Perceived barriers and opportunities to the use of 3D printing in a healthcare system with low adoption: A semi-structured interview study

Study design and ethics

A semi-structured interview guide was developed by the research team, based on previous interviews of this nature^17–19. The interview guide was externally validated by a research nurse and a design engineer. The researchers adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to standardise the conduct and reporting of the study. The complete guidelines can be accessed at Open Science Framework https://doi.org/10.17605/OSF.IO/N352E (https://osf.io/)²⁰. The study was performed in accordance with the Declaration of Helsinki ethical principles for medical research involving human subjects²¹. Ethical approval was obtained from the Research Ethics Committee of the University of Limerick (Reference number REF - 2023_12_04_S&E). Written consent was explicitly sought prior to commencement of each interview. The interview guide is presented in Table 1.

Participants

HCPs who care for patients in both the public and private Irish healthcare system were invited to take part in the interviews. Participants were invited through the research team’s professional associations and through snowball sampling. Purposive sampling was adopted to ensure variation in gender, role, and location. As the study aimed to target various professionals within the healthcare system, a wide reach was sought in its distribution. Recruitment was conducted via email and prospective participants were sent an information leaflet with consent form for review prior to enrolment in the study.

Demographics

A total of ten (n=10) participants were interviewed. Semi-structured interviews were conducted online and in person with four HCPs in the private system and six in the public healthcare system. The private sector interviewees comprised an orthopaedic consultant, plastics consultant, hand therapist and a physiotherapist. The public sector interviewees included an Occupational Therapist (OT) and two physiotherapists. Three nursing professionals were interviewed. One was an innovation nurse specialist, one a nurse working as a university teacher, and one a nurse working for an innovation unit. The geographical span of the interviewees was spread across the country.

Data collection and analysis

The interviews were conducted either on the telephone or in person using an interview script with probing questions being posed when necessary. Audio interviews were recorded verbatim using Otter AI and transcribed notes were entered into qualitative analysis software (Nvivo 14 NVivo - Lumivero) to support the data analysis process. NVivo (Version 14) was used in this study in accordance with the copyright licensing agreement provided by the University of Limerick. Reflexive thematic analysis was used to identify the main themes to provide a rich and detailed account of the data²². Analysis was performed by two female researchers, UMC, a Ph.D. candidate and NM, an Associate Professor. At the beginning of the interview, the participant was given a brief overview of the researcher’s (UMC) background and her motivations for conducting the study. UMC has a nursing background and works in an academic setting as a researcher. NMC is an associate professor, public health educator, and researcher. Following reflexivity guidelines, the researchers critically assessed how their personal characteristics, beliefs, and experiences influenced the research process²². The six-step thematic analysis guide by Braun and Clarke was followed²². The first phase, familiarisation with the data involved the researchers immersing themselves in the data by reading the interviews several times to familiarise themselves. In the second phase, UMC and NMC identified initial codes, which were then organised into relevant themes for the third phase. These themes were discussed by NMC and UMC in the fourth phase to ensure homogeneity and external heterogeneity. The themes were then defined and named, and finally, the last phase involved the final analysis and narrative of the findings.

The study commenced on the 3^rd of April 2024 and closed on the 20^th of July 2024. The Criteria for Demonstrating Trustworthiness in Qualitative Research was applied to mitigate bias and demonstrate rigour and trustworthiness, Table 2²³.

Availability of time sensitive items

The HCPs interviewed provided a wide range of insight and opinion on the needs within the healthcare system that could be supported by 3D printing. One area centred around availability of time sensitive items. Frustration regarding needing a specific item for a patient and having to wait sometimes months for the item to arrive was expressed, whereby all, (n=10) respondents referred to difficulty accessing items.

“Because even if you order a piece that you need specifically for a patient, like by the time it actually goes through, you're waiting so long that it becomes defunct, like it's it would definitely bridge a gap” (P3)

“And there isn't things readily available, or else I find something online and I've got to wait three months for it to come from the UK, whereas let's say in the future, if we'd access to the 3D printer I could probably you know with the right expertise and would also be a lot of training could probably use that in day-to-day practice” (P9).

A small number of interviewees (n=3) reported having access to a design engineer who, in times of urgent need, will design and 3D print an item that the HCP would otherwise have to wait some time for.

“So he will make us kind of one-off pieces that bridge a gap for something we can't find (P6)

“So we had an example of we got new beds because we have a new unit and a piece of equipment that would no longer fit on the beds because they were a different shape. So he came up and was like drawing it out and designing it straight away” (P7)

Scope for improvements in care

One area of concern due to a paucity of resources was custom splinting for upper limb injuries and the quality of the splinting being delivered in some areas. Casts for treatment of fractures were also seen as being an area of potential usage:

“I happen to be lucky here in … as we have a physiotherapist who has a background in custom splinting. But in … there is not one person in the whole catchment area who makes them” (P2)

“for the fractures that would be the perfect place to 3D print..I have so many people coming after bad fractures with complications because of the cast, and then it drags on for months until it heals fully” (P5)

Education

Interviewees discussed how 3D printing could be used to reduce risk for patients. They felt the technology could be used to plan interventions and aid HCPs in practising procedures. There was particular focus on patients who have abnormal anatomies and challenging cases whereby the teams caring for them could practice emergency procedures ahead of time.

“Where I would see it is in quality improvement and to reduce risk and so you know if you had quite a complex surgical procedure coming up and use a 3D printed item from an image and practice on it.." (P6)

“You try a four or five different tubes, which in itself was like loads of extra procedures for the patients that are uncomfortable, you know, to try a lot of trial and error with things and actually sure if you could look at their anatomy and design something that would suit them made from a material that you already knew was going to do the job” (P3)

Awareness

HCPs highlighted that there is very low awareness on the use of 3D printing in healthcare, and little awareness of how to progress in this area. The low adoption of 3D printing in this region means that HCPs have little to no exposure therefore low levels of awareness on how to use it, where to access it and who is available to support.

“Definitely because I think if there was a better awareness, all of it on a better understanding of what it had to offer, people would think of it as solutions to problems much quicker” P1

“So if it was already nearly in your repertoire of things that you thought of as a solution to something, it would be better off” P4

Access to 3D printing

Another subtheme that developed was the lack of access to 3D printing within this healthcare system. Although they were all (n=10) open to using 3D printing, only six of the respondents had any access to a 3D printing facility and expertise. Those who have access, have limited access and rely on a design engineer to be available to work with them on the chosen project. They speak positively about these design engineers and consider them a part of the extended team to help in problem solving.

“but yes, we have a very kind, very nice clinical engineer working with us who has access to a 3D printer” (P6)

“I now have built the relationships with those people; you'd nearly ask them if it could be done as a one-off as a first port of call instead of maybe realising way down the line” (P7)

Interviewees mentioned how, as they have limited knowledge about the use of 3D printing, and do not have access to printers, they are missing opportunities to perhaps provide a better option to patients, if 3D printing was available to them.

“I have never applied it in my clinical practice, but that I would not say that's because it has never been indicated, and I think that the applications for this go beyond my wildest dreams, if I was taught and explained to what's actually possible” (P8)

Systemic healthcare challenges

HCPs refer to the healthcare system they work in being under pressure, with many challenges. They refer to difficulties in strategy development, whereby forward planning to meet demands can be lacking. They feel meeting basic patient care is still a struggle, thus embracing new technologies like 3D printing will be a low priority. This theme has developed into four subthemes: pressurised health system, resistance to change, technology acceptance and leadership.

Pressurised health system. Regarding the current health system, one interviewee felt that there is a need for planning ahead more, to help see the bigger picture and be prepared rather than reactive:

“And it's just all about putting out fires. It's all reactive. There's very little proactivity” (P4)

“I suppose, as a health system, there's such a struggle to do the basics. You know, when you see all the headline grabbing things.. about people waiting for four years for an appointment. It’s hard then to justify, giving a high profile to high tech solutions to things that are already reasonably well looked after” (P2)

“should be looked at later when the basics are running pretty well” (P2)

“get your basic patient care sorted out before we give you any high-tech toys” (P8)

The views expressed reflect the overwhelming pressure on the healthcare system to meet current demands, which leaves little room for the adoption of new technologies until foundational issues are addressed.

Resistance to change. Some HCPs felt that there is a resistance to 3D printing as it may disrupt current roles, practises, relationships, and businesses. If 3D printing were to alter well-established relationships with companies that create certain medical products, and there was no longer a need for that product as 3D printing was creating it onsite on demand, questions over copyright, safety and funding may be raised.

“you’ll find a subsection of the medical community who are threatened by new technology and the 3D printing space, that's where you'll find we don't think that's a great idea. They've invested whatever billions they have in developing the technology, and then someone goes, hey, guys, I've got a new idea. We don't need any of that. We could do it this way instead and will cost way less” (P8)

Other interviewees felt that the healthcare system does not have the appetite nor foresight to change and keep up with innovations.

“why change, this is how we do it. And this is how we do it. And this is how we always do it. And that's the problem” (P2))

“Yeah, I think a lot of the time, we're creatures of habit” (P5)

Technology acceptance. A subtheme around technology acceptance developed throughout the interviews. HCPs felt that the use of technologies for procedures that were typically provided by a therapist, such as providing orthoses, could undermine and make areas of these roles redundant. An example of a 3D printed orthosis is displayed in Figure 2. Permission to publish the photo was given by the patient. The concern was that moving care to a more technological focus could remove the human touch, and the interactions between HCP and patient.

Figure 2. Example of a 3D printed orthosis.

Permission for photo and publication of photo given by patient.

“I think regarding deskilling therapists, I think it is the world we live in. You know, there is certainly times that I feel probably the human touch has taken away a little bit more than we would like out of different facets of life, but that is the nature of the beast. You'll still need that that human touch to assess that person or to input the details or to liaise that person to even introduce the concept with them” (P9)

Leadership. HCPs commented that, within healthcare, there needs to be clinical champions who strive for evidence, and promote, recommend and work to prove a new technology is worth investigating. Peer recommendation and testimony of use appears important to the HCPs interviewed.

“So if there was somebody flying the flag for doing it, I think others would very much fall in line and follow. It has to be proven and it isn't proven within Ireland as yet” (P3)

“it takes someone being able to kind of think outside the box and look for alternatives and using other experts to get there” (P1)

Education

The first subthemes centred around HCPs being interested in learning more about 3D printing and having the opportunity to use 3D printers in their day-to-day care. It was acknowledged that education on 3D printing was considered necessary to extend its reach.

“But so I think you know there has to be just more education and to show the potential and the benefits around it” (P4)

Participant 1 commended the introduction of the concept of 3DP in schools and believes it is beneficial to have exposure to the technology as a young age.

“I think it's the creative minds of the young people and it's, you know, it's quick, you know, and they can actually put something onto print and have a finished product very quickly. So it's great to see it being introduced into the primary school curriculum” (P1)

The question was asked if 3D printing should be added to education for HCPs going forward. Viewpoints differed on whether 3DP should be included in a crowded undergraduate curriculum.

“I think they have a lot to cover at undergraduate level and I think that would be more of a specialised skill like postgraduate, you come out at a rotational level.. I'd say it's probably just a bit too much at that stage” (P7)

“I don't think necessarily, I mean, there's, there's so much on the curriculum already and training time is being shortened so much that the end result and the application of it will be more useful to learn than the process or the design considerations” (P2)

Personalised healthcare

When asked what areas of healthcare HCPs could see 3D printing having the most impact, many referenced how 3D printing could help in the provision of personalised healthcare within hospitals. Some participants discussed experiences of 3D printing providing a bespoke, personalised solution for a patient. A HCP who has access to a 3D printer and design engineer team commented on an example they had seen where 3D printing solved a problem with no other obviously obtainable solution.

“So we had one patient who was having dialysis and wanted to get back to work so needed to do her dialysis at home. She had to keep her lines at home sterile but the lines kept falling on the floor.. and the designer designed a 3D printed tabletop piece that just had like little slots in it..it was fantastic and then enabled her to go home” (P3)

The interviewee stated they had looked for an on-market option that they could use but could not find one, therefore used 3D printing to provide the bespoke solution.

Others highlighted that they felt personalised care options were needed for patients, but timely response and/or appropriate solutions was not available.

“Yeah, you'd be kind of, I guess it's trying to be really pragmatic about stuff and accepting things that it might be substandard instead of actually having something custom that can do the job” (P3)

“But you know when you think about the ways we as nurses think about the individual patient, you know, all these things, one size doesn't fit all” (P4)

“I mean, the beauty of 3D printing is the world is your oyster.

You can, you know, input whatever model you like and get it to come back out again and tweak and adjust. And I love that. I think it's really important for healthcare because every patient is different. That's what I really value” (P10)

Implications and future work

The findings of this study report that these HCPs are open to using this technology, which is promising, but they find embracing new technologies challenging due to general inefficiencies within this hospital system. This singular geographical focus may limit the generalisability of the results for international healthcare settings. Thus, an international focus on the perceived barriers and opportunities to the use of 3D printing in a healthcare system with low adoption would provide further evidence and help to support diffusion of the technology.