TY - JOUR AU - Bibbo, Daniele AU - Corvini, Giovanni AU - Schmid, Maurizio AU - Ranaldi, Simone AU - Conforto, Silvia PY - 2025/2/27 TI - The Impact of Human-Robot Collaboration Levels on Postural Stability During Working Tasks Performed While Standing: Experimental Study JO - JMIR Hum Factors SP - e64892 VL - 12 KW - human-robot collaboration KW - cobot assistance KW - postural control KW - biomechanical risk KW - ergonomics KW - collaborative robot N2 - Background: The integration of collaborative robots (cobots) in industrial settings has the potential to enhance worker safety and efficiency by improving postural control and reducing biomechanical risk. Understanding the specific impacts of varying levels of human-robot collaboration on these factors is crucial for optimizing cobot use. Objective: This study aims to investigate the biomechanical effects of different levels of human-robot collaboration on postural stability and control during simulated working tasks. Methods: A total of 14 participants performed simulated cashier working activities under 4 different collaboration modalities, with increasing levels of cobot assistance: full (Fu), half robot touch (HRT), half robot (HRb), and full robot (FRb). Center of pressure trajectories were extracted from 2 force plates? data to calculate 4 posturography parameters?mean distance (MDIST), mean velocity (MVELO), 95% confidence ellipse area (AREA-CE), and sway area (AREA-SW)?which were analyzed to assess the impact of cobot intervention on postural control. Results: Nonparametric tests showed significance in the effect of the collaboration modalities on the 4 analyzed parameters. Post hoc tests revealed that FRb modality led to the greatest enhancement in postural stability, with a reduction in MDIST (4.2, SD 1.3 cm in Fu vs 1.6, SD 0.5 cm in FRb) and MVELO (16.3, SD 5.2 cm/s in Fu vs 7.9, SD 1.1 cm/s in FRb). AREA-CE and AREA-SW also decreased significantly with higher levels of cobot assistance (AREA-CE: 134, SD 91 cm² in Fu vs 22, SD 12 cm² in FRb; AREA-SW: 16.2, SD 8.4 cm²/s in Fu vs 4.0, SD 1.6 cm²/s in FRb). Complete assistance of the cobot significantly reduced interindividual variability of all center of pressure parameters. In FRb modality, as compared with all other conditions, removing the weight of the object during loading or unloading phases caused a significant decrease in all parameter values. Conclusions: Increased cobot assistance significantly enhances postural stability and reduces biomechanical load on workers during simulated tasks. Full assistance from cobots, in particular, minimizes postural displacements, indicating more consistent postural control improvements across individuals. However, high levels of cobot intervention also reduced the natural variation in how people balanced themselves. This could potentially lead to discomfort in the long run. Midlevel cobot assistance modalities can thus be considered as a good compromise in reducing biomechanical risks associated with postural stability at the same time granting a satisfactory level of user control. UR - https://humanfactors.jmir.org/2025/1/e64892 UR - http://dx.doi.org/10.2196/64892 ID - info:doi/10.2196/64892 ER - TY - JOUR AU - Akksilp, Katika AU - Rouyard, Thomas AU - Isaranuwatchai, Wanrudee AU - Nakamura, Ryota AU - Müller-Riemenschneider, Falk AU - Teerawattananon, Yot AU - Chen, Cynthia PY - 2025/1/2 TI - The Physical Activity at Work (PAW) Program in Thai Office Workers: Mixed Methods Process Evaluation Study JO - JMIR Form Res SP - e57604 VL - 9 KW - process evaluation KW - sedentary behavior KW - physical activity KW - workplace KW - movement breaks N2 - Background: An increasing number of multicomponent workplace interventions are being developed to reduce sedentary time and promote physical activity among office workers. The Physical Activity at Work (PAW) trial was one of these interventions, but it yielded an inconclusive effect on sedentary time after 6 months, with a low uptake of movement breaks, the main intervention component. Objective: This study investigates the factors contributing to the outcomes of the PAW cluster randomized trial. Methods: Following the Medical Research Council?s guidance for process evaluation of complex interventions, we used a mixed methods study design to evaluate the PAW study?s recruitment and context (how job nature and cluster recruitment affected movement break participation), implementation (dose and fidelity), and mechanisms of impact (assessing how intervention components affected movement break participation and identifying the facilitators and barriers to participation in the movement breaks). Data from accelerometers, pedometers, questionnaires, on-site monitoring, and focus group discussions were used for the evaluation. Linear mixed effects models were used to analyze the effects of different intervention components on the movement breaks. Subsequently, qualitative analysis of the focus group discussions provided additional insights into the relationship between the intervention components. Results: The participation in movement breaks declined after the third week, averaging 12.7 sessions (SD 4.94) per participant per week for the first 3 weeks, and continuing to decrease throughout the intervention. On-site monitoring confirmed high implementation fidelity. Analysis of Fitbit data revealed that each additional movement break was associated with a reduction of 6.20 (95% CI 6.99-5.41) minutes in sedentary time and an increase of 245 (95% CI 222-267) steps. Regarding the mechanisms of impact, clusters with higher baseline sedentary time demonstrated greater participation in movement breaks, while those with frequent out-of-office duties showed minimal engagement. Moreover, clusters with enthusiastic and encouraging movement break leaders were associated with a 24.1% (95% CI 8.88%-39.4%) increase in participation. Environmental and organizational support components using posters and leaders? messages were ineffective, showing no significant change in percentage participation in movement breaks (4.49%, 95% CI ?0.49% to 9.47% and 1.82%, 95% CI ?2.25% to 5.9%, respectively). Barriers such as high workloads and meetings further hindered participation, while the facilitators included participants? motivation to feel active and the perceived health benefits from movement breaks. Conclusions: Despite high fidelity, the PAW trial did not significantly reduce sedentary time, with limited uptake of movement breaks due to context-related challenges, ineffective environmental support, and high workloads during the COVID-19 pandemic. UR - https://formative.jmir.org/2025/1/e57604 UR - http://dx.doi.org/10.2196/57604 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57604 ER - TY - JOUR AU - Manning, B. Julia AU - Blandford, Ann AU - Edbrooke-Childs, Julian PY - 2024/10/22 TI - Facilitators of and Barriers to Teachers? Engagement With Consumer Technologies for Stress Management: Qualitative Study JO - J Med Internet Res SP - e50457 VL - 26 KW - teachers KW - stress KW - workplace KW - self-management KW - digital health KW - technology KW - qualitative KW - context KW - high schools KW - wearables KW - apps KW - human-computer interaction KW - HCI KW - personal informatics N2 - Background: Consumer technology is increasingly being adopted to support personal stress management, including by teachers. Multidisciplinary research has contributed some knowledge of design and features that can help detect and manage workplace stress. However, there is less understanding of what facilitates engagement with ubiquitous ?off the shelf? technologies, particularly in a specific occupational setting. An understanding of features that facilitate or inhibit technology use, and the influences of contexts on the manner of interaction, could improve teachers? stress-management opportunities. Objective: The aim of the study was to investigate the interaction features that facilitated or inhibited engagement with 4 consumer technologies chosen by teachers for stress management, as well as the influence of the educational contexts on their engagement. We also examined how use of well-being technology could be better supported in the school. Methods: The choice of consumer technologies was categorized in a taxonomy for English secondary school teachers according to stress-management strategies and digital features. Due to the COVID-19 pandemic, we adapted the study so that working from home in the summer could be contrasted with being back in school. Thus, a longitudinal study intended for 6 weeks in the summer term (in 2020) was extended into the autumn term, lasting up to 27 weeks. Teachers chose to use either a Withings smartwatch or Wysa, Daylio, or Teacher Tapp apps. Two semistructured interviews and web-based surveys were conducted with 8 teachers in England in the summer term, and 6 (75%) of them took part in a third interview in the autumn term. Interviews were analyzed using reflexive thematic analysis informed by interpretive phenomenological analysis. Results: Technology elements and characteristics such as passive data collation, brevity of interaction, discreet appearance, reminders, and data visualization were described by teachers as facilitators. Lack of instructions and information on features, connectivity, extended interaction requirements, and nondifferentiation of activity and exercise data were described as barriers. Mesocontextual barriers to engagement were also reported, particularly when teachers were back on school premises, including temporal constraints, social stigma, and lack of private space to de-stress. Teachers had ideas for feature improvements and how educational leadership normalizing teachers? stress management with consumer technologies could benefit the school culture. Conclusions: Having preselected their stress-management strategies, teachers were able to harness design features to support themselves over an extended period. There could be an important role for digital interventions as part of teachers? stress management, which the school leadership would need to leverage to maximize their potential. The findings add to the holistic understanding of situated self-care and should inform developers? considerations for occupational digital stress support. UR - https://www.jmir.org/2024/1/e50457 UR - http://dx.doi.org/10.2196/50457 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/50457 ER - TY - JOUR AU - Kiani, Parmiss AU - Dolling-Boreham, Roberta AU - Hameed, Saif Mohamed AU - Masino, Caterina AU - Fecso, Andras AU - Okrainec, Allan AU - Madani, Amin PY - 2024/9/10 TI - Usability, Ergonomics, and Educational Value of a Novel Telestration Tool for Surgical Coaching: Usability Study JO - JMIR Hum Factors SP - e57243 VL - 11 KW - augmented reality KW - AR KW - surgical training KW - telestration KW - tele-stration KW - surgical training technology KW - minimally invasive surgery KW - surgery KW - surgeon KW - surgeons KW - surgical KW - surgical coaching KW - surgical teaching KW - telemonitoring KW - telemonitor KW - tele-monitoring KW - tele-monitor KW - usability KW - usable KW - usableness KW - usefulness KW - utility KW - digital health KW - digital technology KW - digital intervention KW - digital interventions N2 - Background: Telementoring studies found technical challenges in achieving accurate and stable annotations during live surgery using commercially available telestration software intraoperatively. To address the gap, a wireless handheld telestration device was developed to facilitate dynamic user interaction with live video streams. Objective: This study aims to find the perceived usability, ergonomics, and educational value of a first-generation handheld wireless telestration platform. Methods: A prototype was developed with four core hand-held functions: (1) free-hand annotation, (2) cursor navigation, (3) overlay and manipulation (rotation) of ghost (avatar) instrumentation, and (4) hand-held video feed navigation on a remote monitor. This device uses a proprietary augmented reality platform. Surgeons and trainees were invited to test the core functions of the platform by performing standardized tasks. Usability and ergonomics were evaluated with a validated system usability scale and a 5-point Likert scale survey, which also evaluated the perceived educational value of the device. Results: In total, 10 people (9 surgeons and 1 senior resident; 5 male and 5 female) participated. Participants strongly agreed or agreed (SA/A) that it was easy to perform annotations (SA/A 9, 90% and neutral 0, 0%), video feed navigation (SA/A 8, 80% and neutral 1, 10%), and manipulation of ghost (avatar) instruments on the monitor (SA/A 6, 60% and neutral 3, 30%). Regarding ergonomics, 40% (4) of participants agreed or strongly agreed (neutral 4, 40%) that the device was physically comfortable to use and hold. These results are consistent with open-ended comments on the device?s size and weight. The average system usability scale was 70 (SD 12.5; median 75, IQR 63-84) indicating an above average usability score. Participants responded favorably to the device?s perceived educational value, particularly for postoperative coaching (agree 6, 60%, strongly agree 4, 40%). Conclusions: This study presents the preliminary usability results of a novel first-generation telestration tool customized for use in surgical coaching. Favorable usability and perceived educational value were reported. Future iterations of the device should focus on incorporating user feedback and additional studies should be conducted to evaluate its effectiveness for improving surgical education. Ultimately, such tools can be incorporated into pedagogical models of surgical coaching to optimize feedback and training. UR - https://humanfactors.jmir.org/2024/1/e57243 UR - http://dx.doi.org/10.2196/57243 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57243 ER - TY - JOUR AU - Turesson, Christina AU - Liedberg, Gunilla AU - Björk, Mathilda PY - 2023/12/11 TI - Evaluating the Clinical Use and Utility of a Digital Support App for Employees With Chronic Pain Returning to Work (SWEPPE): Observational Study JO - JMIR Hum Factors SP - e52088 VL - 10 KW - chronic pain KW - digital support KW - eHealth KW - return-to-work KW - user data KW - mobile phone N2 - Background: The digital app SWEPPE (sustainable worker, a digital support for persons with chronic pain and their employers) was developed to improve the support of people with chronic pain in their return-to-work process after sick leave and includes functions such as the action plan, daily self-rating, self-monitoring graphs, the coach, the library, and shared information with the employer. Objective: This study aims to describe the use of the smartphone app SWEPPE among people with chronic pain who have participated in an interdisciplinary pain rehabilitation program. Methods: This is a case study including 16 people participating in a feasibility study. The analyses were based on user data collected for 3 months. Quantitative data regarding used functions were analyzed with descriptive statistics, and qualitative data of identified needs of support from the employer were grouped into 8 categories. Results: Self-monitoring was used by all participants (median 26, IQR 8-87 daily registrations). A total of 11 (N=16, 69%) participants set a work-related goal and performed weekly evaluations of goal fulfillment and ratings of their work ability. In total, 9 (56%) participants shared information with their employer and 2 contacted the coach. A total of 15 (94%) participants identified a total of 51 support interventions from their employer. Support to adapt to work assignments and support to adapt to work posture were the 2 biggest categories. The most common type of support identified by 53% (8/15) of the participants was the opportunity to take breaks and short rests. Conclusions: Participants used multiple SWEPPE functions, such as daily self-registration, goal setting, self-monitoring, and employer support identification. This shows the flexible nature of SWEPPE, enabling individuals to select functions that align with their needs. Additional research is required to investigate the extended use of SWEPPE and how employers use shared employee information. UR - https://humanfactors.jmir.org/2023/1/e52088 UR - http://dx.doi.org/10.2196/52088 UR - http://www.ncbi.nlm.nih.gov/pubmed/38079212 ID - info:doi/10.2196/52088 ER - TY - JOUR AU - Pacheco, Alissa AU - van Schaik, A. Tempest AU - Paleyes, Nadzeya AU - Blacutt, Miguel AU - Vega, Julio AU - Schreier, R. Abigail AU - Zhang, Haiyan AU - Macpherson, Chelsea AU - Desai, Radhika AU - Jancke, Gavin AU - Quinn, Lori PY - 2023/10/23 TI - A Wearable Vibratory Device (The Emma Watch) to Address Action Tremor in Parkinson Disease: Pilot Feasibility Study JO - JMIR Biomed Eng SP - e40433 VL - 8 KW - Parkinson?s disease KW - action tremor KW - Emma Watch KW - vibration KW - haptic feedback KW - handwriting KW - drawing KW - spirals KW - hand function N2 - Background: Parkinson disease (PD) is a neurodegenerative disease that has a wide range of motor symptoms, such as tremor. Tremors are involuntary movements that occur in rhythmic oscillations and are typically categorized into rest tremor or action tremor. Action tremor occurs during voluntary movements and is a debilitating symptom of PD. As noninvasive interventions are limited, there is an ever-increasing need for an effective intervention for individuals experiencing action tremors. The Microsoft Emma Watch, a wristband with 5 vibrating motors, is a noninvasive, nonpharmaceutical intervention for tremor attenuation. Objective: This pilot study investigated the use of the Emma Watch device to attenuate action tremor in people with PD. Methods: The sample included 9 people with PD who were assessed on handwriting and hand function tasks performed on a digitized tablet. Tasks included drawing horizontal or vertical lines, tracing a star, spiral, writing ?elelelel? in cursive, and printing a standardized sentence. Each task was completed 3 times with the Emma Watch programmed at different vibration intensities, which were counterbalanced: high intensity, low intensity (sham), and no vibration. Digital analysis from the tablet captured kinematic, dynamic, and spatial attributes of drawing and writing samples to calculate mathematical indices that quantify upper limb motor function. APDM Opal sensors (APDM Wearable Technologies) placed on both wrists were used to calculate metrics of acceleration and jerk. A questionnaire was provided to each participant after using the Emma Watch to gain a better understanding of their perspectives of using the device. In addition, drawings were compared to determine whether there were any visual differences between intensities. Results: In total, 9 people with PD were tested: 4 males and 5 females with a mean age of 67 (SD 9.4) years. There were no differences between conditions in the outcomes of interest measured with the tablet (duration, mean velocity, number of peaks, pause time, and number of pauses). Visual differences were observed within a small subset of participants, some of whom reported perceived improvement. The majority of participants (8/9) reported the Emma Watch was comfortable, and no problems with the device were reported. Conclusions: There were visually depicted and subjectively reported improvements in handwriting for a small subset of individuals. This pilot study was limited by a small sample size, and this should be taken into consideration with the interpretation of the quantitative results. Combining vibratory devices, such as the Emma Watch, with task specific training, or personalizing the frequency to one?s individual tremor may be important steps to consider when evaluating the effect of vibratory devices on hand function or writing ability in future studies. While the Emma Watch may help attenuate action tremor, its efficacy in improving fine motor or handwriting skills as a stand-alone tool remains to be demonstrated. UR - https://biomedeng.jmir.org/2023/1/e40433 UR - http://dx.doi.org/10.2196/40433 UR - http://www.ncbi.nlm.nih.gov/pubmed/38875672 ID - info:doi/10.2196/40433 ER - TY - JOUR AU - Almansour, Amal AU - Montague, Enid AU - Furst, Jacob AU - Raicu, Daniela PY - 2023/9/8 TI - Evaluation of Eye Gaze Dynamics During Physician-Patient-Computer Interaction in Federally Qualified Health Centers: Systematic Analysis JO - JMIR Hum Factors SP - e46120 VL - 10 KW - patient-physician-computer interaction KW - nonverbal communication KW - Federally Qualified Health Centers KW - primary care encounter N2 - Background: Understanding the communication between physicians and patients can identify areas where they can improve and build stronger relationships. This led to better patient outcomes including increased engagement, enhanced adherence to treatment plan, and a boost in trust. Objective: This study investigates eye gaze directions of physicians, patients, and computers in naturalistic medical encounters at Federally Qualified Health Centers to understand communication patterns given different patients? diverse backgrounds. The aim is to support the building and designing of health information technologies, which will facilitate the improvement of patient outcomes. Methods: Data were obtained from 77 videotaped medical encounters in 2014 from 3 Federally Qualified Health Centers in Chicago, Illinois, that included 11 physicians and 77 patients. Self-reported surveys were collected from physicians and patients. A systematic analysis approach was used to thoroughly examine and analyze the data. The dynamics of eye gazes during interactions between physicians, patients, and computers were evaluated using the lag sequential analysis method. The objective of the study was to identify significant behavior patterns from the 6 predefined patterns initiated by both physicians and patients. The association between eye gaze patterns was examined using the Pearson chi-square test and the Yule Q test. Results: The results of the lag sequential method showed that 3 out of 6 doctor-initiated gaze patterns were followed by patient-response gaze patterns. Moreover, 4 out of 6 patient-initiated patterns were significantly followed by doctor-response gaze patterns. Unlike the findings in previous studies, doctor-initiated eye gaze behavior patterns were not leading patients? eye gaze. Moreover, patient-initiated eye gaze behavior patterns were significant in certain circumstances, particularly when interacting with physicians. Conclusions: This study examined several physician-patient-computer interaction patterns in naturalistic settings using lag sequential analysis. The data indicated a significant influence of the patients? gazes on physicians. The findings revealed that physicians demonstrated a higher tendency to engage with patients by reciprocating the patient?s eye gaze when the patient looked at them. However, the reverse pattern was not observed, suggesting a lack of reciprocal gaze from patients toward physicians and a tendency to not direct their gaze toward a specific object. Furthermore, patients exhibited a preference for the computer when physicians directed their eye gaze toward it. UR - https://humanfactors.jmir.org/2023/1/e46120 UR - http://dx.doi.org/10.2196/46120 UR - http://www.ncbi.nlm.nih.gov/pubmed/37682590 ID - info:doi/10.2196/46120 ER - TY - JOUR AU - Hwang, Youjin AU - Shin, Donghoon AU - Eun, Jinsu AU - Suh, Bongwon AU - Lee, Joonhwan PY - 2021/3/29 TI - Design Guidelines of a Computer-Based Intervention for Computer Vision Syndrome: Focus Group Study and Real-World Deployment JO - J Med Internet Res SP - e22099 VL - 23 IS - 3 KW - computer-based intervention KW - computer vision syndrome KW - system interface KW - deployment study N2 - Background: Prolonged time of computer use increases the prevalence of ocular problems, including eye strain, tired eyes, irritation, redness, blurred vision, and double vision, which are collectively referred to as computer vision syndrome (CVS). Approximately 70% of computer users have vision-related problems. For these reasons, properly designed interventions for users with CVS are required. To design an effective screen intervention for preventing or improving CVS, we must understand the effective interfaces of computer-based interventions. Objective: In this study, we aimed to explore the interface elements of computer-based interventions for CVS to set design guidelines based on the pros and cons of each interface element. Methods: We conducted an iterative user study to achieve our research objective. First, we conducted a workshop to evaluate the overall interface elements that were included in previous systems for CVS (n=7). Through the workshop, participants evaluated existing interface elements. Based on the evaluation results, we eliminated the elements that negatively affect intervention outcomes. Second, we designed our prototype system LiquidEye that includes multiple interface options (n=11). Interface options included interface elements that were positively evaluated in the workshop study. Lastly, we deployed LiquidEye in the real world to see how the included elements affected the intervention outcomes. Participants used LiquidEye for 14 days, and during this period, we collected participants? daily logs (n=680). Additionally, we conducted prestudy and poststudy surveys, and poststudy interviews to explore how each interface element affects participation in the system. Results: User data logs collected from the 14 days of deployment were analyzed with multiple regression analysis to explore the interface elements affecting user participation in the intervention (LiquidEye). Statistically significant elements were the instruction page of the eye resting strategy (P=.01), goal setting of the resting period (P=.009), compliment feedback after completing resting (P<.001), a mid-size popup window (P=.02), and CVS symptom-like effects (P=.004). Conclusions: Based on the study results, we suggested design implications to consider when designing computer-based interventions for CVS. The sophisticated design of the customization interface can make it possible for users to use the system more interactively, which can result in higher engagement in managing eye conditions. There are important technical challenges that still need to be addressed, but given the fact that this study was able to clarify the various factors related to computer-based interventions, the findings are expected to contribute greatly to the research of various computer-based intervention designs in the future. UR - https://www.jmir.org/2021/3/e22099 UR - http://dx.doi.org/10.2196/22099 UR - http://www.ncbi.nlm.nih.gov/pubmed/33779568 ID - info:doi/10.2196/22099 ER - TY - JOUR AU - Alfred, C. Myrtede AU - Cohen, N. Tara AU - Cohen, A. Kate AU - Kanji, F. Falisha AU - Choi, Eunice AU - Del Gaizo, John AU - Nemeth, S. Lynne AU - Alekseyenko, V. Alexander AU - Shouhed, Daniel AU - Savage, J. Stephen AU - Anger, T. Jennifer AU - Catchpole, Ken PY - 2021/2/9 TI - Using Flow Disruptions to Examine System Safety in Robotic-Assisted Surgery: Protocol for a Stepped Wedge Crossover Design JO - JMIR Res Protoc SP - e25284 VL - 10 IS - 2 KW - robotic surgical procedures KW - patient safety KW - ergonomics KW - crossover design N2 - Background: The integration of high technology into health care systems is intended to provide new treatment options and improve the quality, safety, and efficiency of care. Robotic-assisted surgery is an example of high technology integration in health care, which has become ubiquitous in many surgical disciplines. Objective: This study aims to understand and measure current robotic-assisted surgery processes in a systematic, quantitative, and replicable manner to identify latent systemic threats and opportunities for improvement based on our observations and to implement and evaluate interventions. This 5-year study will follow a human factors engineering approach to improve the safety and efficiency of robotic-assisted surgery across 4 US hospitals. Methods: The study uses a stepped wedge crossover design with 3 interventions, introduced in different sequences at each of the hospitals over four 8-month phases. Robotic-assisted surgery procedures will be observed in the following specialties: urogynecology, gynecology, urology, bariatrics, general, and colorectal. We will use the data collected from observations, surveys, and interviews to inform interventions focused on teamwork, task design, and workplace design. We intend to evaluate attitudes toward each intervention, safety culture, subjective workload for each case, effectiveness of each intervention (including through direct observation of a sample of surgeries in each observational phase), operating room duration, length of stay, and patient safety incident reports. Analytic methods will include statistical data analysis, point process analysis, and thematic content analysis. Results: The study was funded in September 2018 and approved by the institutional review board of each institution in May and June of 2019 (CSMC and MDRH: Pro00056245; VCMC: STUDY 270; MUSC: Pro00088741). After refining the 3 interventions in phase 1, data collection for phase 2 (baseline data) began in November 2019 and was scheduled to continue through June 2020. However, data collection was suspended in March 2020 due to the COVID-19 pandemic. We collected a total of 65 observations across the 4 sites before the pandemic. Data collection for phase 2 was resumed in October 2020 at 2 of the 4 sites. Conclusions: This will be the largest direct observational study of surgery ever conducted with data collected on 680 robotic surgery procedures at 4 different institutions. The proposed interventions will be evaluated using individual-level (workload and attitude), process-level (perioperative duration and flow disruption), and organizational-level (safety culture and complications) measures. An implementation science framework is also used to investigate the causes of success or failure of each intervention at each site and understand the potential spread of the interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/25284 UR - https://www.researchprotocols.org/2021/2/e25284 UR - http://dx.doi.org/10.2196/25284 UR - http://www.ncbi.nlm.nih.gov/pubmed/33560239 ID - info:doi/10.2196/25284 ER -