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Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, IndonesiaDepartment of Midwifery, Universitas Muhammadiyah Sidoarjo, East Java, Indonesia
Address correspondence to: Yunita Widyastuti, Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
The Enhanced Recovery After Surgery (ERAS) program is currently poorly implemented by healthcare workers. Furthermore, several inhibiting and supporting factors for this implementation have been discovered to influence healthcare workers’ perception of the program. This study aims to investigate the perception of healthcare workers regarding the ERAS program.
Design
A scoping review in a systematic manner.
Methods
A systematic search was performed using six databases: PubMed, ScienceDirect, SCOPUS, EBSCO, Proquest, and Sage Journals, from August 2011 to August 2021. The data was extracted using an excel worksheet, and the results obtained were presented descriptively.
Findings
This study selected a total of 10 articles, where both qualitative and quantitative methods were used to discuss the perceptions of healthcare workers about ERAS.
Conclusions
Based on this study's findings, not all healthcare workers have a good perception of ERAS. The implementation of ERAS is often hindered by several factors, including resistance to change and lack of knowledge about the program. However, good teamwork and support from hospital management can support the program's implementation.
The ERAS (Enhanced Recovery After Surgery) program was introduced and implemented in the late 1990s. Patient perioperative management technique for patient recovery immediately after surgery by maintaining preoperative organ function and reducing the stress response.
This program has several primary key components, including preoperative counseling, optimal nutrition, standard anesthetic and analgesic drugs, and early mobilization.
According to previous studies, ERAS helps to reduce the length of hospital stay, the occurrence of readmission, postoperative complications, morbidity rates, as well as treatment costs.
Currently, this protocol has been implemented in various surgical fields across hospitals, however, not all health workers have implemented the program.
Implementation of ERAS (Enhanced Recovery After Surgery) protocols for radical cystectomy patients: The pathway to standardization. A systematic review.
These perceptions are either negative, positive, or indifferent, and each health worker's perception and experience of ERAS is bound to affect their attitude in daily practice. Therefore, these perceptions must be investigated and understood.
Few studies have discussed health workers’ perception of ERAS across various surgical fields. However, this study conducted a scoping review to assess the existing literature related to this topic. The primary purpose of this review is to identify the perceptions of health workers about the ERAS method, while the secondary objective is to identify the factors supporting or hindering the program's implementation.
Method
Research Design
This study used a scoping review methodology because this design provides coverage and scope for a specific issue and aims to review the key concepts from various relevant literature. The scoping review was carried out using Arksey and O'Malley's five-step process, which comprises: defining research questions, finding relevant research studies, study selection, data extraction, and mapping, followed by compiling, summarizing, and reporting results.
The research questions in this scoping review include:
1.
What is the perception of healthcare workers regarding ERAS?
2.
What is the perception of healthcare workers about the factors supporting and hindering the implementation of ERAS?
Step 2: Identifying Relevant Studies
Systematic searches were carried out across six databases: ProQuest, science direct, Scopus, Ebsco, sage, and PubMed, using the Boolean operators “AND” and “OR,” wildcards, and truncation, to broaden the search. Furthermore, the search keywords were (“ERAS” OR “enhanced recovery” OR “fast-track” OR “accelerated recovery” OR “rapid recovery” OR “early discharge” OR “patients discharge”) AND (“perspective” OR “experience” OR “perception”) AND (“professional” OR “staff” OR “nurse” OR “healthcare workers”).
All related primary research published within August 2011 and August 2021, including qualitative and quantitative studies on health workers’ perceptions of ERAS, was included in the review.
Step 3: Study Selection
Inclusion and Exclusion Criteria
The criteria for study include all qualitative and quantitative studies on the perception of healthcare workers about ERAS, published in full-text English. Meanwhile, the exclusion criteria include opinion pieces, conference abstracts, posters, editorials, and textbooks.
Study Selection
The article selection process was performed using Mendeley software, with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.
Subsequently, the data collected were processed and categorized according to the stages of identification, screening, eligibility verification, as well as inclusion and exclusion criteria. The results of two independent searches were compared, and any discrepancies in the article findings were discussed and resolved until an equal number of articles were reported.
Step 4: Extracting and Mapping Data
Data extraction was carried out using an excel worksheet. Subsequently, the data was converted into an extraction table, comprising each article's title, author, year of publication, country, research objectives, research design, number and types of participants, the field of surgery, as well as the main findings.
Step 5: Compile, Summarize and Report Result
Each article found was identified regarding the reasons for carrying out the ERAS protocol or not and the support and obstacles in implementing ERAS. The codes generated from these findings were entered in the codebook then entered into categories, ensuring no overlapping data. From the categorization results, the themes of supporting and inhibiting factors for the implementation of ERAS were generated.
Result
A total of 4,514 articles were identified during the systematic search. Of these articles, the Mendeley software detected 821 duplicate articles, and the remaining 3,693 articles were subjected to the title, as well as abstract filtering, where 3,672 articles were deemed irrelevant, and only 21 articles were selected for the full-text review. Only 10 articles were selected for this study based on the inclusion criteria (Figure 1), and the articles analyzed were publications of studies carried out in the continents Asia, North America, Europe, and Australia (Table 1). Table 2 shows a summary of the perceptions of health workers of the ERAS program, as well as the factors supporting and hindering the program's implementation.
Figure 1The Systematic Review and Meta-Analyses (PRISMA) flowchart for the identification, inclusion, and selection of articles, using the preferred reporting items.
This study aims to discover the difference in patient outcomes before and after the implementation of ERAS and to explore the perception of colorectal surgeons regarding the ERAS program.
The majority of surgeons do not believe that the ERAS program provides different outcomes to patients. Several surgeons only adopt the ERAS program for certain patients. The challenges of implementing ERAS for nurses include resistance to change, logistical or labor constraints, and poor perceptions of the program.
Healthcare professionals’ views of the enhanced recovery after surgery program: a qualitative investigation
This study aimed to investigate the factors supporting and hindering the implementation of ERAS
Qualitative semistructured interview. Normalization process theory framework analysis.
26 health professionals, comprising surgeons, anesthesiologists, nurses, and clinical managers.
Thorax, colorectal, head and neck surgeries
This study concluded that serious efforts are required to successfully implement ERAS, including the abolishment of harmful deep-rooted surgical practices, standardization of the ERAS protocol, collaboration between teams, and the involvement of stakeholders.
A multicenter qualitative study assessing the implementation of enhanced recovery after surgery program
This study aimed to investigate the supporting and inhibiting the implementation of ERAS
Qualitative and online survey
146 health workers, comprising surgeons, anesthesiologists, and nurses for the online survey and 30 health workers for interviews.
All surgical specialties
Applying ERAS to nursing practice is a challenge that requires important changes in clinical practice for all the specialties involved. The main reasons for implementing ERAS are reducing complications, reducing the length of stay in the hospital, as well as increasing patient satisfaction. Furthermore, the main obstacles in implementing ERAS are inadequate time and human resources, as well as reluctance to change.
Neurosurgery perception of enhanced recovery after surgery (ERAS) protocols
This study aims to investigate the implementation of ERAS and the benefits of this implementation.
Online survey with google forms
39 neurosurgeons
Neurosurgery
A total of 69.5% of neurosurgeons implement ERAS in their institutions of work. However, the neurosurgeons believe several protocols in ERAS need to be improved.
Are we doing “better?” the discrepancy between perception and practice of enhanced recovery after cystectomy principles among urologic oncologists
This study aims to discover the perception and application of ERAS in cystectomy surgeon
An online survey using email
128 urologists
Cystectomy
Significant variability was discovered in the choice of the ERAS protocol. Furthermore, there is a significant gap between self-perception and the adoption of ERAS principles.
A Survey of health care providers’ perceptions of enhanced recovery after surgery and perioperative surgical home protocols at tertiary care hospital
This study aimed to evaluate the perception, knowledge, and preferences of the ERAS protocol.
Online survey
223 surgeons and 72 anesthesiologists
All surgical specialties
The respondents rated their colleagues and institutions as supporting ERAS and preferred to learn by participating directly in the institution, rather than participating in seminars and lectures. However, the respondents believed the inadequate time was given to learn about the program.
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualized nursing care in orthopaedic fast-track programmes
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualised nursing care in orthopaedic fast-track programmes.
This study aimed to identify the barriers to implementing ERAS
Qualitative with grounded theory analysis
19 general surgeons, 18 anesthesiologists, 18 nurses.
Colorectal surgery
According to the results, inadequate human resources, poor communication and collaboration, resistance to change, and lack of patience are considered inhibiting factors for implementing ERAS.
Successful implementation of enhanced recovery after surgery program for elective colorectal surgery: a process evaluation of champions’ experiences
Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: A process evaluation of champions' experiences.
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualised nursing care in orthopaedic fast-track programmes.
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualised nursing care in orthopaedic fast-track programmes.
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualised nursing care in orthopaedic fast-track programmes.
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualised nursing care in orthopaedic fast-track programmes.
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualised nursing care in orthopaedic fast-track programmes.
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualised nursing care in orthopaedic fast-track programmes.
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualised nursing care in orthopaedic fast-track programmes.
According to the results, most of the studies on the perception of healthcare workers regarding ERAS were carried out in the field of colorectal surgery. In addition, healthcare workers’ perceptions of ERAS also vary across hospitals. In several hospitals, the protocol has been well received by healthcare workers,
The support of stakeholders aids the implementation of the ERAS protocol in the standard patient care routine and this is beneficial to all stakeholders because the program is bound to reduce treatment costs and increase financial efficacy in hospitals.
However, for the program to be successfully implemented, all healthcare workers must receive continuous training to improve their knowledge of the program, and also demonstrate discipline, strong communication skills, as well as teamwork.
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualised nursing care in orthopaedic fast-track programmes.
Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: A process evaluation of champions' experiences.
Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: A process evaluation of champions' experiences.
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualised nursing care in orthopaedic fast-track programmes.
This is a concern for healthcare workers, considering the protocol comprises several components, including the preoperative, intraoperative, and postoperative pathways.
Several healthcare workers believe some ERAS components require further study, for instance, at the University of Toronto Hospital, early postoperative feeding must be adjusted to the patient's condition, and early mobilization requires the involvement of nurses, as well as the patient's family.
The resistance of healthcare workers has presented a significant challenge in the protocol's implementation at both the group and individual levels because several habits and practices must be changed, and well-seasoned healthcare workers tend to resist these changes, while new healthcare workers tend to be more receptive.
Several healthcare workers do not regard ERAS as a significant change because some of the protocols have already been implemented in daily practice, however, numerous health workers are unfamiliar with the program.
Moving enhanced recovery after surgery from implementation to sustainability across a health system: a qualitative assessment of leadership perspectives.
Therefore, healthcare worker's knowledge of ERAS must be improved, because an inadequate understanding of the program will hinder its effective implementation.
A study conducted in Korea regarding the implementation of ERAS in gastric cancer surgery showed most doctors were well acquainted with the protocol, however, most of these doctors failed to implement the program.
A survey of doctors' perceptions regarding ERAS in gynecological urological surgery discovered the program was not implemented due to distrust of the ERAS concept, as well as inadequate convincing evidence and support from the hospital management.
Therefore, healthcare workers ought to be provided continuous ERAS training to increase their knowledge of the program, while hospital management ought to provide unwavering support to ensure the program is successfully implemented in hospitals.
Only a few studies are available on the perception of healthcare workers regarding the ERAS protocol, and these studies are dominated by the implementation in colorectal surgery. Therefore, future studies on the perception of health workers regarding ERAS in other surgical fields, are required. Knowledge of these perceptions, as well as the inhibiting and supporting factors for the implementation of ERAS, are required to successfully implement the program across hospitals.
Limitations
This research is a scoping review, which covers the breadth of the literature on a certain topic without evaluating the article's quality. The reviewed articles do not cover every aspect of surgery and are focused mainly on colorectal surgery.
Conclusion
Based on the findings of this review, ERAS is currently poorly implemented across all existing surgical fields. In addition, healthcare workers’ perceptions of the program, as well as the availability of resources and support from hospital managements, are critical factors for the program's success.
Acknowledgments
The authors are grateful to LPPM (Lembaga Penelitian dan Pengabdian Masyarakat) Universitas Gadjah Mada) for the provision of assistance towards this study.
Implementation of ERAS (Enhanced Recovery After Surgery) protocols for radical cystectomy patients: The pathway to standardization. A systematic review.
Orchestrating care through the fast-track perspective: A qualitative content analysis of the provision of individualised nursing care in orthopaedic fast-track programmes.
Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: A process evaluation of champions' experiences.
Moving enhanced recovery after surgery from implementation to sustainability across a health system: a qualitative assessment of leadership perspectives.
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