Facilitators and Barriers to Adopting Robotic-Assisted Surgery: Contextualizing the Unified Theory of Acceptance and Use of Technology

MacDorman KF (2011) Facilitators and Barriers to Adopting Robotic-Assisted Surgery: Contextualizing the Unified Theory of Acceptance and Use of Technology. PLoS ONE 6(1): e16395. doi:10.1371/journal.pone.0016395 Facilitators and Barriers to Adopting Robotic-Assisted Surgery: Contextualizing the Unified Theory of Acceptance and Use of Technology Christine BenMessaoud 0 Hadi Kharrazi 0 Karl F. MacDorman 0 Peter McCulloch, University of Oxford, United Kingdom 0 1 Indiana University School of Informatics, Indianapolis, Indiana, United States of America, 2 Purdue University School of Engineering and Technology , Indianapolis, Indiana , United States of America Robotic-assisted surgical techniques are not yet well established among surgeon practice groups beyond a few surgical subspecialties. To help identify the facilitators and barriers to their adoption, this belief-elicitation study contextualized and supplemented constructs of the unified theory of acceptance and use of technology (UTAUT) in robotic-assisted surgery. Semi-structured individual interviews were conducted with 21 surgeons comprising two groups: users and nonusers. The main facilitators to adoption were Perceived Usefulness and Facilitating Conditions among both users and nonusers, followed by Attitude Toward Using Technology among users and Extrinsic Motivation among nonusers. The three main barriers to adoption for both users and nonusers were Perceived Ease of Use and Complexity, Perceived Usefulness, and Perceived Behavioral Control. This study's findings can assist surgeons, hospital and medical school administrators, and other policy makers on the proper adoption of robotic-assisted surgery and can guide future research on the development of theories and framing of hypotheses. - Funding: This study was supported by an IUPUI Signature Center grant for the Android Science Center: http://www.iupui.edu/research/signaturecenters_07_08. html. There is no grant number. The total size of the grant is $420,000; however, the grant is used only to pay the PLoS ONE publication fee. The study itself is based on an unfunded MS in health informatics thesis of the first author. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Technological innovations have spawned the development of new surgical techniques. For certain operations, open surgery has given way to standard laparoscopic and robotic-assisted surgery, in which surgeons use micro equipment through small incisions [1], [2], [3]. Nevertheless, many surgeons resist incorporating roboticassisted surgery into their routine practice. The purpose of this qualitative study is to understand the rationale behind surgeons decision to reject or adopt robotic-assisted surgical techniques. This study attempts to elicit common beliefs among surgeons to contextualize the unified theory of acceptance and use of technology (UTAUT) in robotic-assisted surgery. The elicited beliefs, obtained from in-depth interviews, are used to identify dominant UTAUT constructs. Consequently, this study attempts to answer two research questions: 1) What are the most important facilitators and 2) barriers to surgeons adoption of robotic-assisted surgery? So far, little research has been conducted on this topic and, as with other health technologies, the application of theory to the study of physicians behavior has been limited [4]. This is the first study to apply a technology acceptance model to surgeons adoption of surgical robots. Based on data from the study, the UTAUT model is modified to include two new main constructs, Attitude toward Using Technology and Leadership. This study also identifies the most important facilitators and barriers to the adoption of robotic-assisted surgery. Robotic-Assisted Surgery The following paragraphs briefly review the advantages and disadvantages of open, laparoscopic, and robot-assisted surgery (Table 1): Open Surgery. Open surgery consists of cutting skin and tissues to expose organs and other structures. Open surgery provides direct access to the operative site with depth perception and dexterity for one or more sets of hands. Open surgery is the only option for many procedures and for certain kinds of patients (e.g., obese patients, patients with prior surgeries or multiple adhesions). However, open surgery usually requires a long incision, which leaves a visible scar. The trauma caused in gaining access to the organs can result in a more painful recovery, a longer healing process, prolonged hospital stays, a higher risk of infection [5], [6], and sometimes even disability and morbidity [7]. Laparoscopic Surgery. Minimally invasive procedures have advantages for certain kind of operations [6], [8]: shorter hospital stays, reduced postoperative pain, fewer infections, and better cosmetic outcomes [3]; however, they also have disadvantages for the surgeon: limited dexterity, loss of depth perception, camera instability, awkward movement of instruments and scopes (e.g., fulcrum effect), poor ergonomics, fatigue, and miscommunication caused by the reversed image on the monitor [5], [6]. Robotic-Assisted Surgery. A surgical robot is a self-powered, computer-controlled manipulator that can be programmed to aid in positioning and manipulating surgical instruments [9]. The robotic manipulator acts as a remote arm extension governed by the surgeons movements [3], [10]. Robotic-assisted surgical techniques can enable surgeons to carry out more complex tasks than standard laparoscopic surgery and achieve better performance for specific operations [11]. Other advantages include greater dexterity and accuracy, scalable motions, camera stability, improved surgeon ergonomics, elimination of tremor, depth perception, and better patient outcomes [5], [6], [10], [12], [13]. Surgical robots also help hospitals market themselves as cutting edge [11]. However, a robotic system lacks tactile and force feedback [2], [9], affords the surgeon less control over patient safety [14], has the risk of malfunction or failure [14], has risks associated with port placement [15], is bulky, suffers incompatibilities with conventional laparoscopic instruments, has less availability of parts [13], and sometimes requires surgeon troubleshooting [14]. A further disadvantage is that a robotic procedure can take longer than a standard laparoscopic procedure because of increased setup time [16]. Robotic-assisted surgery also costs more than other techniques because of the fixed cost of the robotic system (on average $1.5 million [17], higher maintenance and support costs [12], and the cost of expensive equipment upgrades. Nevertheless, roboticassisted procedures receive the same reimbursement in the United States as laparoscopic procedures from commercial health insurance and federally administered Medicare [18]. This stu (...truncated)