A total of 63 interviews were conducted, involving 25 clinicians, between July 2022 to October 2023. Sixteen clinicians were interviewed across three timepoints, six were interviewed at two timepoints and three were interviewed at one timepoint. Drop-outs occurred due to extended leave (n = 2) or resignations (n = 2). Interviews ranged from 19 to 83 min, with an average duration of 48 min. Participants included nine occupational therapists, eight physiotherapists, three recreational therapists, two speech pathologists, two allied health assistants and one dietician. Participant demographics can be found in Table 2.

Table 2 Participant demographics across each timepoint

One overarching finding comprised of three major themes and 12 subthemes, each detailed below, with key de-identified quotes from participants in italics used to illustrate findings. Additional participant quotes can be found in Additional File 2. Figure 1 depicts a schematic representation of findings, while Table 3 provides an overview of themes and subthemes linked to research questions and data collection aims.

Fig. 1

Schematic representing study findings of clinician experiences of integrating advanced technology into rehabilitation practice

Table 3 Overview of themes and subthemes linked to research questions and data collection aimsHuman interactions remain at the heart of rehabilitation with advanced technology

Repeated interviews with allied health clinicians across the first 16 months of the technology centre opening revealed that clinician uptake of technology did not happen by chance or by the devices simply being made available to clinicians. Rather, integrating advanced technology required substantial learning, practice change and targeted initiatives. Successful integration of advanced technology into rehabilitation relied on clinician buy-in to champion change in an enabling person-centered context that retains human interactions at the heart of rehabilitation.

Theme 1: Technology integration involves cognitive and emotional labour for clinicians

Incorporating advanced technology into rehabilitation demanded a significant investment of time and energy from clinicians, as reflected in the following three subthemes.

Determining the value-add and relevance of advanced technology

To undertake the cognitive and emotional labour associated with integrating advanced technology, clinicians had to first determine the value-add and relevance of technology for their practice. Many participants were enthusiastic about technology, excited to be at the forefront of rehabilitation advancement and growth. This enthusiasm was accompanied by a sense that technology offered personal benefits such as professional development, mental stimulation, increased creativity and enhanced clinical reasoning.

Yet, positivity towards technology was not universal. Some participants noted the time and energy required to learn how to use advanced technology was disproportionate to the small role it played in their practice: “How can I…contribute all of this time and effort into training…when there’s so many other things. I guess that comes back to, it’s not impactful on my day-to-day because it’s a smaller portion of my day”. Others were concerned about narrowing their skillset to a niche area of rehabilitation, potentially losing other important skills, such as conventional manual handling.

Juggling overwhelming learning and emotional demands

Regardless of their attitudes towards technology, all interviewees articulated the struggle to prioritise learning and using technology in a time-poor clinical environment. Beyond the constraints of time, this involved overwhelming cognitive labour for clinicians while keeping up with numerous demands in busy clinical settings. Participants also described navigating a myriad of complex patient emotions in rehabilitation, arising from expectations of recovery, adjustment to illness and supporting transitions into the community. Managing these emotions alone was at times overwhelming and took an emotional toll on clinicians: “At the end of a day [clinicians] can be absolutely shattered, energy, emotionally and physically.”

Many participants also grappled with feeling daunted in the early phase of technology uptake. Clinicians felt responsible for delivering effective therapy and did not want to appear incompetent to patients. Applying new knowledge while still developing competence made some “feel like a fraud”, and going from having confidence in their clinical skills to feeling like a novice again left many participants feeling vulnerable.

Given the labour of integrating advanced technology, most participants perceived patient satisfaction with advanced technology to be higher than theirs. To choose to invest their precious time and energy into advanced technology, some were bolstered by open-mindedness and a love of learning, while others were motivated by successful experiences of using technology with patients.

Negotiating pressures from patients’ high expectations of advanced technology

A major aspect of the emotional labour many clinicians undertook was a direct result of patients’ high expectations of advanced technology. Clinicians in this study described patients as being overwhelmingly positive and excited about technology, particularly robotic devices. This excitement triggered false hopes and unrealistic expectations in many patients, felt to be driven by individuals seeking a “cure”. The messaging promoting advanced technology in media and marketing campaigns was also felt to exacerbate patients’ high expectations. In the early stages of integrating technology, although participants described the importance of minimising false hopes, understanding of how to effectively manage patients’ expectations of technology was limited. This added an additional layer of responsibility on clinicians.

“Some clients think tech is the magic that’s going to make everything perfect for them. For some people it will work really beautifully, but for some clients it [won’t]. I’ve really had to work on my ability to set realistic expectations around it.”

Recognising the human elements of clinicians and their own emotional needs was crucial for integrating advanced technology into practice. Despite the cognitive and emotional labour, many clinicians in this study bought into technology as part of the future of rehabilitation and were willing to take on the extra work, acknowledging the need to embrace technology to “evolve and move with the times”.

Theme 2: Contextual factors shape clinician uptake and ongoing use of technology

An interplay of contextual factors influenced clinician access to, perceived need for, and uptake of advanced technology. The following five subthemes detail these factors.

Organisational culture and initiatives impact clinician engagement with technology

Organisational factors were pivotal in influencing clinician engagement, uptake and attitudes towards advanced technology. A key organisational initiative was appointing an advanced technology lead to facilitate training, guide implementation, answer clinical questions and assist with technological troubleshooting. “[The lead is] such a good resource. You need someone…in that role”. Clinicians also highly valued learning from, collaborating with and supporting each other. As such, a positive workplace culture of respect and support was a powerful facilitator for many interviewees, including an enabling dynamic of being equally willing to ask for and provide help: “Everybody’s really approachable and keen to learn and keen to help and so that really breaks down barriers”.

Leadership also played a significant role in shaping workplace culture and facilitating technology engagement. Amid the ongoing practice change required for technology uptake, managerial support and recognition were key for maintaining team morale. Practical supports included providing clinical backfill, allowing time to learn technology, and reducing pressures to meet quotas for clinical care while learning. Other initiatives included employing allied health assistants to assist with set-up, use and cleaning of devices. Meanwhile, inefficient processes, such as requiring bookings to access devices were seen as barriers.

Clinicians’ professional discipline influences their relationship with technology

Interviewees from different professional disciplines exhibited distinct differences in their therapeutic approaches and uptake of advanced technology. A common observation was that the advanced technologies were predominantly “impairment focused”. Consequently, incorporating technology into therapy required additional considerations for disciplines, such as occupational and recreational therapists, who typically work towards participation-level goals within real-world contexts (e.g., return to work or sport). In contrast, physiotherapists, who routinely address impairments (e.g., muscle weakness) and activity limitations (e.g., difficulty walking), found it easier to incorporate advanced technology into their practice.

The make-up of a clinician’s role also influenced their capacity for practice change. For example, occupational therapists are commonly involved in environmental modification and equipment prescription. Meanwhile, recreational therapists often address activity modification, equipment and support needs, which involve substantial learning given the diverse recreational interests of patients. The more tasks outside impairment-based therapy and task-practice occupied a clinician’s role, the less capacity they had to learn and use advanced technology.

Rehabilitation setting influences clinician access to and need for technology

There were substantial differences in technology uptake between inpatient, outpatient and community services. The convenience of patients coming directly to the therapist was a significant facilitator for outpatient services co-located in the technology centre. Meanwhile, logistical barriers, such as device booking, getting to and transporting the device, were particularly noteworthy for clinicians in community-based services. Scheduling sessions with advanced technology in inpatient settings was also challenging due to the reduced control clinicians had over their day. Inpatient clinicians required flexibility with their therapy sessions, which was challenging when sharing technology with services requiring regimented scheduling such as in outpatient or community settings.

Study participants also reported inpatient clinicians face many competing high priorities. These included patient discharges, admissions, writing funding reports, conducting group classes, addressing home modifications, equipment prescription, and patient safety on the ward. Longer admission periods, slower turnover of patients and the generally static nature of specialist inpatient rehabilitation caseloads also resulted in less opportunities for inpatient clinicians to build and maintain confidence in using devices. Finally, in inpatient settings, therapy objectives and pressures were often shaped by patient adjustment and facilitating safe discharges. In community settings, “goals are around resettling at home and transitioning to a reduction in care”. Meanwhile, rehabilitation in the outpatient setting was primarily focused on providing impairment- and activity-related therapy. Therefore, in this study, advanced technology was easier to fit into an outpatient service model.

Patient characteristics influence clinician ability to utilise technology

Participants found their use of technology fluctuated depending on the presence of appropriate patients in their case-mix. Cognitive impairment was the most reported patient-related barrier to technology use. Participants found it challenging to introduce advanced technologies and explain the functional relevance to patients with cognitive impairment. Conventional therapy methods were described as more conducive for cognitively impaired patients due to familiarity and availability of contextual cues. Physical impairments in patients, such as contractures and spasticity also limited clinician use of advanced technology. One participant reported the advanced technologies currently available were often only suitable for addressing one impairment, “for people who have issues in isolation… [not a] combination of issues”, making it challenging to accommodate the needs of patients with multiple complex impairments.

Time since injury was another important factor influencing clinician use of advanced technology, with participants expressing a preference for use with patients in the acute or sub-acute phase due to “active rehab goals” from being “right in the middle of that neuroplasticity and relearning”. In contrast, achieving functional gains was reportedly harder for patients in the chronic phase of their condition, where improvements were often incremental and impairment-focused. Advanced technology was also thought to be most helpful for patients who were motivated in their therapy as they were more ready to carryover feedback and learned skills into conventional therapy and daily life. Many interviewees noted the importance of patient adherence to independent therapy outside of therapy sessions: “You can’t just come here, the robot’s not going to “fix” you…you “fix” yourself by doing the work”.

Device variety and versatility influence technology usability

Having a wide range of devices available was largely positive, as it offered variety in therapy and increased the likelihood of finding a device suitable for a patient’s needs. However, having many devices increased the demand on training resources and contributed to challenges in clinician selection of a device to use. Clinicians in this study preferred devices which were easy to set-up, easy to use, not prescriptive and versatile in tailoring to a range of patients and activities. Conversely, technologies which did not replicate the demands of activities of daily living and had restricted movements or a “fiddly set-up” were less appealing.

The increasingly nuanced understanding of the contextual factors across timepoints revealed their dynamic interplay. Clinicians’ experiences and uptake of technology were not only shaped by distinct factors, such as discipline or patient characteristics, but also by how factors intersected across settings and types of devices. This illuminated the need for direct communication channels between clinicians and leaders in the organisation to effectively address contextual barriers. Such interactions ensure clinicians can provide feedback and “[stay] in the loop”, while leaders can ensure “the integration of feedback from below”.

Theme 3: Shared understanding and priorities promote technology implementation and sustainment

Clinicians’ understanding of implementing advanced technology became more sophisticated over time. Some participants, especially occupational therapists found themselves learning how to “relate technology to function”. Others found increased confidence and experimentation with advanced technology was accompanied by less apprehension. By the third timepoint, many clinicians spoke more confidently about using the devices, as technology use became part of their everyday language. However, evidence of the additional load on clinicians and the five contextual factors remained, with some feeling fatigued from the intense focus on technology and referring to advanced technology as “one part of many things that we do, and every bit is as important as the other”. Ultimately, clinicians’ focus remained on their patients and interactions with patients. Four subthemes related to clinicians’ priorities during technology implementation and sustainment are described below.

Understanding the role of advanced technology in relation to conventional therapy

Participants in this study consistently positioned technology as a tool in the rehabilitation clinician’s toolbox. Almost all participants reported the main benefit of using advanced technologies as increasing therapy dosage through its ability to enhance patient engagement in rehabilitation: “[Technology] allows people to achieve the big amount of repetitions that are needed…[it can] make rehab a little less scary, a bit more fun”. Advanced technology can also reduce the manual handling load on clinicians, collect objective measures and provide precise “real-time feedback”. Due to the additional support provided by some devices, participants felt using advanced technology increased safety in therapy and allowed clinicians to do more therapy and challenge patients earlier in their rehabilitation journey.

However, advanced technologies were not considered endpoints of therapy in themselves. Conventional therapy was viewed as essential for translating impairment and activity-level gains into real-world benefits. Therefore, participants emphasised that advanced technology should not be positioned as better than, but complimentary to conventional methods.

A well-designed training model to develop clinician competence and confidence

Developing and maintaining clinician competence and confidence with technology was core to implementing and sustaining advanced technology use in practice. Participants want to “feel confident to use [technology]…know what types of patients [to] use it for…what indications or contra indications there might be…how to adapt it to the patient…and if issues come up…[to] know how to trouble shoot it”. Developing confidence appeared to occur in two stages. Learning the practical device set-up and operation was followed by learning intricacies and using the device for a range of purposes with in-depth clinical reasoning.

Practical and hands-on initial training with a device was most useful, with guidance for device set-up and supervised sessions with patients. Participants also desired ongoing training in a variety of formats, including internal, external, one-to-one and small groups. Immersive learning in blocks of protected time or days was preferred by participants, opposed to intermittent sessions which posed challenges for consolidating learning. Train-the-trainer models, where trained clinicians were responsible for training untrained clinicians, were particularly challenging due to difficulties with coordinating clinicians’ busy schedules. It was also important for the organisation to create opportunities for clinicians to “peer problem-solve” issues without judgement or the expectation to master all aspects of technology.

Equipping clinicians to delicately manage patient expectations

Equipping clinicians to navigate delicate conversations was also fundamental for implementing and sustaining advanced technology use in rehabilitation: “We need to skill up the staff in everything. Not just in using the tech, but other aspects that come around that.” Such conversations are not new in rehabilitation, with clinicians often discussing negative prognosis, patients “plateauing”, and managing general expectations “around rehab…and what rehab means”. However, advanced technology added a layer of complexity to these conversations.

Underpinning this was distinguishing between hope and false expectation and learning to establish realistic expectations without quashing hope. Clinicians in this study found that delicate conversations were best approached with transparency, clear communication and compassion. Raising these conversations with patients at the beginning of therapy and throughout was crucial, including setting realistic goals directly linked to activities of daily living to ensure the functional goal, not the technology, was the focus. Once patients achieved their goals or if they plateaued, it was seen as important to wean off advanced technology, try a different therapy approach or focus on patient self-management. Within outpatient services, one approach to managing patient expectations described by many participants was to offer time-limited blocks of therapy. Timeframes prompted clinicians and patients to revisit delicate conversations and retain realistic goals as the focus of therapy. To aid in managing patient expectations and alleviating pressure on clinicians, several also suggested that media and marketing should avoid “promoting and showcasing [technology] for social media”, but rather, highlight “real patient outcomes and for real people”.

Ongoing commitment to evidence-based practice to resolve uncertainties

Clinicians’ sustained use of advanced technology remained fragile due to many ongoing uncertainties regarding evidence about device effectiveness, prescription and selection. The need for better clinical reasoning and evidence-based guidelines for device selection was highlighted by many participants: “[We need] clearer clinical pathways for selection of devices…It would be good to see the research coming out…about what works, and why…to help with the development of clinical reasoning.”

In the absence of high-quality evidence, using outcome measures to inform appropriateness of technology use was considered crucial to justify therapy decisions and ensure evidence-based practice. Participants believed more rigorous evidence to support advanced technology use in rehabilitation should be prioritised, particularly regarding effectiveness for improving patient outcomes. There was a clear commitment amongst clinicians to align their practices to research evidence. However, the limited availability of robust evidence added to the fragility of implementing and sustaining advanced technology use in practice.

Participant checking

Prior to finalising the results and themes, 19 participants were invited via email to provide feedback on the study results. The other six participants were not able to be contacted due to resignations. Of the 19 participants, five provided feedback (26%). Feedback was positive, with participants reporting that the findings captured their experiences, the complexity of integrating technology into practice and reflected ongoing discussions across the organisation. One clinician reported that the findings “validate [their] own experience…and gave great insight into the wider experiences of team members”. No participants expressed disagreement with the findings, however one participant reported that the high expectations from patients was not their experience, as in their discipline the “high tech equipment” was less relevant. Finally, one clinician reported expecting more discussion regarding the value of the advanced technology lead, as this was “absolutely critical to successful implementation”.