Ergonomics

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The compatibility of exoskeletons in perioperative

environments and workflows: an analysis of
surgical team members’ perspectives and
workflow simulation

Alec Gonzales, Dechristian França Barbieri, Alfredo M. Carbonell, Anjali

Joseph, Divya Srinivasan & Jackie Cha

To cite this article: Alec Gonzales, Dechristian França Barbieri, Alfredo M. Carbonell, Anjali
Joseph, Divya Srinivasan & Jackie Cha (26 Jul 2023): The compatibility of exoskeletons
in perioperative environments and workflows: an analysis of surgical team members’
perspectives and workflow simulation, Ergonomics, DOI: 10.1080/00140139.2023.2240045

To link to this article: https://doi.org/10.1080/00140139.2023.2240045

Published online: 26 Jul 2023.

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ERGONOMICS
https://doi.org/10.1080/00140139.2023.2240045

The compatibility of exoskeletons in perioperative environments and

workflows: an analysis of surgical team members’ perspectives and
workflow simulation
Alec Gonzalesa, Dechristian França Barbieria, Alfredo M. Carbonellb,c, Anjali Josephd, Divya Srinivasana and
Jackie Chaa
a
Department of Industrial Engineering, Clemson University, Clemson, South Carolina, USA; bDepartment of Surgery, Prisma Health -
Upstate, Greenville, South Carolina, USA; cUniversity of South Carolina School of Medicine-Greenville, Greenville, South Carolina, USA;
d
School of Architecture, Clemson University, Clemson, South Carolina, USA

ABSTRACT ARTICLE HISTORY

Surgical team members in perioperative environments experience high physical demands. Received 1 March 2023
Interventions such as exoskeletons, external wearable devices that support users, have the Accepted 15 July 2023
potential to reduce these work-related physical demands. However, barriers such as workplace
KEYWORDS
environment and task compatibility may limit exoskeleton implementation. This study gathered
Wearable robotics;
the perspectives of 33 surgical team members: 12 surgeons, four surgical residents, seven oper­ operating room; surgeon;
ating room (OR) nurses, seven surgical technicians (STs), two central processing technicians nurse; technician; resident
(CPTs), and one infection control nurse to understand their workplace compatibility. Team mem­
bers were introduced to passive exoskeletons via demonstrations, after which surgical staff (OR
nurses, STs, and CPTs) were led through a simulated workflow walkthrough where they com­
pleted tasks representative of their workday. Five themes emerged from the interviews (work­
flow, user needs, hindrances, motivation for intervention, and acceptance) with unique
subthemes for each population. Overall, exoskeletons were largely compatible with the duties
and workflow of surgical team members.

PRACTITIONER'S SUMMARY
The goal of this study was to identify exoskeleton compatibility across various surgical team
members through a thematic analysis of interviews and a simulated workflow walkthrough.
Results revealed five unique themes (workflow, user needs, hinderances, motivation for interven­
tion, acceptance) and that exoskeletons were largely compatible with daily duties.

Abbreviations: OR: Operating Room; ST: Surgical Technician; CPT: Central Processing Technician;
WMSD: Work-related Musculoskeletal Disorder; MIS: Minimally Invasive Surgery

1. Introduction (Tavakkol et al. 2020). As summarised in Table 1, more

Surgical team members involved in the perioperative
process are particularly susceptible to physical
demands such as repetitive bending, manual-handling
tasks, and standing for long-hours that can lead to
work-related musculoskeletal disorder (WMSD) devel­
opment (Anderson and Oakman 2016; Cavdar et al.
2020). As duties vary across surgical team members
like surgeons, surgical residents, operating room (OR)
nurses, surgical technicians (STs), and central process­
ing technicians (CPTs), so does the prevalence and
body region where these WMSDs develop. Depending
on the occupation, common areas of pain among sur­
gical team members include the back and upper limbs
than half of all surgical team members showed preva­
lence of WMSD symptoms, with the lower back being
the most common location, due to the physical
demands of their job.
Although the specific tasks may differ, highly
demanding work, combined with the frequently non-
ergonomic, high stress environments in which tasks
have to be performed, is common across all surgical
team members. For example, surgeons who practice
minimally invasive surgery (MIS) (i.e. operations with
small incisions in the patient with laparoscopic instru­
ments) and open surgery often experience pain due
to long-durations of awkward postures and non-ergo­
nomic work environments (Aghilinejad et al. 2016;

CONTACT Jackie S. Cha jackie@clemson.edu Department of Industrial Engineering, Clemson University, 211 Fernow St. 268 Freeman Hall,
Clemson, South Carolina, USA
� 2023 Informa UK Limited, trading as Taylor & Francis Group
2 A. GONZALES ET AL.

Table 1. Prevalence of WMSDs in surgical team members.

Population
Surgeons
Surgical residents
Operating room nurses
Surgical technicians
Central processing technicians
Job Responsibilities Prevalence of WMSDs Source
Surgical procedures 77% reported symptoms in their neck (Dalager et al. 2019)
and lower back
50% reported pain in their back, 48% (Stucky et al. 2018)
reported pain in their neck, and 43%
in their shoulders per a systematic
review
Surgical assistance (e.g. suturing, holding 58.8% reported symptoms in their lower (Yizengaw et al. 2021)
retractors) back
97% experienced WMSD pain after a day (McQuivey et al. 2021)
in the operating room
Operating room preparation between 62% reported symptoms in their lower (Clari et al. 2021)
procedures, moving patient beds in and back
out of the operating room, positioning 67.7% had experienced low back pain at (Cavdar et al. 2020)
the patient during surgery, interacting some point in time
with the non-sterile filed during a
procedure
Operating room preparation between 84% reports symptoms in their lower (Sheikhzadeh et al. 2009)
procedures, moving patient beds in back, 74% in their ankle/foot, and 74%
and out of the operating room, in their shoulders
positioning the patient during surgery,
moving equipment carts, surgical
assistance (e.g. camera holding)
Sterilizing surgical instruments and 50% reported symptoms in the neck, (Moreira da-Silva et al.
packaging them prior to procedures lower back, shoulders, wrists, knees 2021)
75% reported symptoms in their lower (Nino, Marchak, and
back Claudio 2020)

Athanasiadis et al. 2021; Stucky et al. 2018). Surgical
residents are even more susceptible to these risks as
those with lower experience levels have been found
to experience greater WMSD symptoms (Khan et al.
2021; Thurston et al. 2022). OR nurses and STs fre­
quently perform tasks such as pulling and pushing,
repetitive movements, and lifting heavy loads that
contribute to their pain (Abdollahi et al. 2020; Cavdar
€ster et al. 2020).
et al. 2020; Choobineh et al. 2010; Tro
CPTs face high demands from performing repetitive
movements, congested workspaces, and a short time
frame to clean instruments between cases coupled
with an inadequate amount of staff that can lead to
CPTs rushing through their job duties in ways that
contribute to WMSDs (Alfred et al. 2020; Brooks,
Williams, and Gorbenko 2019).
To mitigate potential WMSDs, interventions inside
and outside the OR have been adopted to reduce
pain and injuries among healthcare professionals.
These come in the form of changes to the working
environment, training, and supportive technologies
(Ali, Lam, and Coonar 2018; Al-Qaisi et al. 2020;
Disbrow et al. 2018; Gilbert 2009; Hwang et al. 2019;
Monfared et al. 2022; Rodr�ıguez-Sanju�an et al. 2016;
�St�adler et al. 2021; Z�arate Rodriguez et al. 2019).
Robotic-assisted surgical systems offer improved work­
ing ergonomics and have resulted in less reported
pain and fatigue in common areas (e.g. shoulders,
back, legs) for the surgeons (Monfared et al. 2022;
Rodr�ıguez-Sanju�an et al. 2016; �St�adler et al. 2021;
Z�arate Rodriguez et al. 2019). However, robotic
procedures can lead to an increased cost of care and
operating times (Olavarria et al. 2020; H. Yu et al.
2012). Early opportunities for robotic procedure train­
ing and proper OR ergonomics can help surgical resi­
dents and trainees reduce, or delay, the development
of WMSDs (Disbrow et al. 2018). Slide boards and
tilted tables are current interventions that reduce
physical demands for OR nurses and STs during
patient transfer (Al-Qaisi et al. 2020; Hwang et al.
2019). Yet, manual lifting without equipment often
occurs due is to the additional time it takes to use
these devices (Al-Qaisi et al. 2020; Kucera et al. 2019;
Noble and Sweeney 2018). Physical demands that
come with assisting MIS can be diverted from the
assistant (i.e. trainee or ST) to various supportive
technologies such as devices to hold laparoscopic
cameras (Ali, Lam, and Coonar 2018; Gilbert 2009).
Although promising, these interventions often lead to
longer setup and procedure times (Kucera et al. 2019;
Noble and Sweeney 2018; Olavarria et al. 2020). Since
surgical team members often operate in dynamic
environments, they require an intervention that inte­
grates with their dynamic tasks. As such, despite all
these interventions, WMSDs are still highly prevalent
in these populations, and continue to pose a serious
threat to the health and safety of the workers,
thereby making the need for a more dynamic inter­
vention both critical and urgent.
Exoskeletons could be a potential intervention to
support surgical teams. Passive exoskeletons are wear­
able mechanical devices that can redistribute loads

from a particular body region to others (e.g. from
shoulders to back and legs), or provide external tor­
ques and/or structural support about specific body
joints (e.g. hips/trunk), thereby reducing the physical
demands on the affected body regions. Exoskeletons
have recently been considered for surgeons and surgi­
cal staff due to their ability to reduce physical
demands for healthcare workers (Aoki et al. 2020; Cha
et al. 2020; Hwang et al. 2021; Liu et al. 2018;
O’Connor 2021; Tetteh, Hallbeck, and Mirka 2022;
Tro€ster et al. 2020; Wang et al. 2021; Zheng, Hawke,
and Evans 2022). Shoulder-support and back-support
exoskeletons have shown to reduce muscle activity,
fatigue, and self-reported pain and discomfort during
simulated surgical tasks (Liu et al. 2018; Tetteh,
Hallbeck, and Mirka 2022). Specifically, shoulder-sup­
port exoskeletons have shown to reduce muscle activ­
ity in the dominant deltoid muscle groups during
simulated laparoscopic tasks representative of bariatric
and vascular surgery; they also have the potential to
support push and pull tasks commonly performed by
surgical staff (Aoki et al. 2020; Tetteh, Hallbeck, and
Mirka 2022; Tro €ster et al. 2020). Similarly, back-support
exoskeletons have shown to reduce trunk extensor
muscle activity during patient transfer tasks (Hwang
et al. 2021). Although studies have shown exoskele­
tons as a potential intervention to reduce physical
demands, these were mostly laboratory simulations of
clinical tasks. The potential for exoskeletons as an
actual intervention in surgical environments is still an
open question as few studies have examined exoskel­
eton compatibility with the OR environment.
Barriers identified by a previous study such as add­
itional time to don and doff the devices, sterility, stor­
age of the devices, and overall workflow disruptions,
could hinder the implementation of exoskeletons in OR
environments (Cha et al. 2020). Similarly, despite finding
statistically significant benefits of back-support exoskele­
tons for caregivers, Hwang et al. (2021) found that two
of the three evaluated exoskeletons received an
unacceptable usability rating (i.e. system usability ratings
of 50-60) (Hwang et al. 2021). This barrier to ease-of-use
could also deter surgical team members from using exo­
skeletons, as this has been found to be an important
factor especially for nurses (Zheng, Hawke, and Evans
2022). Although Cha et al. (2020) provides foundational
themes for understanding exoskeleton compatibility
with surgical team members that might influence ease-
of-use, the consideration of exoskeleton-use in actual
OR environments could provide these populations a
better perspective of its compatibility with their work­
flow. While these studies have considered the
ERGONOMICS 3
perspectives of surgical teams (e.g. surgeons, surgical
residents, and nurses), other roles in perioperative envi­
ronments such as those of STs and CPTs should be con­
sidered to better understand exoskeleton compatibility
in ORs. Additional population specific themes could pro­
vide further insight into the intricacies of each surgical
team member’s unique job demands and requirements.
As such, this study aims to understand acceptance
factors for exoskeletons for potential implementation
in OR environments. To accomplish this, surgical team
members were given demonstration time with back-
and shoulder-support exoskeletons and were subse­
quently interviewed to gain insight into the devices’
compatibility with their work duties. Specific user
needs and workflow considerations were identified for
five surgical team populations: 1) surgeons, 2) surgical
residents, 3) OR nurses, 4) STs, and 5) CPTs using a
simulated workflow walkthrough method.
2. Methods
2.1. Study participants
Participants from a large regional healthcare system in
the southeast region of the United States were recruited
for this study. Surgeon and surgical resident participants
were recruited through word of mouth from a partici­
pating surgeon. The remaining surgical team members
(e.g. OR nurses, STs, and CPTs) were recruited through
the implant coordinator in the perioperative services. A
total of 34 participants (18 male, 16 female) participated
in this study, including 11 surgeons (i.e. seven MIS bari­
atric surgeons, one trauma surgeon, two vascular sur­
geons, and one orthopaedic surgeon), one MIS bariatric
fellow, six surgical residents, seven OR nurses, seven
STs, and two CPTs. The total number of study partici­
pants included employees who were interested in par­
ticipating at the time of this study. This research was
approved by the Institutional Review Board and written
informed consent was obtained from all participants
prior to any data collection.
2.2. Procedure
Surgical team members were first introduced to the
exoskeleton devices through demonstrations and were
subsequently interviewed about their impressions.
Further insight was captured through a follow-up
simulated workflow walkthrough.
2.2.1. Exoskeleton demonstration
Each population was given the opportunity to interact
with the exoskeletons through an hour-long
4 A. GONZALES ET AL.

demonstration event. During this demonstration, par­
ticipants had the opportunity to don the exoskeletons
with the assistance of trained researchers. Although
they did not complete any work tasks, participants
were asked to self-report their impressions about the
devices’ comfort and compatibility with their job
duties. Separate demonstrations were completed for
1) surgeons and fellows, 2) surgical residents, and 3)
the remaining surgical staff (i.e. OR nurses, STs, and
CPTs). For each demonstration, study team members
explained the purpose of the study and showcased
two back-support exoskeletons: 1) SuitX BackXTM
(Ottobock SE & Co. KGaA, Duderstadt, Germany) and
2) HeroWear Apex Exosuit (Herowear, Nashville, TN,
USA), and two shoulder-support exoskeletons: 1)
Paexo Shoulder (Ottobock SE & Co. KGaA,
Duderstadt, Germany) and 2) Ekso EVOTM (Ekso
Bionics, Inc., San Rafael, CA, USA) (Figure 1). These
exoskeletons were selected due to their potential to
support the surgical teams’ work tasks, based on ini­
tial observations of surgical teams’ work duties, and
access to these devices.

Figure 1. Exoskeletons included in the demonstration event. Two back-support exoskeletons: A) SuitX BackXTM and B) HeroWear
Apex Exosuit. Two shoulder-support exoskeletons: C) Paexo Shoulder, and D) Ekso EvoTM.
An example of a SuitX BackX back-support exoskeleton.
An example of a HeroWear Apex Exosuit back-support exoskeleton.
An example of a Paexo shoulder-support exoskeleton.
An example of an Ekso Evo shoulder-support exoskeleton.
 ERGONOMICS 5

2.2.2. Surveys & interviews procedures and how the devices’ sterilisation protocols
2.2.2.1. Surveys. Participants completed a series of sur­ would vary between users were addressed.
veys at the beginning of interviews or focus groups.
Surveys included a modified version of the Nordic 2.2.3. Simulated workflow walkthrough simulation
Musculoskeletal Disorder questionnaire to measure self- Surgical staff (i.e. OR nurses, STs, CPTs) raised the
reported pain throughout the user’s body (Kuorinka importance of understanding how the exoskeletons
et al. 1987). Participants reported pain and discomfort affected their workflow during their interviews. As a
frequency over the past three months (e.g. never, 1- result, a simulated workflow walkthrough was created
7 days, 8-30 days, 30þ days, every day) and level of where these populations had the opportunity to wear
pain intensity over the last seven days on a 0-10 scale the exoskeleton while performing simulated tasks rep­
(Dalager et al. 2019; Szeto et al. 2009). In addition, the resentative of their workday. Based on initial conversa­
short version of the International Physical Activity tions with surgical team members during the
Questionnaire (IPAQ) was used to record self-reported exoskeleton demonstration, a back-support exoskel­
physical activity (Craig et al. 2003). Users reported vig­ eton was identified to best support OR nurses (Suit-X
orous and moderate physical activity as well as walking BackX TM) and shoulder support exoskeletons (Ekso
in minutes over the past seven days. Physical activity EVO TM and Ottobock Paexo Shoulder) were identified
was calculated and categorised based on metabolic to best support STs and CPTs respectively.
equivalents (METs) where one MET is the amount of During the simulated workflow, one member of each
energy spent sitting. An adapted workstyle question­ surgical staff population volunteered and donned the
naire was completed to gather the behavioural and selected exoskeleton and completed simulated tasks;
cognitive factors that influence worker responses to participants not wearing exoskeletons shadowed the
demanding physical work (Feuerstein and Nicholas surgical team member conducting the tasks and com­
2006; Szeto et al. 2009). This questionnaire consisted of mented on additional workflow aspects. Simulated work­
11 questions on a five-point scale from strongly dis­ flow tasks (Table 2) were selected from preliminary
agree to strongly agree. Demographic information was observations and varied between populations. After
also collected, and job-specific questions (e.g. surgeons completing the simulated task, the participants wearing
were asked: what is your surgical specialty) were the exoskeleton were then asked questions regarding
adapted for each population. how the exoskeletons affected their workflow and work
tasks (Appendix B). Observing participants were then
2.2.2.2. Surgical team interviews. Participants asked the same questions to gather additional insights.
responded to questions adapted from Cha et al. (2020) The simulated sessions were audio recorded with an
that aimed to establish perspectives of how compatible audio recording device (Zoom Corporation, Chiyoda City,
exoskeletons would be with their job duties and work­ Tokyo, Japan) and video recorded with GoPro Hero 10
flow, as well as potential limitations of the technology recorders (GoPro, San Mateo, CA).
that needed to be overcome (Appendix A). Surgeons
and surgical residents completed one-on-one interviews Table 2. Simulated workflow tasks for surgical staff.
(virtually or in-person) while the remaining surgical Population Tasks
team members (e.g. OR nurses, STs, and CPTs) com­ OR nurses 1. Exoskeleton donning
pleted in-person focus groups of two to five individuals 2. OR prep
3. Patient transfer from pre-operative area to OR
from the same department. All interviews and focus 4. Four-person patient transfer from bed
groups were audio-video recorded. 5. Surgery assistance
6. Supply maintenance
7. Informal break (lunch and restroom)
2.2.2.3. Infection control interview. To understand 8. Exoskeleton doffing
STs 1. Exoskeleton donning
the entire adoption workflow, an infection control 2. Moving equipment carts
nurse from the same regional hospital was interviewed 3. OR prep
4. Surgery assistance
in-person to better understand sterilisation and stor­ 5. Informal break (lunch and restroom)
age of the exoskeleton devices. The exoskeletons’ 6. Exoskeleton doffing
CPTs 1. Exoskeleton donning
manuals were provided to the nurse and information 2. Lifting equipment crates
regarding the exoskeletons’ materials, potential steril­ 3. Packaging equipment
4. Storing equipment crates
isation procedures, and available cleaning equipment 5. Moving equipment carts
at the healthcare centre’s disposal were discussed. 6. Informal break (lunch and restroom)
Further, maintaining the devices sterility during OR 7. Exoskeleton doffing
6 A. GONZALES ET AL.
2.3 Data analysis
Survey data was aggregated and analysed for each
population. The Nordic Musculoskeletal Disorder ques­
tionnaire frequency and intensity of pain was con­
verted to a percentage for comparison. The number of
participants who reported pain in each region was
also converted to a percentage.
An inductive thematic analysis was conducted to
capture surgical team members’ perspectives of exo­
skeleton compatibility with their job duties. Video and
audio recordings were first transcribed by a profes­
sional transcription service (Rev, Austin, TX). The quali­
tative analysis was conducted using Atlas.ti (ATLAS.ti
Scientific Software Development GmbH, Berlin,
Germany). Three raters independently coded tran­
scripts from each population. The first three transcripts
for each population (two for CPT) were reviewed and
coded independently by each rater. Raters then came
together to assess for inter-coder agreement for each
population and resolve any discrepancies between the
codes. The aim of this process was to reach thematic
saturation based on the data saturation model
explained by Saunders et al. (2018) where the focus is
to identify redundancy of data (Saunders et al. 2018).
If saturation still was not met, where new themes
emerged, the raters independently went through an
additional transcript and followed the same process
until saturation was met and agreed upon. As a result,
a unique codebook was created for each population.
The remaining transcripts for each population were
then coded based on the established codebook. Each
transcript was then reviewed by the raters to confirm
it was coded appropriately. After the first seven sur­
geons, seven OR nurses, seven STs, and two CPTs
were interviewed, adjustments were made to the
interview questions to capture additional information
about the participants’ daily workflow. Four surgeons
and four surgical residents were interviewed with
these additional questions. As a result, two raters fol­
lowed the same process as above and additional
themes emerged. The entirety of the transcripts was
recoded, and the new themes were included where
appropriate.
3. Results
3.1. Survey results
Demographic results are shown in Table 3. The MIS fel­
low was included with the surgeon population due to
their similarity in work demands. While demographics
and survey responses were recorded for all six residents,
Table 3. Participant mean (SD) demographics.
Age Experience Gender
Population (years) (years) (male, female)
Surgeons (n ¼ 12) 43 (6) 11 (6) 11, 1
Surgical residents (n ¼ 6) 29 (2) 3 (2) 5, 1
OR Nurses (n ¼ 7) 40 (13) 14 (13) 2, 5
ST (n ¼ 7) 51 (6) 17 (10) 1, 6
CPT (n ¼ 2) 54 (8) 19 (3) 1, 1
only four were interviewed due to time constraints with
their schedules. All populations were categorised as low
physical activity (i.e. less than 600 MET-min/week)
according to the IPAQ results (Appendix C). Distribution
of work experience are shown in Figure 2.
Participants in each population completed unique
work duties, as found in Table 1, respective of their
position. Results from the Nordic musculoskeletal
questionnaire (Figure 3) show that, in the last three
months, surgeons felt the most pain in their neck and
shoulders with 33% feeling neck pain every day and
42% feeling shoulder pain for 30þ days (Appendix D).
Surgeons felt the largest intensity of pain in their neck
(37%) and lower back (36%) (Appendix E). Responses
from 33% of surgical residents report they felt the
most pain in their shoulders, upper back, and lower
back for 8-30 days. Surgical residents felt the strongest
pain in their neck (22%), shoulders (20%), and lower
back (20%). Responses from 29% of OR nurses report
they felt pain in their upper back and lower back for
8-30 days. OR nurses reported the strongest pain in
their shoulders (22%), and lower back (22%). STs
reported pain in their neck (50%), shoulders (29%),
upper back (33%), and lower back (29%) for 30þ days.
STs reported the largest pain intensity in their should­
ers (53%) and lower back (50%). CPTs self-reported
pain across all body parts (50%) for 1-7 days.
The workstyle questionnaire can be found in
Appendix F and responses in Appendix G. Responses
show that most surgical team members are aware of
the physical toll and potential WMSD repercussions
their job has on them. Yet, they continue to work
through the pain in a way that contributes to it
because of the high expectations they have of
themselves.
3.2. Thematic analysis results
Five primary themes emerged across all surgical team
members: (1) workflow, (2) user needs, (3) hindrances,
(4) motivation for intervention, and (5) acceptance.
Codes under the (1) workflow theme were defined
based on how the exoskeletons would fit in and inter­
act with the user’s workday. Codes in the (2) user
needs theme acknowledged what the user needs from

Figure 2. Years of working experience for each population.
Figure 3. Frequency of high prevalent areas of self-reported pain for each population according to Nordic musculoskeletal ques­
tionnaire responses. Surgeon, n ¼ 12; surgical resident, n ¼ 4; OR nurses, n ¼ 7; ST, n ¼ 7; CPT, n ¼ 2.
this device, when the surgical team member would
use it, and who would use it. Codes from the (3) hin­
drances theme addressed issues that would prevent
the exoskeleton from being implemented. Codes from
the (4) motivation for intervention theme address why
exoskeletons are needed. This could be root issues in
the OR that led to the need for exoskeleton interven­
tions, or positive outcomes that could be gained from
their implementation. Codes in the (5) acceptance
theme address factors that would facilitate exoskeleton
adoption in the OR. From these primary themes, sub­
themes emerged that were unique to each population
(Table 4). Primary themes are represented by the cor­
responding number in the primary themes column.
Subthemes are represented as letters in the sub­
theme’s column. Table 5 summarises the percent of
total themes that emerged for each population (e.g.
surgeons discussed 80% of the total identified sub­
themes for workflow).
ERGONOMICS 7
3.2.1. Theme 1: Workflow
All populations addressed the process their healthcare
system would follow should there be a malfunction or
inclement incident with the exoskeleton (1a). Most
surgeons agreed the exoskeleton would fit into their
workday (1b). STs were the most concerned with add­
itional spatial constraints from the device (1c) com­
pared to the other populations. All populations except
for CPTs recognised the donning/doffing process of
the exoskeleton as a factor to consider. OR nurses
acknowledged how time sensitive their workday is
(1e) and how exoskeletons may affect their workflow.
Specifically, they mentioned, ‘I feel like time is a big
thing. Everything’s a time saver, and so you’re … try­
ing to do things quickly’. Exactly how the exoskeletons
would be stored and cleaned was minimally addressed
by the surgeons and STs (1f). No consensus for
whether the exoskeleton would be individualised or
shared was reached among surgical residents as 25%
8 A. GONZALES ET AL.

Table 4. Themes and Subthemes of Adoption Factors of Exoskeletons Across Surgical Team Members.
Surgical
Surgeon, Residents, OR Nurses, ST, CPT,
Primary themes Subthemes Tertiary themes n ¼ 12 (%) n ¼ 4 (%) n ¼ 7 (%) n ¼ 7 (%) n ¼ 2 (%)
1.Workflow (a.) Unexpected and ✓ (100) ✓ (100) ✓ (71) ✓ (71) ✓ (50)
adverse events
(b.) Job compatibility ✓ (67) ✓ (50) – ✓ (43) ✓ (50)
(c.) Spatial constraint ✓ (25) – ✓ (14) ✓ (57) –
(d.) Donning/doffing ✓ (58) ✓ (100) ✓ (57) ✓ (14) –
(e.) Time is essential – ✓ (75) ✓ (86) – –
(f.) Storage/ maintenance ✓ (42) ✓ (100) – ✓ (14) –
(h.) Individual device ✓ (17) ✓ (25) – – –
(i.) Shared device ✓ (17) ✓ (25) – – –
(j.) Dynamic work ✓ (42) ✓ (100) – – –
schedule
(k.) Does not expand job – ✓ (25) – – –
compatibilities
2. User needs (a.) Benefits surgical team ✓ (67) ✓ (75) ✓ (71) ✓ (43) ✓ (50)
(b.) Benefits my position ✓ (75) ✓ (75) ✓ (14) ✓ (29) –
(c.) Requirements of i. Anthropometric ✓ (17) – – ✓ (29) –
exoskeletons compatibility
ii. Comfortable ✓ (25) – – ✓ (14) –
iii. Low profile ✓ (8) – – – –
iv. Additional support ✓ (8) ✓ (50) – – –
(d.) Use cases i. Task specific ✓ (92) ✓ (100) – ✓ (57) ✓ (100)
ii. Constant use ✓ (17) ✓ (50) – ✓ (57) ✓ (50)
iii. Duration of procedure ✓ (67) ✓ (75) – – –
(e.) Benefits from back ✓ (25) – ✓ (43) – –
support
(f.) Benefits from shoulder – – ✓ (14) – –
support
3.Hinderances (a.) Current state of i. Unfamiliarity with ✓ (17) – ✓ (14) ✓ (14) ✓ (50)
technology exoskeleton
ii. Too hot ✓ (25) – ✓ (14) ✓ (14) –
iii. ✓ (67) ✓ (75) ✓ (43) ✓ (29) –
Cumbersome
iv. Weight ✓ (17) – – ✓ (29) ✓ (100)
v. Gown compatibility ✓ (42) ✓ (25) – ✓ (43) –
(b.) Social resistance ✓ (25) – – – –
(c.) Time is prioritised over – – ✓ (43) – –
safety
(d.) No ergonomic issues ✓ (8) ✓ (25) – ✓ (14) –
4. Motivation for (a.) Alternative ✓ (83) ✓ (75) ✓ (71) ✓ (57) ✓ (50)
intervention intervention
(b.) Training ✓ (100) ✓ (100) ✓ (100) ✓ (71) ✓ (100)
(c.) Retention ✓ (83) ✓ (100) ✓ (86) ✓ (71) ✓ (50)
(d.) Symptoms of MSDs i. Persistent discomfort ✓ (50) ✓ (50) ✓ (71) ✓ (71) –
ii. Back pain – – ✓ (29) ✓ (14) ✓ (50)
iii. Shoulder pain – – ✓ (14) – –
iv. Neck pain ✓ (42) – – – –
v. Feet pain – – ✓ (29) – –
vi. Lower body pain – – ✓ (29) – –
vii. Current MSDs – – – ✓ (14) –
viii. Hand pain – ✓ (25)
(e.) Treatment for MSDs ✓ (17) – – ✓ (14) –
(f.) Physical demands ✓ (83) ✓ (50) – ✓ (29) ✓ (50)
(g.) Operating room ✓ (33) ✓ (25) – – –
ergonomics
(h.) Decrease of – – ✓ (29) – –
supplies/injuries
(i.) Healthcare is dynamic – ✓ (50) ✓ (14) – –
(j.) Inadequate equipment – ✓ (50) – – –
5.Acceptance (a.) Value ✓ (83) ✓ (75) ✓ (86) ✓ (71) ✓ (100)
(b.) Adapt to technology ✓ (58) ✓ (100) ✓ (57) ✓ (14) –
(c.) Educated on ✓ (8) – ✓ (57) ✓ (57) ✓ (50)
technology
(d.) Perceived benefits i. Decreased fatigue/pain ✓ (25) ✓ (75) – ✓ (71) ✓ (100)
ii. Improved ✓ (42) ✓ (25) ✓ (43) ✓ (14) –
ergonomics/posture
iii. Mental health ✓ (17) – – – –
iv. Neutral – ✓ (50) ✓ (14) – –
(e.) Evidence of usefulness ✓ (50) ✓ (75) – – ✓ (50)
(f.) Individual perception i. Outlook ✓ (50) ✓ (75) – – –
(continued)
 ERGONOMICS 9

Table 4. Continued.
Surgical
Surgeon, Residents, OR Nurses, ST, CPT,
Primary themes Subthemes Tertiary themes n ¼ 12 (%) n ¼ 4 (%) n ¼ 7 (%) n ¼ 7 (%) n ¼ 2 (%)
ii. Worker safety is – – ✓ (29) – –
important
iii. The institution does – – ✓ (14) – –
not care about
employees
(g.) Exoskeleton exposure – ✓ (75) ✓ (29) – ✓ (100)
(h.) Administration process ✓ (75) ✓ (75) – – –
(i.) Considers worker input – – ✓ (29) – –
(j.) Team buy-in – ✓ (50) – – –
(k.) Creates interest – ✓ (25) – – –
(l.) Experience matters ✓ (17) ✓ (25) – – –
(m.) Reps initiate ✓ (8) ✓ (50) – – –
(n.) Slow implementation – ✓ (50) – – –
(o.) Individual choice – ✓ (75) – – –

Table 5. Percentage of subthemes addressed by each popula­ 3.2.3. Theme 3: Hinderances

tion for each primary theme. Multiple technological limitations of the devices were
Surgical identified that may hinder implementation (3a). The
Primary themes Surgeon Residents OR Nurse ST CPT largest of these concerns was the exoskeleton’s
Workflow 80 90 40 50 20 weight, that they could be cumbersome, and may not
User needs 83 50 67 67 33
Hinderances 75 50 50 50 50 be compatible with sterile gowns. Surgeons believed
Motivation for intervention 70 80 60 60 40 that there may be social resistance to the implementa­
Acceptance 60 87 47 27 27
tion of exoskeletons (3b). OR nurses believed that
time spent completing tasks was currently prioritised
believed it would be individualised, while another over their safety thus overshadowing the need for
25% believed it would be shared (1h and 1i). All surgi­ exoskeletons (3c). This was emphasised by one nurse
cal residents thought the dynamic work schedules of who explained, ‘When the goal is to turn over rooms
surgery might affect their use of the exoskeleton (1j). as quickly as possible, then you do what you gotta do
One surgical resident expanded on this saying, ‘your to get it done’. A small population of STs believed
cases can be 30 minutes and they can be five hours, there was currently no issues in the OR that would
or eight hours’. Further, 25% of surgical residents did call for them to need exoskeletons (3d).
not believe exoskeletons would expand their job com­
patibility (1k) such as completing additional work 3.2.4. Theme 4: Motivation for intervention
duties. Most of the surgeons interviewed addressed robotics
(4a) as a potential substitute for exoskeletons but
mentioned caveats such as their limited availability
3.2.2. Theme 2: User needs and cost. The current training programs, and their lim­
Surgeons and OR nurses overwhelmingly believed the itations, were acknowledged by 100% of surgeons and
technology would benefit those around them (2a) OR nurses (4b). The potential for exoskeletons to help
while 75% of surgeons believed it would benefit their with workforce retention (4c) was mentioned by most
duties specifically (2b). One surgeon said, ‘I think it of the interviewed populations, although its connota­
would be useful for all of us’; additionally, they tion was mixed. All the populations mentioned pain in
believed they needed it the most stating, ‘I think it various locations (4d). One ST highlights this issue say­
would be me. You know, to be totally honest with ing, ‘I’ve developed, you know, physical injuries, not
you’. Surgeons believed the devices would be easier all at one time, but like of repetitive use’. Several sur­
to adopt if it addressed user needs (2c). Most of the geons and STs mentioned they had already received
surgical team members believed that exoskeletons treatment (4e) to ease the pain and discomfort they
would be used for task specific duties instead of all were feeling. Surgeons largely addressed the physical
the time (2d). Out of those who stated a preference, demands of their work that could contribute to pain
43% of OR nurses believed they would benefit from they were feeling (4f) and 33% attributed it to the cur­
back support (2e) while 14% believed they would rent, or lack of, ergonomics of the OR (4 g). OR nurses
benefit from shoulder support (2f). felt exoskeletons were necessary to reduce the
10 A. GONZALES ET AL.
amount of supply use and injuries (4h) and 14% men­
tioned they would fit in due to the healthcare field
constantly growing and adapting (4i). Half of the sur­
gical residents thought that outdated, and unergo­
nomic, equipment caused them to contort to bodies
in ways that may lead to WMSD (4j). One surgical resi­
dent explained her thoughts on the issue saying, ‘we
all just, like, create ways to use it. But the actual
design is improper for its use’.
3.2.5. Theme 5: Acceptance
Over 70% of each population addressed how impor­
tant the value of exoskeletons was, with respect to its
cost and benefits, for adoption (5a). One surgeon
emphasised this by saying, ‘if it’s a new cost we’re
gonna incur, but it keeps employees healthy, or it
increases efficiency, well then it’s worth the cost’.
Most surgeons were willing to adapt to exoskeletons if
the devices proved to be helpful (5b). Over half of OR
nurses and STs acknowledged how important proper
training with the devices was for implementation (5c).
Most surgical team members found that the most
likely benefits of the device would be decreased pain
and improved posture (5d). Surgeons would like to
see quantitative proof that exoskeletons reduced
physical demands before implementing them (5e).
How individuals view new technology, the culture of
their workspace, and personal mindsets were deemed
important factors to consider (5f). All CPTs believed
they needed more exposure to exoskeletons to give a
sound opinion on their usefulness (5 g). Most surgeons
mentioned the role of an ‘expert’ committee that eval­
uates new technology and ultimately decides if they
should be implemented (5h). OR nurses stated that
their opinion on the devices would be taken into con­
sideration if they were to be implemented (5i). Half of
the surgical residents agreed that team buy-in was
important to facilitate exoskeleton integration in the
OR (5j), but that implementation would likely be slow
and trickle down to other users (5n). The importance
of team buy-in is stated as, ‘[if] you can get enough
people on board, that would be something that’d defin­
itely be adopted’. Half also mentioned that manufac­
turer representatives are important to integration as
they often initiate its use (5 m). Surgical residents
thought that exoskeletons may increase outside inter­
est in their healthcare centre, 25% believed that their
current lack of surgery experience contributes to the
amount of WMSD symptoms they feel when perform­
ing cases (5 l). Most of the surgical residents believed
that it would ultimately be up to the individual if they
would want to wear the exoskeleton during the work
duties (5o).
3.2.6. Infection control nurse
Interview results of the infection control nurse reveal
that the device would likely be simple enough to
implement. The healthcare centre was mostly capable
of sanitising and storing the devices per their respect­
ive manufacturer guidelines. However, alternative
cleaning agents other than the recommended ones
would likely be used to account for healthcare stand­
ards (e.g. anti-viral). Specific cleaning agents were sug­
gested that would properly sanitise the device
without degrading the materials. The infection control
nurse suggested that the devices could likely be
wiped down between users if the exoskeleton was
worn under gowns. Intensive cleaning would only
need to take place in the instance where the device is
exposed to bodily or chemical fluids. Certain sections
of the device, such as padded sections, would pose
some issues as they were recommended to be air-
dried but their healthcare centre currently has no dry-
air sanitisation machine to expedite the process. The
use of ultra-violet lights was also suggested as an
alternative form of sanitisation. As for storage, the
infection control nurse suggested that the device be
stored in a central location that is easily accessible to
all the ORs, or where the lead gowns are stored. This
was recommended partially because they would be
sanitised in a similar fashion, but also because they
have similar form factors. It was also suggested that
the exoskeletons would likely be hung on the wall or
a cart.
3.3. Workflow simulation walkthrough results
3.3.1. Workflow simulation
Results from the workflow simulation (Figure 4)
showed the exoskeleton was largely compatible for
each surgical staff population (Table 6). OR nurses
believed the back-support exoskeleton would be com­
patible with their daily duties and noted they would
likely leave it activated all day. Specifically, they
believed tasks that required repetitive bending and
pushing and pulling tasks would benefit from exoskel­
eton support. The exoskeleton was also noted as
being helpful when wearing a lead gown. The OR
nurses did not believe that donning and doffing the
device would take enough time to deter use.
However, they did note that if they wore the exoskel­
eton, they would wear it all day. During restroom or
lunch breaks, the OR nurses believed they would doff
 ERGONOMICS 11

Figure 4. Simulated workflow walkthrough: A) OR nurse conducting a patient transfer task while wearing a back-support exoskel­
eton, B) OR nurse moving a patient bed while wearing a back-support exoskeleton, C), ST simulates moving an equipment cart
while wearing a shoulder-support exoskeleton, D) ST simulates holding a laparoscopic camera while wearing a shoulder-support
exoskeleton underneath a sterility gown, E) CPT moving an equipment crate while wearing a shoulder-support exoskeleton, F)
CPT sanitising surgical tools while wearing a shoulder-support exoskeleton.

the exoskeleton and leave it in the locker room. The were not used to the equipment extending from
OR nurses did not think it affected their posture or them.
range of motion, but it was observed that they OR nurses believed that the exoskeletons would be
bumped into their environment several times as they sanitised with disinfectant wipes or sterilised using
12 A. GONZALES ET AL.
Table 6. Workflow simulation responses for exoskeleton use.
Surgical team member Tasks for exoskeleton use
Operating room nurse Bending and pushing Would wear exoskeleton all
Surgical technician Overhead lifting and Would wear it for specific
laparoscopic camera
holding
Central processing technician Daily repetitive tasks Would wear it all day.
ultra-violet light but could not say for certain due to
the multiple materials used in the device (e.g. hard,
and soft surfaces). They believed the exoskeleton
would be stored in a central location in the OR.
STs believed the shoulder-support exoskeleton
could be useful for specific tasks and believed it took
an acceptable amount of time to don and doff. They
felt it would be beneficial for tasks that required them
to lift above their head or when they would hold the
laparoscope during MIS. However, they noted that the
device was restrictive during other tasks such as mov­
ing equipment boxes to the equipment carts or may
encroach on the sterile space below their elbows
when they scrub in. Further, the exoskeleton caught
on the gown as the ST scrubbed in. As such, they
would like to activate and deactivate the exoskeleton
as needed for their tasks. They also mentioned that it
inhibits bending. The ST noted that it may be difficult
to manoeuvre in and out of the storage room at this
facility. Additionally, they noted that the support they
felt when their arms were at their side was disruptive
as the support was too strong (i.e. in its medium-sup­
port setting). STs believed the exoskeletons would be
sanitised with disinfectant wipes and would be stored
in the OR for sterility purposes.
CPTs believed the shoulder-support exoskeleton
would be largely beneficial, and were compatible, with
their daily tasks. CPTs did not believe the exoskeleton
interfered with their workflow and took an acceptable
amount of time to don and doff. The CPT noted that
they were more aware of the exoskeleton on their
back but did not believe it would cause additional
bumps with the environment or co-workers. CPTs
noted they would remove the exoskeletons, and add­
itional personal protective equipment, every time they
leave the CPD. CPTs believed the exoskeletons would
be stored in the locker room where they don their
scrubs.
Effects on performance /
Wear pattern range of motion Storage and disinfection
Would not adversely affect Stored in a central location
day. Temporary storage range of motion. Lead in the operating room.
(i.e. restroom breaks) gown compatible. Would be sanitised with
would be the locker disinfectant wipes or
room. ultra-violet light.
Potentially restrictive or Stored in the operating
tasks intrusive of sterile zones. room. Would be
Exoskeleton would sanitised with
reduce mobility. Support disinfectant wipes.
was too strong.
Did not affect performance. Stored in the locker room
Would remove when where they don their
leaving the central scrubs.
processing department.
4. Discussion
This study aimed to create a comprehensive analysis
of all surgical team members’ perspectives of exoskel­
eton compatibility in their workplace. Five primary
themes were identified that captured surgical team
members’ perceptions of exoskeleton adoption in sur­
gery including workflow, user needs, hinderances,
motivation for intervention, and acceptance. Aligned
with the findings of Cha et al. (2020), the results of
interviews with surgical team members show that exo­
skeletons are largely compatible with their work duties
and could serve as an intervention to reduce WMSD
symptoms. Unique themes were identified for each
surgical team member as well as how often this
theme occurred amongst participants. Further, key
workflow components for different surgical popula­
tions such as how these devices fit in with the daily
duties of surgical staff were synthesised from the
simulated walkthrough. This allowed participants to
get a clear understanding of how exoskeletons would
assist their work duties and where specific hinderances
may occur.
Surgeons and surgical residents believed exoskele­
tons would be helpful for their daily tasks, but
whether they would use it or not would depend on
the expected duration of the procedure and ultimately
personal choice; however, most of the surgeons inter­
viewed believed they would use exoskeletons. Many
surgeons in this study perform MIS procedures which
have been found to have high levels of extreme, non-
neutral postures that contribute to WMSDs (Aitchison
et al. 2016; Yang et al. 2021). While this perspective
was in part due to the novelty of the technology,
another important aspect was that these surgeons
were aware of the physical toll surgery had on their
bodies but continued to work through it, which is
reflected in their Nordic MSD and workstyle question­
naire results. As surgeons have an influence over the

equipment purchased by the hospital, they have the
potential to be leading drivers in the adoption of exo­
skeletons (Perl et al. 2021). Particularly, younger sur­
geons from teaching hospitals are the most likely to
be early adopters (Barrenho et al. 2021). Adoption of
exoskeletons among surgeons is also a unique case as
it has been found that surgeons’ adoption of technol­
ogy is influenced by their peers’ positive and negative
opinions of technology (Barrenho et al. 2021). Surgical
residents also mentioned experience level as a reason
for implementation, as trainees are still learning
proper OR ergonomics. This reasoning coincides with
previous findings that lower experienced surgeons
have higher levels of muscle activity that can contrib­
ute to fatigue (Thurston et al. 2022). As such, surgical
residents and surgeons early in their career may be an
ideal population to facilitate adoption of emerging
technology (Cha et al. 2020; Stumpo et al. 2021).
Interestingly, surgeons believed back-support exoskel­
eton would be most beneficial for their duties while
surgical residents preferred the shoulder-support exo­
skeleton. Although there was no consensus between
the two populations, both types of exoskeletons have
shown to reduce muscle activity and self-reported
pain in their respective locations (Liu et al. 2018;
Tetteh, Hallbeck, and Mirka 2022). However, while
these devices have proven to be beneficial in simu­
lated settings, surgeons and surgical residents
emphasised that empirical data would be important to
justify the implementation of exoskeletons.
OR nurses and STs also believed that exoskeletons
may be helpful for their job duties; however, time was
a concern. As their job duties are time-sensitive, they
noted in their initial interviews that if donning/doffing
time was too long, it may deter its use. This concern
was reduced after they participated in the simulated
workflow. Another important influencer of adoption
that OR nurses discussed was the comfort of the devi­
ces, not only to their workflow but to the users. During
the simulated workflow walkthrough, a male nurse vol­
unteered to wear the back-support exoskeleton which
had a metal plate that pushed against his chest to offer
support. However, a large majority of the nursing staff
were female. As discussed by the female population,
and in conjunction with findings of Zheng, Hawke, and
Evans (2022), special considerations need to be made
when designing exoskeletons to be compatible with
female workers.
Discrepancies in responses were noticed during the
initial interview of surgical staff depending on the
interviewee’s role and time working for the healthcare
centre. Those with more administrative roles were
ERGONOMICS 13
generally optimistic about the healthcare centre’s will­
ingness to adopt the devices to support their staff and
believed the current training regimen was sufficient in
its current state. Staff working under them, who had
worked for the healthcare system for a long time,
were more pessimistic about the institution’s willing­
ness to listen to their views. This in part came back to
the time-sensitive nature of the job – even with
regards to training. Although proper ergonomic train­
ing has been shown to reduce the risk of WMSD
symptoms in nurses (Abdollahi et al. 2020), the inter­
viewed nurses found that the current training curricu­
lum was unrealistic in practice when time demands
outweigh personal safety. As such, the exoskeletons
may offer additional support when deviating from
safety standards. An additional component to this
could be due to the high physical and emotional
demands of their work and other factors that contrib­
ute to a sense of burnout in nurses (Kelly, Gee, and
Butler 2021; Van der Heijden, Brown Mahoney, and Xu
2019). A lack of motivation could lead workers to
forego proper lifting techniques which could put them
at risk of acquiring a WMSD. STs believed it would be
helpful for similar job duties as the nurses. Many of
the surgical staff pointed to STs as a prime candidate
for exoskeleton support due to high demand tasks
such as retracting and camera holding that increase
the likelihood of WMSDs (Lee et al. 2009; D. Yu et al.
2016). While the ST noted that the shoulder-support
exoskeleton was helpful for lifting tasks during the
workflow simulation, she mentioned that it offered
too much support during the camera holding task and
was even restrictive. As a result, it would often get in
the way of her normal actions and even made her
arms more fatigued as she resisted the device. It
should be noted, however, that this device was a dif­
ferent model than that worn by the CPT. The model
worn by the ST activated at a lower angle and offered
more support (i.e. the device was at a medium set­
ting). STs were also concerned with how this device
would integrate with tight-spaced, sterile, environ­
ments when they assist with procedures. Interestingly,
they were more sensitive to this issue than the sur­
geons who noted they would keep the exoskeleton
under their gown.
Originally, the interviewed CPTs mentioned that
they needed more exoskeleton exposure to under­
stand its usefulness, but after their simulated workflow
walkthrough they believed that it would be beneficial
for the repetitive lifting their job required of them. In
addition, a prominent issue amongst CPTs at this
healthcare centre was staffing. Participants noted that
14 A. GONZALES ET AL.
their workload typically required double the staffing
that was available and as a result, STs were often
rotated into the department to assist with duties. As
found in previous work, understaffing can lead to
increased WMSD symptoms as staff put productivity
over their own safety (Nino, Marchak, and Claudio
2020).
Perspectives from the infection control nurse ech­
oed the sentiments of the interviewed surgical team
members. The perspective of this nurse was obtained
after being identified as a key influencer in the adop­
tion process as noted by other surgical team mem­
ber’s interviews. Further, proper infection control
procedures are related to the healthcare-associated
infections in patients (Deryabina et al. 2021). The inter­
viewed infection control nurses noted very little
opportunities for resistance in the implementation of
the exoskeleton. One of the most vital considerations
for implementation is the sanitisation of the device.
Since the exoskeleton would be sanitised similarly to
lead gowns, wiping between users would likely be the
safest option as weekly cleaning of lead aprons may
allow bacterial contamination to accumulate (Gilat
et al. 2020). Alternatively, she noted the use of ultra-
violet light sterilisation systems as an alternative
method as this process has shown to be successful in
reducing bacterial contamination on surfaces (El
Haddad et al. 2017; Fridman et al. 2013; Simmons
et al. 2013). These cleaning methods would likely be
met with little resistance as surgical staff noted they
would likely limit the device to one user per day
based on who had the most demanding cases.
Implementation of exoskeletons in a healthcare
context poses unique challenges and opportunities
when compared to other industries. In an industrial
context, assembly workers have benefitted from exo­
skeleton-support during assembly tasks with forward
bending and shoulder-support exoskeletons have
reduced muscle activity in manual handling tasks
(Bosch et al. 2016; Theurel et al. 2018). Although
industry tasks differ from those performed by surgical
team members, exoskeletons have similarly shown
favourable results in healthcare by reducing muscle
activity and self-reported pain during surgical tasks
and common push-pull and patient transfer tasks
(Aoki et al. 2020; Hwang et al. 2021; Liu et al. 2018;
Tetteh, Hallbeck, and Mirka 2022). Even with promising
results there are factors that continue to affect exo­
skeleton adoption across domains. Like most indus­
tries, a vital component of integration is the
compatibility of the device with the existing work
environment. Kim and colleagues emphasised this in a
qualitative analysis of construction industry stakehold­
ers that identified the compatibility of exoskeletons
with worker tasks and existing equipment as a vital
aspect for adoption (Kim et al. 2019). A unique consid­
eration between surgeons and other surgical team
members is that surgeons complete a smaller set of
tasks during their workday compared to other surgical
staff whose tasks vary significantly throughout the
day. This may make certain exoskeletons easier to rec­
ommend for surgeons of a particular specialty.
Further, surgeons in the OR are in a different socio-
economic demographic compared to assembly work­
ers or other construction trades workers. As they have
a higher level of control over their jobs, and different
motivation for staying employed, exoskeleton imple­
mentation in the OR is a unique case, and studies like
ours suggest that surgeons seem to be largely willing
to adapt to the device. Furthermore, studies suggest
that a key motivational factor for teaching and operat­
ing is access to new technology for surgeons (Leitch
and Walker 2000). Unlike other industries where the
social perception of exoskeletons seems to have a
generally negative connotation and exoskeleton
implementation efforts are largely facing resistance,
particularly if they are made mandatory (Elprama,
Vanderborght, and Jacobs 2022), surgeons could be
both the advocates for the device and the users. This
places surgeons in the position to be key stakeholders
in the implementation of exoskeletons in the health­
care domain.
5. Limitations
As this study was conducted in one hospital system,
the views of the interviewed population may not be
representative of workers across different healthcare
systems. However, this study found similar results as
Cha et al. (2020), which was completed in a different
region of the U.S. (Cha et al. 2020). The surgeons’
views were also representative of mostly MIS surgeons
in general surgery, and these may differ in other special­
ties. However, surgical staff were asked to respond to
the interview questions while keeping their work duties
in mind. These work duties are often standardised across
healthcare institutions and as such still provide insight
into exoskeleton compatibility. It should be noted that
the study could improve by including more perspectives
of CPTs as only two were included in this study.
Moreover, a single industrial exoskeleton that was pri­
marily designed for a manufacturing context was used
during the simulated workflow. Since such exoskeletons
are not currently designed specifically for the healthcare

context, the range of postures that they support are not
optimal for some of the tasks that were examined here,
and the available manufacturer’s manuals for the exo­
skeletons also do not typically include details for devices
in clinical environments.
6. Conclusion
Surgical team members experience physical demands
in their daily work duties that can contribute to the
development of WMSDs. Exoskeletons are wearable
devices that can support the changing and dynamic
needs of such workers. Based on the perspectives gath­
ered from interviews and simulated workflow walk­
throughs, most of the surgical team members believe
exoskeletons would be beneficial in supporting their
daily work tasks. Although barriers such as when is the
most appropriate time to wear the exoskeleton and
sterility constraints need to be addressed, many of the
surgical team members believe the exoskeletons are
largely compatible with their workflow. Most impor­
tantly, the evaluated population is willing to help facili­
tate exoskeleton adoption should it prove to reduce
their WMSD symptoms. Future work that addresses the
gathering of evidence to demonstrate the efficacy of
exoskeletons in reducing WMSD risk for surgical team
members, especially when integrated into different sur­
gical task contexts and workflows, is needed to further
research and translation in this domain, to help foster a
safer environment for surgical workers.
Disclosure statement
No potential conflict of interest was reported by the
author(s).
Funding
This work was supported in part by the Agency for
Healthcare Research and Quality (AHRQ) (grant
1R03HS029247-01) and a Prisma Health Research Seed
Grant.
References
Abdollahi, T., S. Pedram Razi, D. Pahlevan, M. S. Yekaninejad,
S. Amaniyan, C. Leibold Sieloff, and M. Vaismoradi. 2020.
“Effect of an Ergonomics Educational Program on
Musculoskeletal Disorders in Nursing Staff Working in the
Operating Room: A Quasi-Randomized Controlled Clinical
Trial.” International Journal of Environmental Research and
Public Health 17 (19): E7333. doi:10.3390/ijerph17197333.
Aghilinejad, M., A. A. Ehsani, A. Talebi, J. Koohpayehzadeh,
and N. Dehghan. 2016. “Ergonomic Risk Factors and
Musculoskeletal Symptoms in Surgeons with Three Types
ERGONOMICS 15
of Surgery: Open, Laparoscopic, and Microsurgery.”
Medical Journal of the Islamic Republic of Iran 30: 467.
Aitchison, L. P., C. K. Cui, A. Arnold, E. Nesbitt-Hawes, and J.
Abbott. 2016. “The Ergonomics of Laparoscopic Surgery: A
Quantitative Study of the Time and Motion of
Laparoscopic Surgeons in Live Surgical Environments.”
Surgical Endoscopy 30 (11): 5068–5076. doi:10.1007/
s00464-016-4855-4.
Alfred, M., K. Catchpole, E. Huffer, L. Fredendall, and K. M.
Taaffe. 2020. “Work Systems Analysis of Sterile Processing:
Decontamination.” BMJ Quality & Safety 29 (4): 320–328.
doi:10.1136/bmjqs-2019-009422.
Ali, J. M., K. Lam, and A. S. Coonar. 2018. “Robotic Camera
Assistance: The Future of Laparoscopic and Thoracoscopic
Surgery?” Surgical Innovation 25 (5): 485–491. doi:10.1177/
1553350618784224.
Al-Qaisi, S. K., A. El Tannir, L. A. Younan, and R. N. Kaddoum.
2020. “An Ergonomic Assessment of Using Laterally-Tilting
Operating Room Tables and Friction Reducing Devices for
Patient Lateral Transfers.” Applied Ergonomics 87: 103122.
doi:10.1016/j.apergo.2020.103122.
Anderson, S. P., and J. Oakman. 2016. “Allied Health
Professionals and Work-Related Musculoskeletal Disorders:
A Systematic Review.” Safety and Health at Work 7 (4):
259–267. doi:10.1016/j.shaw.2016.04.001.
Aoki, K., H. Kawahira, Y. Shimomura, and A. K. Lefor. 2020.
“An Exoskeleton Upper Extremity Support for
Laparoscopic Surgery: A Pilot Simulation Study.” Journal of
Japan Society of Computer Aided Surgery 22 (1): 33–39.
doi:10.5759/jscas.22.33.
Athanasiadis, D. I., S. Monfared, H. Asadi, C. L. Colgate, D. Yu,
and D. Stefanidis. 2021. “An Analysis of the Ergonomic
Risk of Surgical Trainees and Experienced Surgeons during
Laparoscopic Procedures.” Surgery 169 (3): 496–501. doi:
10.1016/j.surg.2020.10.027.
Barrenho, E., M. Miraldo, C. Propper, and B. Walsh. 2021.
“The Importance of Surgeons and Their Peers in Adoption
and Diffusion of Innovation: An Observational Study of
Laparoscopic Colectomy Adoption and Diffusion in
England.” Social Science & Medicine (1982) 272: 113715.
doi:10.1016/j.socscimed.2021.113715.
Bosch, T., J. van Eck, K. Knitel, and M. de Looze. 2016. “The
Effects of a Passive Exoskeleton on Muscle Activity,
Discomfort and Endurance Time in Forward Bending
Work.” Applied Ergonomics 54: 212–217. doi:10.1016/j.
apergo.2015.12.003.
Brooks, J. V., J. A. R. Williams, and K. Gorbenko. 2019. “The
Work of Sterile Processing Departments: An Exploratory
Study Using Qualitative Interviews and a Quantitative
Process Database.” American Journal of Infection Control
47 (7): 816–821. doi:10.1016/j.ajic.2018.12.010.
Cavdar, I., A. Karaman, Y. Ozhanli, and A. Ozbas. 2020. “Low
Back Pain in Operating Room Nurses and Its Associated
Factors.” Pakistan Journal of Medical Sciences 36 (6): 1291–
1296. doi:10.12669/pjms.36.6.2836.
Cha, J. S., S. Monfared, D. Stefanidis, M. A. Nussbaum, and D.
Yu. 2020. “Supporting Surgical Teams: Identifying Needs
and Barriers for Exoskeleton Implementation in the
Operating Room.” Human Factors 62 (3): 377–390. doi:10.
1177/0018720819879271.
Choobineh, A., M. Movahed, S. H. Tabatabaie, and M.
Kumashiro. 2010. “Perceived Demands and
16 A. GONZALES ET AL.
Musculoskeletal Disorders in Operating Room Nurses of
Shiraz City Hospitals.” Industrial Health 48 (1): 74–84. doi:
10.2486/indhealth.48.74.
Clari, M., A. Godono, G. Garzaro, G. Voglino, M. R. Gualano,
G. Migliaretti, A. Gullino, C. Ciocan, and V. Dimonte. 2021.
“Prevalence of Musculoskeletal Disorders among
Perioperative Nurses: A Systematic Review and META-
Analysis.” BMC Musculoskeletal Disorders 22 (1): 226. doi:
10.1186/s12891-021-04057-3.
Craig, C. L., A. L. Marshall, M. Sjo€stro
€ m, A. E. Bauman, M. L.
Booth, B. E. Ainsworth, M. Pratt, U. Ekelund, A. Yngve, J. F.
Sallis, and P. Oja. 2003. “International Physical Activity
Questionnaire: 12-Country Reliability and Validity.”
Medicine and Science in Sports and Exercise 35 (8): 1381–
1395. doi:10.1249/01.MSS.0000078924.61453.FB.
Dalager, T., K. Søgaard, E. Boyle, P. T. Jensen, and O.
Mogensen. 2019. “Surgery is Physically Demanding and
Associated with Multisite Musculoskeletal Pain: A Cross-
Sectional Study.” The Journal of Surgical Research 240: 30–
39. doi:10.1016/j.jss.2019.02.048.
Deryabina, A., M. Lyman, D. Yee, M. Gelieshvilli, L. Sanodze,
L. Madzgarashvili, J. Weiss, C. Kilpatrick, M. Rabkin, B.
Skaggs, and A. Kolwaite. 2021. “Core Components of
Infection Prevention and Control Programs at the Facility
Level in Georgia: Key Challenges and Opportunities.”
Antimicrobial Resistance & Infection Control 10 (1): 39. doi:
10.1186/s13756-020-00879-3.
Disbrow, D. E., S. M. Pannell, B.-A. Shanker, J. Albright, J. Wu,
A. Bastawrous, M. Soliman, J. Ferraro, and R. K. Cleary.
2018. “The Effect of Formal Robotic Residency Training on
the Adoption of Minimally Invasive Surgery by Young
Colorectal Surgeons.” Journal of Surgical Education 75 (3):
767–778. doi:10.1016/j.jsurg.2017.09.006.
El Haddad, L., S. S. Ghantoji, M. Stibich, J. B. Fleming, C.
Segal, K. M. Ware, and R. F. Chemaly. 2017. “Evaluation of
a Pulsed Xenon Ultraviolet Disinfection System to
Decrease Bacterial Contamination in Operating Rooms.”
BMC Infectious Diseases 17 (1): 672. doi:10.1186/s12879-
017-2792-z.
Elprama, S. A., B. Vanderborght, and A. Jacobs. 2022. “An
Industrial Exoskeleton User Acceptance Framework Based
on a Literature Review of Empirical Studies.” Applied
Ergonomics 100: 103615. doi:10.1016/j.apergo.2021.103615.
Feuerstein, M., and R. A. Nicholas. 2006. “Development of a
Short Form of the Workstyle Measure.” Occupational
Medicine (Oxford, England) 56 (2): 94–99. doi:10.1093/
occmed/kqi197.
Fridman, A., L. A. Bruno-Murtha, R. Osgood, and J. McAllister.
2013. “Decreasing Operating Room Contamination of
Surfaces and Air with Pulsed Xenon Ultraviolet
Disinfection.” American Journal of Infection Control 41 (6):
S36. doi:10.1016/j.ajic.2013.03.076.
Gilat, R., I. Mitchnik, E. Beit Ner, N. Shohat, E. Tamir, Y. A.
Weil, T. Lazarovitch, and G. Agar. 2020. “Bacterial
Contamination of Protective Lead Garments in an
Operating Room Setting.” Journal of Infection Prevention
21 (6): 234–240. doi:10.1177/1757177420947466.
Gilbert, J. M. 2009. “The EndoAssist Robotic Camera Holder
as an Aid to the Introduction of Laparoscopic Colorectal
Surgery.” Annals of the Royal College of Surgeons of
England 91 (5): 389–393. doi:10.1308/003588409X392162.
Hwang, J., V. N. Kumar Yerriboina, H. Ari, and J. H. Kim. 2021.
“Effects of Passive Back-Support Exoskeletons on Physical
Demands and Usability during Patient Transfer Tasks.”
Applied Ergonomics 93: 103373. doi:10.1016/j.apergo.2021.
103373.
Hwang, J., V. A. Kuppam, S. S. R. Chodraju, J. Chen, and J. H.
Kim. 2019. “Commercially Available Friction-Reducing
Patient-Transfer Devices Reduce Biomechanical Stresses
on Caregivers’ Upper Extremities and Low Back.” Human
Factors 61 (7): 1125–1140. doi:10.1177/0018720819827208.
Kelly, L. A., P. M. Gee, and R. J. Butler. 2021. “Impact of
Nurse Burnout on Organizational and Position Turnover.”
Nursing Outlook 69 (1): 96–102. doi:10.1016/j.outlook.2020.
06.008.
Khan, W. F., A. Krishna, A. Roy, O. Prakash, A. K. Jaryal, K. K.
Deepak, H. Bhattacharjee, V. Sreenivas, and V. K. Bansal.
2021. “Effect of Structured Training in Improving the
Ergonomic Stress in Laparoscopic Surgery among General
Surgery Residents.” Surgical Endoscopy 35 (8): 4825–4833.
doi:10.1007/s00464-020-07945-2.
Kim, S., A. Moore, D. Srinivasan, A. Akanmu, A. Barr, C. Harris-
Adamson, D. M. Rempel, and M. A. Nussbaum. 2019.
“Potential of Exoskeleton Technologies to Enhance Safety,
Health, and Performance in Construction: Industry
Perspectives and Future Research Directions.” IISE
Transactions on Occupational Ergonomics and Human Factors
7 (3-4): 185–191. doi:10.1080/24725838.2018.1561557.
Kucera, K. L., A. L. Schoenfisch, J. McIlvaine, L. Becherer, T.
James, Y.-L. Yeung, S. Avent, and H. J. Lipscomb. 2019.
“Factors Associated with Lift Equipment Use during
Patient Lifts and Transfers by Hospital Nurses and Nursing
Care Assistants: A Prospective Observational Cohort
Study.” International Journal of Nursing Studies 91: 35–46.
doi:10.1016/j.ijnurstu.2018.11.006.
Kuorinka, I., B. Jonsson, A. Kilbom, H. Vinterberg, F. Biering-
Sørensen, G. Andersson, and K. Jørgensen. 1987.
“Standardised Nordic Questionnaires for the Analysis of
Musculoskeletal Symptoms.” Applied Ergonomics 18 (3):
233–237. doi:10.1016/0003-6870(87)90010-X.
Lee, G., T. Lee, D. Dexter, C. Godinez, N. Meenaghan, R.
Catania, and A. Park. 2009. “Ergonomic Risk Associated
with Assisting in Minimally Invasive Surgery.” Surgical
Endoscopy 23 (1): 182–188. doi:10.1007/s00464-008-0141-4.
Leitch, K. K., and P. M. Walker. 2000. “Surgeon Compensation
and Motivation.” Archives of Surgery (Chicago, Ill: 1960) 135
(6): 708–712. doi:10.1001/archsurg.135.6.708.
Liu, S., D. Hemming, R. B. Luo, J. Reynolds, J. C. Delong, B. J.
Sandler, G. R. Jacobsen, and S. Horgan. 2018. “Solving the
Surgeon Ergonomic Crisis with Surgical Exosuit.” Surgical
Endoscopy 32 (1): 236–244. doi:10.1007/s00464-017-5667-x.
McQuivey, K. S., D. G. Deckey, Z. K. Christopher, C. S.
Rosenow, L. Mi, M. J. Spangehl, and J. S. Bingham. 2021.
“Surgical Ergonomics and Musculoskeletal Pain in
Orthopaedic Surgery Residents: A Multicenter Survey
Study.” Journal of the American Academy of Orthopaedic
Surgeons. Global Research & Reviews 5 (3): 1–9. doi:10.
5435/JAAOSGlobal-D-20-00119.
Monfared, S., D. I. Athanasiadis, L. Umana, E. Hernandez, H.
Asadi, C. L. Colgate, D. Yu, and D. Stefanidis. 2022. “A
Comparison of Laparoscopic and Robotic Ergonomic Risk.”
Surgical Endoscopy 36 (11): 8397–8402. doi:10.1007/
s00464-022-09105-0.

Moreira da-Silva, V., D. O. Pontes, P. P. da S. Pereira, J. C.
Monteiro, and M. N. Cruz. 2021. “Evaluation of Working
Conditions at a Central Sterile Services Department in
Northern Brazil.” Revista Brasileira de Medicina Do
Trabalho: publicacao Oficial da Associacao Nacional de
Medicina Do Trabalho-ANAMT 19 (4): 472–481. doi:10.
47626/1679-4435-2021-623.
Nino, L., F. Marchak, and D. Claudio. 2020. “Physical and
Mental Workload Interactions in a Sterile Processing
Department.” International Journal of Industrial Ergonomics
76: 102902. doi:10.1016/j.ergon.2019.102902.
Noble, N. L., and N. L. Sweeney. 2018. “Barriers to the Use of
Assistive Devices in Patient Handling.” Workplace Health &
Safety 66 (1): 41–48. doi:10.1177/2165079917697216.
O’Connor, S. 2021. “Exoskeletons in Nursing and Healthcare:
A Bionic Future.” Clinical Nursing Research 30 (8): 1123–
1126. doi:10.1177/10547738211038365.
Olavarria, O. A., K. Bernardi, S. K. Shah, T. D. Wilson, S. Wei,
C. Pedroza, E. B. Avritscher, M. M. Loor, T. C. Ko, L. S. Kao,
and M. K. Liang. 2020. “Robotic versus Laparoscopic
Ventral Hernia Repair: Multicenter, Blinded Randomized
Controlled Trial.” BMJ (Clinical Research ed.) 370: m2457.
doi:10.1136/bmj.m2457.
Perl, J. R., K. R. Sheth, K. G. Shea, and J. Wall. 2021. “Hospital
Value Committees: The Role of the Surgeon in New
Technology Adoption.” Surgical Innovation 28 (4): 401–
402. doi:10.1177/15533506211031094.
Rodr�ıguez-Sanju�an, J. C., M. Go � mez-Ruiz, S. Trugeda-Carrera,
C. Manuel-Palazuelos, A. Lo �pez-Useros, and M. Go �mez-
Fleitas. 2016. “Laparoscopic and Robot-Assisted
Laparoscopic Digestive Surgery: Present and Future
Directions.” World Journal of Gastroenterology 22 (6):
1975–2004. doi:10.3748/wjg.v22.i6.1975.
Saunders, B., J. Sim, T. Kingstone, S. Baker, J. Waterfield, B.
Bartlam, H. Burroughs, and C. Jinks. 2018. “Saturation in
Qualitative Research: Exploring Its Conceptualization and
Operationalization.” Quality & Quantity 52 (4): 1893–1907.
doi:10.1007/s11135-017-0574-8.
Sheikhzadeh, A., C. Gore, J. D. Zuckerman, and M. Nordin.
2009. “Perioperating Nurses and Technicians’ Perceptions
of Ergonomic Risk Factors in the Surgical Environment.”
Applied Ergonomics 40 (5): 833–839. doi:10.1016/j.apergo.
2008.09.012.
Simmons, S. E., J. Stachowiak, M. Stibich, and M. Croteau.
2013. “Using Pulsed Xenon Ultraviolet to Decrease
Contamination in Operating Rooms during Terminal
Cleaning.” American Journal of Infection Control 41 (6):
S34–S35. doi:10.1016/j.ajic.2013.03.072.
�St�adler, P., J. Dorosh, L. Dvo�r�a�cek, P. Vit�asek, P. Matou�s, and
J. C. Lin. 2021. “Review and Current Update of Robotic-
Assisted Laparoscopic Vascular Surgery.” Seminars in
Vascular Surgery 34 (4): 225–232. doi:10.1053/j.semvasc­
surg.2021.10.007.
Stucky, C.-C. H., K. D. Cromwell, R. K. Voss, Y.-J. Chiang, K.
Woodman, J. E. Lee, and J. N. Cormier. 2018. “Surgeon
Symptoms, Strain, and Selections: Systematic Review and
Meta-Analysis of Surgical Ergonomics.” Annals of Medicine
and Surgery (2012) 27: 1–8. doi:10.1016/j.amsu.2017.12.013.
Stumpo, V., V. E. Staartjes, A. M. Klukowska, A. K. Golahmadi,
€ der, A. Veeravagu, M. N. Stienen,
P. S. Gadjradj, M. L. Schro
C. Serra, and L. Regli. 2021. “Global Adoption of Robotic
ERGONOMICS 17
Technology into Neurosurgical Practice and Research.”
Neurosurgical Review 44 (5): 2675–2687. doi:10.1007/
s10143-020-01445-6.
Szeto, G. P. Y., P. Ho, A. C. W. Ting, J. T. C. Poon, S. W. K.
Cheng, and R. C. C. Tsang. 2009. “Work-Related
Musculoskeletal Symptoms in Surgeons.” Journal of
Occupational Rehabilitation 19 (2): 175–184. doi:10.1007/
s10926-009-9176-1.
Tavakkol, R., A. Karimi, S. Hassanipour, A. Gharahzadeh, and
R. Fayzi. 2020. “A Multidisciplinary Focus Review of
Musculoskeletal Disorders among Operating Room
Personnel.” Journal of Multidisciplinary Healthcare 13: 735–
741. doi:10.2147/JMDH.S259245.
Tetteh, E., M. S. Hallbeck, and G. A. Mirka. 2022. “Effects of
Passive Exoskeleton Support on EMG Measures of the
Neck, Shoulder and Trunk Muscles While Holding
Simulated Surgical Postures and Performing a Simulated
Surgical Procedure.” Applied Ergonomics 100: 103646. doi:
10.1016/j.apergo.2021.103646.
Theurel, J., K. Desbrosses, T. Roux, and A. Savescu. 2018.
“Physiological Consequences of Using an Upper Limb
Exoskeleton during Manual Handling Tasks.” Applied
Ergonomics 67: 211–217. doi:10.1016/j.apergo.2017.10.008.
Thurston, T., J. P. Dolan, F. Husain, A. Stroud, K. Funk, C.
Borzy, and X. Zhu. 2022. “Assessment of Muscle Activity
and Fatigue during Laparoscopic Surgery.” Surgical
Endoscopy 36 (9): 6672–6678. doi:10.1007/s00464-021-
08937-6.
€ster, M., D. Wagner, F. M€
Tro uller-Graf, C. Maufroy, U.
Schneider, and T. Bauernhansl. 2020. “Biomechanical
Model-Based Development of an Active Occupational
Upper-Limb Exoskeleton to Support Healthcare Workers in
the Surgery Waiting Room.” International Journal of
Environmental Research and Public Health 17 (14): 5140.
doi:10.3390/ijerph17145140.
Van der Heijden, B., C. Brown Mahoney, and Y. Xu. 2019.
“Impact of Job Demands and Resources on Nurses’
Burnout and Occupational Turnover Intention towards an
Age-Moderated Mediation Model for the Nursing
Profession.” International Journal of Environmental
Research and Public Health 16 (11): 2011. doi:10.3390/
ijerph16112011.
Wang, T., Bernardo. C. Mendes, M. S. Hallbeck, E. Tetteh, T.
Smith, and H. Norasi. 2021. “Introducing Exoskeletons into
the Operating Room: A Pilot Study with Vascular
Surgeons.” Proceedings of the Human Factors and
Ergonomics Society Annual Meeting 65 (1): 1376–1380. doi:
10.1177/1071181321651212.
Yang, L., T. Wang, T. K. Weidner, J. A. Madura, M. M. Morrow,
and M. S. Hallbeck. 2021. “Intraoperative Musculoskeletal
Discomfort and Risk for Surgeons during Open and
Laparoscopic Surgery.” Surgical Endoscopy 35 (11): 6335–
6343. doi:10.1007/s00464-020-08085-3.
Yizengaw, M. A., S. Y. Mustofa, H. E. Ashagrie, and T. G.
Zeleke. 2021. “Prevalence and Factors Associated with
Work-Related Musculoskeletal Disorder among Health
Care Providers Working in the Operation Room.” Annals of
Medicine and Surgery (2012) 72: 102989. doi:10.1016/j.
amsu.2021.102989.
Yu, D., B. Lowndes, C. Thiels, J. Bingener, A. Abdelrahman, R.
Lyons, and S. Hallbeck. 2016. “Quantifying Intraoperative
18 A. GONZALES ET AL.
Workloads across the Surgical Team Roles: Room for
Better Balance?” World Journal of Surgery 40 (7): 1565–
1574. doi:10.1007/s00268-016-3449-6.
Yu, H., N. D. Hevelone, S. R. Lipsitz, K. J. Kowalczyk, and J. C.
Hu. 2012. “Use, Costs and Comparative Effectiveness of
Robotic Assisted, Laparoscopic and Open Urological
Surgery.” The Journal of Urology 187 (4): 1392–1398. doi:
10.1016/j.juro.2011.11.089.
Z�arate Rodriguez, J. G., A. M. Zihni, I. Ohu, J. A. Cavallo, S.
Ray, S. Cho, and M. M. Awad. 2019. “Ergonomic Analysis
of Laparoscopic and Robotic Surgical Task Performance at
Various Experience Levels.” Surgical Endoscopy 33 (6):
1938–1943. doi:10.1007/s00464-018-6478-4.
Zheng, L., A. L. Hawke, and K. Evans. 2022. “Critical Review
on Applications and Roles of Exoskeletons in Patient
Handling.” International Journal of Industrial Ergonomics
89: 103290. doi:10.1016/j.ergon.2022.103290.
Appendix A: Surgical team interview questions
adapted from cha. et al (2020)
Focus Group Questions:
(Start with showing pictures) This study focuses on the con­
sideration and implementation of exoskeletons in the oper­
ating room. An exoskeleton is an external device that
supports and protects its user during tasks that require pro­
longed static/constrained posture or strenuous lifting. The
purpose of exoskeletons would be to mitigate over-strenu­
ous activities in an effort to reduce fatigue and subsequently
lower the risk of developing musculoskeletal disorders.
Technology Adoption: Not specific to exoskeletons
1. Can you describe the general approach(es) used by
Prisma in adopting new technology?
2. If there are only long-term benefits, that may not be
immediately observable, for a new technology what can
be the most important factor(s) for adopting new tech­
nology in general? (i.e. you only know a helmet works
when you need it).
Supporting Worker Tasks/Jobs
1. Considering the potential benefits, such as mitigating
fatigue and offering support, and your knowledge of
exoskeletons, do you think that exoskeleton technology
is or could be useful in your daily duties? Note: Remind
about the strengths if needed.
1. (probe) in what way?
2. Are there any other interventions not-including
exoskeletons that may be beneficial?
2. If you had to choose ONE worker role to pilot test exo­
skeleton technology, which would it be? (See Pictures
are end)
1. Which specific tasks are you considering when
making this decision? Why? (Risk, posture, weight,
duration, strain, potential impact to operations
(good & bad), operational process, etc.)
2. If these were to be implemented, do you
think everyone would get an exo or only a certain
number of people a day? How might that be
decided?
3. What impact will this exoskeleton have on you?
1. How will it benefit users?
2. How may it hinder users’ work?
4. Would the device be used constantly or occasionally in
your daily duties?
1. Would it be task specific?
2. What is the most important factor in this decision?
3. How long do you think you would use an exoskel­
eton in a typical shift?
5. Based on your responses, do you believe there is a
need for exoskeleton interventions? Do you think exo­
skeletons would be the best intervention or are there
any other alternatives you can think of?
Workflow
We are interested in how exoskeletons may fit into your
daily workflow:
1. Can you describe to me a typical workday? (i.e. When
you come in, when you go to lunch, any break times
you have in between)
2. Where would exos fit into this this workday?
3.
Donning/doffing: when would you put them on and
when you would take them off?
1. How much time do you foresee this taking? How
much time do you think you have to spare for this
process?
2. Would you need assistance?
3. Where would you put them on? (i.e. when you
change into your scrubs or in a designated room
before a procedure?)
Where do you think these devices would be stored?
4. Do you think you would share these devices or have
one that is personalised (measurements and fitting) to
each individual?
1. How do you think your answers would change if
they were individual/shared?
2. Are there extra steps if it were shared?
5. How do you think these devices may be cleaned or
sanitised?
6. Do you foresee any other considerations related to
wearing and taking off these devices during your work,
that may affect your willingness to use exos?
Technology Adoption 2:
3. Are the technology adoption factors you mentioned ear­
lier still valid specifically for exoskeletons?
1. (probe) Does the relative importance of each factor
remain the same?
2. If not, can you tell what might be important factors for
the adoption of exoskeletons in your field? Emphasise
previous responses.

4. Do you foresee any potential for exoskeletons to help
with workforce retention, expansion, or otherwise?
1. (probe) Can this be an important factor to prompt the
adoption of exoskeletons?
2. Do you think you would be able to do any additional
tasks with exoskeletons?
5. What do you see as potential barriers for wide-spread
adoption of exoskeletons in your field?
Safety and Health
1. What ergonomic problems are currently encountered?
How often do they occur? What are their causes and
consequences? Emphasise survey responses (i.e.
“thinking of your survey response, do you think there
are any ergonomic problems … ”)
2. Can you tell what types of safety and health training,
and education are currently available for workers?
1. How often is safety and health training and/or edu­
cation given to workers?
ERGONOMICS 19
2. Is there any specific aspects in the current training
and education programs or methods that you think
needs to be improved?
3. (If there is no training and education program)
1. Can you explain what alternatives there are
for workers in terms of safety and health train­
ing and/or education?
3. Adopting a new technology may create unexpected
safety and health concerns. Is there typically a proced­
ure to address potential safety and health in your com­
pany in general?
1. If so, please elaborate and give a specific example
if possible.
2. If not, can you explain how potential safety and
health problems are typically addressed?
Appendix B: Simulated workflow walkthrough
tasks and question sheet for or nurses.
Example task: or prep
20 A. GONZALES ET AL.

Appendix C: IPAQ results: Physical activity Appendix E: Nordic musculoskeletal

over the past 7 days according to metabolic questionnaire responses: Intensity of pain in
equivalent (METs) the last 7 days, mean (SD). intensity is
presented as a percentage
Population (Total n) MET-min/week (SD)
Surgeon (12) 176 (936)
Surgical resident (6) 347 (1869)
Operating room nurse (7) 331 (1756) Surgeon Surgical resident OR Nurse ST CPT
Surgical technician (7) 586 (2819) Neck 37 (22) 22 (23) 13 (15) 42 (31) 0 (0)
Central processing technician (2) 175 (1053) Shoulder 24 (23) 20 (17) 22 (25) 53 (29) 0 (0)
Upper Back 23 (23) 15 (13) 15 (14) 30 (20) 0 (0)
Elbows 5 (17) 0 (0) 15 (12) 20 (0) 0 (0)
Wrists/hands 13 (19) 23 (29) 23 (10) 23 (15) 0 (0)
Appendix D: Nordic musculoskeletal Lower back 36 (22) 20 (14) 22 (13) 50 (24) 0 (0)
Hips/thighs 13 (24) 7 (12) 14 (13) 40 (42) 0 (0)
questionnaire responses: Frequency in the last Knees 17 (29) 18 (15) 13 (15) 25 (7) 0 (0)
3 months Ankles/feet 15 (24) 10 (14) 22 (12) 44 (27) 0 (0)

Body part Never, 1-7 days, 8-30 days, 30þ days, Every day,
(Total n) n (%) n (%) n (%) n (%) n (%) Appendix F: Workstyle measure questionnaire
Surgeon
Neck (12) 1 (8) 4 (33) 2 (17) 1 (8) 4 (33)
Shoulder (12) 3 (25) 2 (17) 1 (8) 5 (42) 1 (8) Workstyle Measure
Upper back (12) 3 (25) 3 (25) 4 (33) 1 (8) 1 (8) 1. I continue to work with pain and discomfort so that the quality of
Elbows (12) 9 (75) 2 (17) 0 (0) 1 (13) 0 (0) my work won’t suffer
Wrists/hands (12) 4 (33) 7 (58) 1 (8) 0 (0) 0 (0) 2. My hands and arms feel tired during the workday
Lower back (12) 0 (0) 5 (42) 3 (25) 2 (17) 2 (17) 3. I continue to work in a way that contributes to pain in order to
Hips/thighs (12) 7 (58) 2 (17) 2 (17) 0 (0) 1 (0) get my work done
Knees (12) 8 (67) 1 (8) 0 (0) 1 (8) 2 (17) 4. I take medications to manage pain, muscle tension, or symptoms
Ankles/Feet (8) 7 (58) 0 (0) 3 (25) 0 (0) 2 (17) in my fingers, wrists, hands, or arms in order to keep working
Surgical Resident 5. If I have to talk to my supervisor about symptoms, it will appear
Neck (6) 1 (17) 3 (50) 1 (17) 1 (17) 0 (0) that I cannot handle the work
Shoulder (6) 4 (67) 0 (0) 2 (33) 0 (0) 0 (0) 6. My schedule at work is very uncontrollable
Upper back (6) 3 (50) 1 (17) 2 (33) 0 (0) 0 (0) 7. I really don’t have time to take a break because of everything that
Elbows (6) 6 (100) 0 (0) 0 (0) 0 (0) 0 (0) must get done
Wrists/hands (6) 4 (67) 1 (17) 1 (17) 0 (0) 0 (0) 8. I am physically exhausted at the end of the day
Lower back (6) 3 (50) 1 (17) 2 (33) 0 (0) 0 (0) 9. I push myself and have higher expectations than my supervisors
Hips/thighs (6) 5 (83) 1 (17) 0 (0) 0 (0) 0 (0) and others that I have to deal with at work
Knees (6) 3 (50) 2 (33) 1 (17) 0 (0) 0 (0) 10. I always try to do my best because that’s what I owe myself
Ankles/feet (6) 4 (67) 2 (33) 0 (0) 0 (0) 0 (0) 11. I put a lot of pressure on myself
OR Nurse
Neck (5) 2 (40) 2 (40) 1 (20) 0 (0) 0 (0)
Shoulder (6) 1 (17) 3 (50) 1 (17) 0 (0) 1 (17)
Upper back (7) 3 (43) 2 (29) 2 (29) 0 (0) 0 (0)
Elbows (5) 2 (40) 3 (60) 0 (0) 0 (0) 0 (0)
Wrists/hands (5) 1 (20) 3 (60) 1 (20) 0 (0) 0 (0)
Lower back (7) 1 (14) 3 (43) 2 (29) 0 (0) 1 (14)
Hips/thighs (6) 2 (33) 2 (33) 1 (17) 0 (0) 1 (17)
Knees (5) 1 (20) 4 (80) 0 (0) 0 (0) 0 (0)
Ankles/feet (7) 2 (29) 3 (43) 2 (29) 0 (0) 0 (0)
ST
Neck (6) 1 (17) 2 (33) 0 (0) 3 (50) 0 (0)
Shoulder (7) 1 (14) 2 (29) 2 (29) 2 (29) 0 (0)
Upper back (6) 1 (17) 1 (17) 2 (33) 2 (33) 0 (0)
Elbows (3) 2 (67) 0 (0) 1 (33) 0 (0) 0 (0)
Wrists/hands (5) 2 (40) 0 (0) 2 (40) 1 (20) 0 (0)
Lower back (7) 1 (14) 2 (29) 1 (14) 2 (29) 1 (14)
Hips/thighs (4) 2 (50) 1 (25) 1 (25) 0 (0) 0 (0)
Knees (4) 2 (50) 1 (25) 1 (25) 0 (0) 0 (0)
Ankles/feet (6) 1 (17) 1 (17) 2 (33) 1 (17) 1 (17)
CPT
Neck (1) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0)
Shoulder (1) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0)
Upper back (1) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0)
Elbows (1) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0)
Wrists/hands (1) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0)
Lower back (1) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0)
Hips/thighs (1) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0)
Knees (1) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0)
Ankles/feet (1) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0)
 ERGONOMICS 21

Appendix G: Workstyle questionnaire responses

Population (Total n) Strongly disagree, n (%) Disagree, n (%) Neutral, n (%) Agree, n (%) Strongly agree, n (%)
Surgeon
Q1 (12) 0 (0) 1 (8) 2 (17) 3 (25) 6 (50)
Q2 (12) 2 (17) 0 (0) 6 (50) 2 (17) 2 (17)
Q3 (12) 1 (8) 2 (17) 2 (17) 5 (42) 2 (17)
Q4 (12) 9 (75) 1 (8) 1 (8) 1 (8) 0 (0)
Q5 (12) 5 (42) 3 (25) 4 (33) 0 (0) 0 (0)
Q6 (12) 5 (42) 2 (17) 2 (17) 1 (8) 2 (17)
Q7 (12) 3 (25) 4 (33) 1 (8) 3 (25) 1 (8)
Q8 (12) 0 (0) 2 (17) 6 (50) 4 (33) 0 (0)
Q9 (12) 1 (8) 2 (17) 3 (25) 5 (42) 1 (8)
Q10 (12) 0 (0) 0 (0) 0 (0) 7 (58) 5 (42)
Q11 (12) 0 (0) 1 (8) 1 (8) 4 (33) 6 (50)
Surgical Resident
Q1 (6) 0 (0) 0 (0) 1 (17) 3 (50) 2 (33)
Q2 (6) 2 (33) 3 (50) 1 (17) 0 (0) 0 (0)
Q3 (6) 2 (33) 1 (17) 1 (17) 2 (33) 0 (0)
Q4 (6) 5 (83) 0 (0) 0 (0) 1 (17) 0 (0)
Q5 (6) 4 (67) 0 (0) 2 (33) 0 (0) 0 (0)
Q6 (6) 1 (17) 1 (17) 1 (17) 2 (33) 1 (17)
Q7 (6) 0 (0) 2 (33) 1 (17) 3 (50) 0 (0)
Q8 (6) 0 (0) 3 (50) 1 (17) 2 (33) 0 (0)
Q9 (6) 0 (0) 1 (17) 2 (33) 3 (50) 0 (0)
Q10 (6) 0 (0) 0 (0) 0 (0) 4 (67) 2 (33)
Q11(6) 0 (0) 1 (17) 3 (50) 2 (33) 0 (0)
OR Nurse
Q1 (6) 0 (0) 1 (17) 3 (50) 1 (17) 1 (17)
Q2 (7) 1 (14) 0 (0) 2 (29) 4 (57) 0 (0)
Q3 (6) 1 (17) 2 (33) 1 (17) 2 (33) 0 (0)
Q4 (7) 5 (71) 0 (0) 0 (0) 1 (14) 1 (14)
Q5 (7) 2 (29) 3 (50) 2 (29) 0 (0) 0 (0)
Q6 (7) 1 (14) 2 (29) 2 (29) 1 (14) 1 (14)
Q7 (7) 1 (14) 3 (50) 2 (29) 1 (14) 0 (0)
Q8 (7) 0 (0) 3 (43) 0 (0) 3 (43) 1 (14)
Q9 (7) 1 (14) 0 (0) 1 (14) 3 (43) 2 (29)
Q10 (7) 0 (0) 0 (0) 0 (0) 3 (43) 4 (57)
Q11 (7) 0 (0) 1 (14) 2 (29) 2 (29) 2 (29)
ST
Q1 (6) 0 (0) 0 (0) 2 (33) 1 (17) 3 (50)
Q2 (7) 1 (14) 0 (0) 2 (29) 2 (29) 2 (29)
Q3 (7) 1 (14) 0 (0) 2 (29) 2 (29) 2 (29)
Q4 (7) 2 (29) 0 (0) 3 (43) 1 (14) 1 (14)
Q5 (6) 3 (50) 1 (17) 1 (17) 1 (17) 0 (0)
Q6 (7) 2 (29) 1 (14) 0 (0) 1 (14) 3 (43)
Q7 (7) 2 (29) 0 (0) 2 (29) 1 (14) 2 (29)
Q8 (7) 1 (14) 0 (0) 0 (0) 5 (71) 1 (14)
Q9 (7) 1 (14) 0 (0) 1 (14) 3 (43) 2 (29)
Q10 (7) 1 (14) 0 (0) 1 (14) 1 (14) 4 (57)
Q11 (7) 1 (14) 1 (14) 2 (29) 0 (0) 3 (43)
CPT
Q1 (1) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0)
Q2 (1) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0)
Q3 (1) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0)
Q4 (1) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0)
Q5 (1) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0)
Q6 (1) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0)
Q7 (1) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0)
Q8 (1) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0)
Q9 (1) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0)
Q10 (1) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0)
Q11 (1) 0 (0) 0 (0) 2 (50) 0 (0) 0 (0)