equipment:

“a key part of the actual procurement….and convincing some people that this was a pursuit worth undertaking…and standing that against clearly the considerable costs involved.” P2S22, Surgeon (RAS User).

This inability to articulate the benefits of RAS to management was sometimes a significant barrier to adoption, as the individuals involved in the management and executive structures of the organisation were instrumental in enabling implementation. One Specialty Lead highlighted the essential requirement of convincing commissioners to overlook the stereotypical portrayal of surgeons and instead appreciate RAS benefits in isolation of any prejudicial views:

“… to convince commissioners that, “Look, there is benefit here.” Benefit is that it’s not just a toy for the boys, which is how we are described very often..”. P01S, Specialty Lead.

The perceived weakness of the evidence base and procurement structure could also be problematic in the process of obtaining a reasoned or rational procurement decision. The relative dependence on industry’s value proposition and marketing information in the process was considered challenging. In addition, it can be easy for surgeons to persuade managers of the benefits of RAS, particularly if managers do not possess a sound understanding of the evidence.

“. . . and the problem with the managers is they don’t understand the evidence, so the surgeons can persuade them, I think, that there is evidence when there isn’t.” P2S25, Policy-maker/Commissioner.

Outcomes of RAS & influence on adoption (Dominant domain: Beliefs about consequences, linked to knowledge).

Outcomes of RAS appeared to be a substantial influencer in its procurement. The Managers in the current study were convinced that the outcomes of RAS are positive due to data reported in scientific literature and/or discussions with surgeons, which contributed to the decision to implement RAS locally. Beliefs about positive patient outcomes associated with RAS were reported by Managers, such as shorter length of hospital stay and improved recovery as compared to open surgery, while other interviewees indicated that the patient outcomes associated with RAS, as reported in the literature, were not dissimilar to the outcomes associated with laparoscopic surgery in certain specialties. The notion that more robust evidence of RAS benefits is required to justify the introduction of RAS in the NHS was suggested by a few interviewees.

Many interviewees spoke about the evidence of RAS benefits in relation to a specific specialty and/or procedure, and one stakeholder acknowledged that it was very difficult to judge the benefits of RAS based on the heterogeneity that exists in the field of robotics, including the literature:

“I think it’s very muddled. . . And I think it’s an area where it’s impossible just to take the evidence for one and apply it to another. That is part of the difficulty.” P2M10, Policy maker/Commissioner.

Nevertheless, some interviewees possessed disproportionately strong beliefs about the benefits of RAS. There was also acknowledgments that contrasting perspectives among the surgical community can be a hindrance to widespread adoption.

Beliefs about long-term effects of RAS and impact on adoption.

One of the most influential (positive) drivers of RAS service implementation were the beliefs associated with the perceived long-term effects of implementation. Some interviewees indicated that long-term implementation could reduce overall health inequalities by widening access to minimally invasive surgery and enabling operations to be conducted on more patients, with positive outcomes:

“…And, actually, that was something that won me over as well….. That the frail, elderly, and the obese patients can be operated on using the robot more. . . I think with better outcomes…” P2SM20, Policy-maker/Commissioner.

Other beliefs about outcomes which motivated implementation included the notion that RAS implementation would enable research and foster collaboration between institutions. Some interviewees also expressed the belief that introducing RAS on a wider scale could positively transform the way in which clinical staff and patients interact with the healthcare system, including the idea that robotic platforms facilitate digital data collection which can translate to positive patient and societal outcomes. In addition, the belief that data generated by robotic platforms can be used to improve workforce training was also cited as a reason to implement RAS. Many interviewees also acknowledged that robotic surgery is a rapidly expanding field. Some suggested that local implementation would be necessary due to the rapid national/international escalation of RAS, sometimes with reference to the implications for workforce training. The potential of acquiring a robot to attract surgical talent and retain existing staff, especially in some regions of the UK where recruitment/retention is problematic, was often cited as a motivator for local implementation.

“…I know from personal experience, colleagues who have given up because their Trust just did not want to go down robotic and they just did not see themselves doing the same old, same old, same old. So having access to new technology, innovation, stimulating things, a reason to go to work, has been really, really important”. P14S, Surgeon (RAS user).

Pre-implementation consideration of cost and economic viability.

The significant upfront cost of RAS equipment was reported as a barrier to initial adoption. Many interviewees also acknowledged at an early stage that RAS would not be cost-effective if the robotic platform was not utilised in an economically appropriate manner. Acknowledgments of the importance of high surgical volume and ensuring optimum use, i.e. ‘being able to sweat the asset/robot’, was present during pre-implementation:

“. . . and also because it wasn’t so cost effective unless you really sweated the asset, that to me was the most persuasive argument…” P2SM20, Policy-maker/Commissioner.

Similarly, one Industry representative recognised that while there were demonstrable patient outcomes of RAS in certain niche specialities, such as Head and Neck, the application of RAS in a single specialty context may not be seen to be worthy of investment due to the expected low surgical volume. There was recognition that multi-specialty implementation can allow for increased volume and program efficiency.

Institution branding and profiling associated with RAS procurement (reinforcement).

Some interviewees postulated that the introduction of RAS provides individuals with the opportunity to brand their respective hospitals as ‘innovative’ and modern. This was sometimes cited as an incentive for NHS hospitals to introduce RAS:

“I think the biggest driver even in the NHS at the moment is a driver to promote your organisation through the introduction of new technology. . .” P2S21, Specialty Lead.

RAS influenced role modifications (Dominant domains: Social professional role & identity; social influences).

Interviewees reported shifts in professional roles and duties as a result of implementation during the early phase of adoption. Increased multi-specialty exposure and greater intraoperative responsibilities were reported for some nursing staff. This characteristic was expressed both as a barrier and enabler. The Scrub Nurses in the current study regarded adaptations to their roles as positive overall. However, initial difficulties in assimilating to changes were reported by one Scrub Nurse, namely regarding the confidence to perform in theatre:

“…You literally are stepping over a big fence between something that’s never been allowed to be your role to, oh no, this is what you’re doing now. It did take time.” P2N5, Scrub Nurse.

Notably, two interviewees suggested that RAS can be sub-optimal from a general surgical training perspective, particularly outside specific RAS training and when utilising a single console robotic platform (note that dual console robotic platforms, a more recent development, will not generate this issue). The lack of requirement for the classic “surgical assistant” can deprive trainees of close operative field experience and peri-operative verbalised teaching.

The greater separation of operative experience/technique from duties of pre-operative/post-operative medical care was also highlighted for RAS surgery by trainees, as well as access to dual console equipment, which may have a bearing on confidence and trust within theatre. There was controversy over the impact of RAS on the Anaesthetist’s role and their need for involvement in the procurement process. Some interviewees suggested that the Anaesthetist’s role becomes more demanding as a result of RAS, warranting their wider engagement, while others suggested that the change to their role is less fundamental:

“there’s not a huge amount of difference in terms of the actual anaesthetics that are administered, but there is a little bit of difference in terms of how the patient would be positioned, how they’re handled in the operating theatre….” P03I, Industry Representative.

A few interviewees also mentioned changes to the Surgeon’s role as a result of introducing certain robotic platforms in theatre: RAS often removes the requirement for a single ‘master’ operator and necessitates greater reliance on the surgical team. Whilst such a change can be seen to have merit for a process that is very team dependent, sometimes this change was reported to create resistance amongst some Surgeons who enjoy operating in a more solo mode during open cases. An increased dependence on a team approach could also bring limitations and be a barrier. There is an idea that the successful conduct of RAS depends on effective teamwork, therefore a stable and consistent team is required. It was reported that RAS is often conducted with team members not always familiar with each other for every procedure:

“We needed the same people and everyone knew to be clear on the team what their roles were and the surgeon found that beneficial. They want the same team in there. As time goes on you’re not able always to implement that because you can’t use the same people every time, so then you get someone new in and then it kind of goes backwards a little bit …” P12N, Scrub Nurse.

Reliance on industry & international collaboration (Dominant domain: Environmental context & resources).

The need to rely on industry or international mentorship for the early implementation of RAS training created both opportunities and challenges for some interviewees. The opportunities were related to the training package resource provided and the challenges included the transition from company led support (“hand holding”) to confident independent use. The responsibilities (such as for proctoring) in the transition phase between learning and established practice is not well defined and an area for attention. Commercial input extends to technical support, but not clinical.

Perception of competencies required to conduct RAS (Dominant domain: Skills).

There were conflicting views around whether RAS demands the same set of skills as other minimally invasive techniques, and sometimes this was quoted to be dependent on the robotic platform in use and the type of procedure conducted:

“There is a skill set that needs to be trained to understand how to use the articulation, how to use clutching systems in robots that wouldn’t exist at all in laparoscopy.” P2I26 Industry stakeholder.

Surgical adaptation and acquiring ‘good screen skills’ was regarded as essential, according to a few interviewees:

“Robotic is ten times magnified, so you’ve got to realise and adapt … when you think you’re moving one centimetre, it looks a lot more than that on a screen and things like that, so yeah. Just that whole skill-set that I didn’t have before, so yeah, I had to learn all of that.” P2N5, Scrub Nurse.

Enhanced motor (dexterity) skills were cited to be important for the effective conduct of RAS, not dissimilar to laparoscopic surgery, while efficient surgical decision-making remained a necessity. Many interviewees viewed RAS technology as simply ‘a tool’ to do the same operation, demanding similar skills that would be required to perform other types of minimally invasive surgery. However, others highlighted that the advanced functionality of certain robotic technology allowed operators to achieve tasks which would otherwise be impossible using other types of laparoscopic technology, often with positive patient outcomes (Beliefs about Consequences):

“Then it actually became the tool which I thought made surgery better, so particularly something like unicompartmental arthroplasty…For me, it’s kind of a game changer. It’s an operation that is very technique dependent and it almost takes the technique out of it because it becomes a re-surfacing procedure that’s computer guided, so that was the next thing.” P13S, Surgeon (RAS User).

Working in a RAS theatre: Impact on cognitive processes (Dominant domains: Memory, attention & decision processes, environmental context & resources).

The conduct of RAS in theatre was reported to demand greater mental effort and utility of cognitive processes during early implementation. Whilst this may be similar for other innovations and technology, for RAS it was often as a result of a loss in tactile sensation whilst operating certain robotic platforms and the environmental changes introduced in theatre. Changes to the physical layout of the theatre cited included the inability to gain intraoperative access to the patient, and an increased distance between surgical team members. This was sometimes reported to create apprehension and anxiety amongst clinical staff, with associated feelings of ‘losing control’ (Emotion). In addition, the inability to see other clinical staff (e.g. Scrub Nurses) because the Surgeon is sometimes immersed in a RAS console provided more opportunities for distraction. Lack of mechanisms in place to accommodate for these changes could be a significant barrier to implementation:

“…you’re operating away from the patient, you have a distance operating role and you sometimes feel losing control and if that’s the thing that bothers you too much and you’re going to be very worried, you’re not going to be able to focus on the task in front of you.” P12S, Surgeon (RAS User).

Other theatre changes that were presented as challenges to early implementation included the size of certain robotic platforms and the inconvenience of it occupying a large area of physical space. Some interviewees also commented that the chances of staff getting injured by RAS equipment (e.g. being hit by a moving robot arm) were higher during initial phases of implementation. One Scrub Nurse mentioned that the changes in ways of working in a RAS theatre created resistance amongst some surgical staff during early implementation:

“There’s been a couple of times, a couple of surgeons have said, I can’t work like this and there was one occasion where one flatly refused and said, well I can’t work like this. But it was a problem we could… we overcame it, we did overcome it but at that point it was… there was resistance”. P12N Scrub Nurse.

In addition, some interviewees suggested that the time it takes to set-up theatre, such as the requirement to dock certain RAS equipment and to operate with ‘extra caution’, meant that RAS procedures take longer to conduct during the initial phase of implementation. This prolongation could form a barrier to acceptance of RAS in the early stage of adoption.

Social and environmental hospital structures: Access to RAS (social influences, environmental context & resources).

Scheduling issues and the inability to gain access to a robotic platform within a hospital was sometimes cited as a barrier to optimal early implementation. The scheduling issue could be particularly troublesome with the inability to move robotic equipment around the hospital to enable multi-specialty use of the equipment:

“A lot of the challenges have actually been about getting the disciplines to work, using it as a multidisciplinary tool and you can imagine the in-fighting that, you know, results then.” P02S, Specialty Leader.

Another factor which was also reported to hinder access was the competitiveness amongst clinicians within hospitals, and the formation of ‘elite groups’ that typically comprise those who were able to gain access because of preferential treatment from management/leaders and/or they belong to a specialty with an established reputation for conducting RAS on a regular basis. The inability to gain access to a robotic platform in order to practice RAS was also deemed to be frustrating for the Trainees:

“…I went from a robotic job where I was on the robot every week, to a robotic job where I had a consultant that was quite early on in their trajectory who wouldn’t give me the access I wanted, but the previous job gave me all the skills. And then what you create is a huge amount of frustration on everyone’s part.” P2SF17, Trainee.

Maintenance costs (CFIR costs) & relationship with industry.

One barrier which was unique to the long-term implementation of RAS as a health service included the cost of maintaining RAS equipment, sometimes highlighted with reference to relying on sole providers to sustain service provision.

Technological limitations of robotic platforms.

Some interviewees also acknowledged that there were technological limitations of certain robotic platforms that hindered optimal performance/use, which became more apparent during later phases of adoption:

“I think there are limitations to the technology, but I think that’s because the technology is probably still in development. I think that it probably doesn’t have as much utility as it can do, so I think it could be a smarter, more streamlined machine than it currently is. I think it could age things better.” P2SF17, Trainee.

Working in a RAS theatre over the longer term (Dominant domain: Memory, attention & decision processes).

Interviewees suggested that RAS demanded higher levels of concentration and adaptation to new ways of working in theatre in the early phase of implementation. Some interviewees indicated that this becomes less of a barrier during later phases of RAS adoption because repeated practice of RAS eventually engages instinctive/automatic cognitive processes and enhances efficiency in theatre.

Social and environmental hospital structures: Long-term access to RAS (Social influences, environmental context & resources).

A few interviewees mentioned that some surgeons had abandoned or stalled their use of RAS at later phases of implementation. Sometimes this was cited with reference to access limitations and the complex social structures of organisations, also cited as a barrier in early implementation, as well as a lack of long-term support from management:

“One of the biggest challenges is what we would call stalling and dabbling surgeons, so they go through their learning curve, and it’s not just about doing 50 or 100 procedures, but it’s about doing two a week or three a week or whatever it is that is required to get them to that stage. What we see is that for the first three months, they will try their hardest and essentially stick to that routine because they’ve made a huge commitment with the training upfront, after three months, often, you start to see it dropping off…” P03I, Industry stakeholder.

The importance of management support during long-term service integration was highlighted in relation to mitigating the risks and associated cost implications of RAS under-utilisation:

“But the drawback is the risk of the finance to the organisation and it’s becoming a pretty objet d’art in the corner, but that you have to manage way before, during and after, but it is a risk and a drawback; you can’t argue with that.” P2M9, Service Manager.

Perceived clinical, financial, and surgeon-related outcomes (Dominant domain: Beliefs about consequences, linked to knowledge).

As in the pre-implementation phase, many interviewees acknowledged that surgical volume of RAS is important (‘sweat the asset’), but also highlighted that some hospitals had reaped the benefits of RAS because they were able to maximise the use of robotic technology, resulting in (perceived) positive patient outcomes and increased cost-effectiveness. This was an enabler to longer-term implementation as internal beliefs about the benefits of RAS motivated sustained use. Impressions of RAS benefits included perceived positive patient outcomes and the ability to conduct more complex surgery with long term use:

“Well over the years we’ve realised that we can do more complex surgery than we used to be able to with standard minimally invasive techniques… So I think the complexity of the operation, it allows you to innovate, there’s a lot more that you can do with robotics than you can do with standard minimally invasive surgery.” P14S, Surgeon (RAS User).

However, not all interviewees shared the same beliefs. One Surgeon (RAS User) indicated that their specialty specific knowledge of the evolving evidence-base and related beliefs about the clinical outcomes of RAS discouraged their use of robotic technology in an orthopaedic setting. Likewise, the generation of evidence against the use of RAS for certain procedures impacted long-term evaluation and influenced the volume of procedures conducted over time.

As well as the clinical and cost effectiveness of RAS, interviewees also discussed the outcomes of RAS on Surgeons. The improved ergonomics achieved with RAS was reported as an enabler of long-term RAS implementation. Related to the perceived importance of maximising surgical volume, some interviewees mentioned that the continued use and resultant increase in familiarity of robotic technology can minimise stress overall in theatre, significantly reduce postural strain and enhance the longevity of a Surgeon’s career:

“… it’s better ergonomics, we as a surgeon are feeling that it’s going to give us more time to carry on operating like this, it’s ergonomically better and comfortable for the surgeons and prolongs your careers and yes, it’s much more controlled way of doing something which is very, very precise.” P12S, Surgeon (RAS User).

Perceived effects of RAS on surgical competency (Dominant domain: Skills).

Assuming that not all surgeons have equal skill sets and capability, the ability of RAS to offer some standardisation of performance was perceived as an enabler for the longer-term implementation of RAS, particularly in a public health setting. Many interviewees highlighted that the long-term use of robotic assisted technology can reduce variability in surgical performance and ‘level the playing field’ amongst surgeons considered to be low/moderate performing at baseline. Although some interviewees indicated that this would not apply to ‘expert’ surgeons with pre-existing superior skill-sets.

Rewards associated with RAS implementation (Dominant domain: Reinforcement).

RAS implementation was regarded as rewarding for many interviewees: this was associated with the belief that RAS adoption enables healthcare workers to build their professional profiles, become ‘attractive clinicians’, sometimes linked to opportunities to develop their private practice and market their affiliated organisation:

“…and thirdly actually it’s a security because if we were not to be robotic enabled, I don’t think we would be as attractive an organisation as without a robot.” P11S, RAS-user Surgeon.