Background
Methods
Study design and recruitment
Speciality | SUR/ANS | NUR/AHP | CLINMAN/MAN | Total |
---|---|---|---|---|
Cross-cutting | 0 | 3 | 2 | 5 |
Thoracic | 4 | 2 | 1 | 7 |
Colorectal | 2 | 4 | 1 | 7 |
Head & Neck | 3 | 3 | 1 | 7 |
Total | 9 | 12 | 5 | 26 |
Data analysis
Normalisation process theory
Results
NPT construct | Facilitating factors | Challenges |
---|---|---|
Coherence | - Alignment with evidence based practice - Standardising practice – incorporation into routine activity - Drawing on evidence base in other specialtiesa
| - Resistance: Breaking down entrenched surgical dogmasa
- Standardisation affecting personalised patient care |
Cognitive Participation | - Cohesive, visible leadership amongst surgeons and nurses - Teamwork – engagement of all relevant stakeholders - ERAS meetings | - Buy-in of relevant stakeholders - Keeping ERAS visible |
Collective Action | - Patient involvement and education – ERAS diariesa
- Pre-operative assessment unit - Staff educationa
- Resources attached to obtaining CQUIN money (e.g. data collectors, ring fence nursing time) - Ward layout – protected beds | - Information provision to patients – volume affecting retention - Resources - Staff (being short staffed, high turnover, lack of weekend workers)a
- Lack of time (to attend meetings, educate staff and patients) - Lack of management support - Ending (e.g. money attached to CQUINs) - Nutritional drinks – palatabilitya
- Merger – aligning different ward cultures - Patients going to non-ERAS departments – ICUa
- Spread within the hospital - Health issuea
- Segmental approach |
Reflective Monitoring | - Data collection and feedback - Adapting the care pathway |
Coherence – Making sense of the ERAS programme
Evidence and standardization
The nutritional aspects of ERAS across the specialties (no prolonged fasting, pre-operative carbohydrate loading and post-operative early feeding) were reported to be important and “make sense” (SUR/ANS-TH-16). Some interviewees within the thoracics specialty mentioned a lack of evidence with regard to the ERAS elements relating to nutrition. However, this didn’t deter the implementation of these elements, and the nutritional status of the patient was considered important. In the absence of evidence, they looked to the evidence base surrounding other specialties.…so there is a decision making that happens as evidence-based as possible. (SUR/ANS-TH-14)…it’s starting off by taking an evidence based approach to what we do, so protocolising with as much care as we can (SUR/ANS-TH-13)
However, setting up and enacting ERAS practices were not always smooth processes. Some participants reported encountering resistance from colleagues, and in a few cases, especially within the colorectal speciality, described the need to break down entrenched surgical dogmas with regard to feeding practices:So it kind of makes intuitive sense that we should feed these patients. Erm, but we don’t really have an evidence base for that, but because the pathways looked appropriate in colorectal, we just essentially copied and pasted, and the same with pre-op carbohydrate loading. Well, it makes sense not to have your patients dehydrated. (SUR/ANS-TH-16)
ERAS was seen as a trigger to the standardisation of care along evidence-based lines. It enabled the standardisation of certain aspects of work, for example, in the case of nutritional screening, which was not previously organised, ERAS was thus described as “a vessel for change” (NUR/AHP-CC-4), improving patient care. Standardising practice was considered important to help overcome inconsistencies in patient care:…we’ve had a lot of resistance. Clinical colleagues, consultant colleagues - a few yes and a few no – “I've done it for 20 years, why should I do anything different?”(SUR/ANS-CO-20)
Those within the thoracics speciality, reported that the distribution of nutritional drinks (e.g. Fortisips) three times a day had been logistically challenging as other aspects of patient care could take priority. The team protocolized this element of ERAS and incorporated it into a routine activity, which facilitated its implementation.So I think protocols are the way forward to do these things, because … a patient comes in on a Monday, Tuesday and Wednesday for the same operation, they should get the same service irrespective of whether I am there or not, because we should all be doing the same thing. (SUR/ANS-TH-16)
For some, protocols were considered to be a tool to “nudge” (SUR/ANS-TH-16) them to carry out particular components of ERAS. One individual spoke about the protocol as providing the means to challenge practice that deviated from agreed actions:But what we do now, it’s just built into our normal daily routine is that we do the Fortisip drink rounds. So someone will put all the drinks on a trolley three times a day and walk around the ward, and offer [them to] patients. (NUR/AHP-TH-17)
Although standardisation was generally viewed positively by participants, a few voiced concerns that ERAS had turned into a ‘tick-box’ exercise and that sticking to protocol monitoring too rigidly absorbed time better given to personalised patient care:We had a patient where, erm, the tracheostomy protocol wasn’t followed … it was quite useful to actually be able to, erm, say, you know, to the consultant who was involved in that, “Look. This actually is something that we agreed and this wasn’t followed” … we felt like we had some evidence, as a consensus view that, you know, to, to challenge, erm, practice that wasn’t following standard practice. (NUR/AHP-HN-9)
Some participants stressed the need for flexibility in implementing protocols in practice to ensure a desired level of clinical autonomy so individual patient needs were met:I think the barrier there is just too much documentation and not enough onus on physically giving the care to the patient. You can spend an hour just filling in a care plan, where that hour could be even just talking to a patient, “How are you feeling”. (NUR/AHP-HN-12)
It’s very much based on the patients, and I think we, as much as the patients have their goals from a mobility point of view it’s, “You will sit out for two hours four times a day, and you’ll walk 60 meters once today, and tomorrow you’ll do it twice.” We ignore that completely and basically go on each patient and their functional capabilities. (NUR/AHP-CC-3)
Cognitive participation – Investing in the ERAS programme
Buy-in and maintenance
Once commitment had been established, consolidating enthusiasm for the programme and keeping ERAS visible was another of the main challenges:I think it can be quite a thankless task at times doing this sort of work … you can take a horse to water, but you can't make it drink. And that's what it feels like sometimes. (CLINMAN/MAN-CC-1)One of the problems, um, we’ve had is engagement of the nursing group as a whole. (SUR/ANS-HN-7)
There’s only so much nagging of a team that you can do … People can’t absorb information constantly … And put it all into practice. It’s difficult. (NUR/AHP -TH-19)This job has made me realise that - my own ward I used to manage how if you don’t enforce it they will forget. (NUR/AHP-HN-12)
Leadership and teamwork
Having leadership at the nursing level was reported as being equally important to be able to drive the programme forward on the ward. The vision for many was for ERAS to be nurse-led:I think the most important person to have really signed up and really driving it forward is a consultant surgeon who’s taking the lead for a particular area. (NUR/AHP-CC-4)
One individual described how they felt implementation in their speciality was restricted because the programme hadn’t been surgeon or nurse-led:Arguably, just as important, from the nursing perspective, is making sure that you’ve got senior members of the nursing team that are able to sort of push it forward, as well. Because … the day-to-day running of ERAS is very much down to the nursing staff on the ward. (NUR/AHP-HN-10).. it would be nice if overall nurses would realise that this is something that they deliver and it’s extremely important for the patients’ recoveries. It’s probably more important than the surgery itself. Um, and they should take it as an ownership of it. (SUR/ANS-TH-14)
Whilst a few suggested that it was key to have one person to focus enthusiasm and push implementation forward, many reported that implementation had been stymied when such an individual had left and the skills and support they offered had not been replaced. A “centre pin” (SUR/ANS-TH-16) approach was not considered conducive to sustaining implementation efforts:… but I think it is an issue having two anesthetists running it because actually the vast majority of what’s required is actually the ward stuff, and it’s hard for us to take leadership of the ward stuff. It really needs to come either from the nurses or from the surgeons, erm, so, I think that’s partly why I feel we’ve stalled at the moment because …the bit that we’re much more involved in which is the in-theatre bit and the pre-op assessment bit, well, that was, kind of, already in place anyway. (SUR/ANS HN-8)
Instead, participants described the engagement of all relevant stakeholders, teamwork and collaboration as critical facilitators for successful programme implementation:I think there’s certain key things that need to be addressed … key boxes that need to be ticked by an enhanced recovery programme to make sure it is sustainable … so it can’t be reliant on one individual or one role, because – well, for obvious reasons. If you take that person out of the equation then the whole thing will come crumbling down. (NUR/AHP-CC-4)
I think it should be led by the team really. I think it’s one of those things that someone can initiate it and someone can start to lead, but if the team doesn’t take over then it’s probably doomed. (NUR/AHP-TH-19)
ERAS meetings
I think the ward staff and the, allied health professionals and the surgeons having a chance to sit down and talk through what they each thought was going on, which was not always the same (Laughter)…was quite a useful process in itself. So it was really about you know, streamlining and, clarifying what was going on. (SUR/ANS-HN-8)
Collective action – Implementing the ERAS programme
Available resources
Education of staff was necessary to encourage the early feeding element of ERAS:…you’re trying to educate a very busy group of people, and that can be difficult. They’re not the type of people you can say, “Right, everyone that works here, drop off your Wednesday afternoon, and I’ll come and teach you.” Because it just doesn’t work like that. Erm, everyone’s got patients to look after, and you know, the fundamental problem with educating a group of people that are here 365 days a year, 24 hours a day, like nurses, is that you can never get them all in one place. (NUR/AHP-CC-4)
Resource limitations in terms of staffing issues (being short staffed, high staff turnover, lack of weekend workers including dietitians) and time constraints (to attend meetings, educate staff and patients) were also reported as significant challenges to implementing the ERAS programme by many of the participants across roles:…and to educate the nursing staff on the ward, erm, and generate the consensus among my colleagues that, erm, we can look after the patients according to the ERAS protocol and not just starve them for three days. (SUR/ANS-CO-21)
The role of money attached to CQUIN scheme was recognized by many staff as key to facilitating implementation, as successfully reaching ERAS-related targets provided the funds for additional resources. For example, project nurses time was back filled, extra equipment and data collectors were available. Staff in the thoracics speciality described having used CQUIN money to ring-fence nursing time dedicated to the implementation of the ERAS programme. Many considered this to have enabled ERAS implementation as the allocated time had maintained ERAS focus and enthusiasm:That's one area which I think we can work better because some patients get stomas and I think that delays their ERAS a little bit because we don't have enough staff or manpower to educate them about stomas pre-operatively. (SUR/ANS-CO-21)It was, very much from my perspective … “we’ve implemented ERAS, these meetings have gone on, we decided that’s what we’re going to do, we’ve got the booklets and then let’s roll with it.” “So tell as many nurses as possible,” but we didn’t have the time to actually tell them in-depth what it means. (NUR/AHP-HN-12)
However, a few participants reported that it was challenging when project-associated resources ended:…certainly early on there was a drift in – it was introduced and everyone was signed up to it and then it drifted back a bit … And so my feeling was when the two ERP nurses came, they were already on the ward, but were appointed into that role, I think they were very good at keeping it ticking over with the nurses … (SUR/ANS-TH-13)…there was some bit of protected time given to some of the thoracic staff to take some time out and that’s how it got so micro-managed and how it got so embedded in thoracics. (NUR/AHP-CO-24)
Despite senior management asserting support for the programme e.g. through a transformation programme, this support was not always experienced by clinicians:…it’s more difficult now because we don’t get allocated time. So everything’s done on the run, whereas when we were doing the project nurse we were given specific hours. (NUR/AHP-TH-18)
Participants felt a lack of support was demonstrated by the failure to replace key staff or provide staff such as data collectors, which challenged implementation as they could not receive feedback on the success of their efforts:I think the Trust implementation, they think it’s a great idea … implementation is one thing, follow up is another and, actually, this sort of work isn’t being done by the Trust … and so, it’s sort of setting off on, um, potentially a tick box exercise if there is nobody actually following it up and, you know, removing the barriers. So I think that is a barrier, is the Trust’s real involvement. (SUR/ANS-HN-6)
One individual in a management position was aware that their support may not have been recognised:I'm a bit frustrated at the moment because I feel a bit let down by the Trust, in that, you know, everybody’s worked very hard to get this up and running and about the only thing the Trust themselves needed to do on the management side was, you know, provide the data collector and they’ve failed (Laughter) … and then everybody just gets a bit, sort of, er, “That was all a bit of a waste of time,” and then it’s - that’s really difficult to try and keep the momentum. (SUR/ANS-HN-8)
I'm not sure the teams on the ground would feel that it's absolutely something that's being really supported. And just as I'm sitting here … I can't tell you exactly how much we're doing and that frustrates me … if the clinical teams were able to find a really clear way of doing it, and the, er, senior manager find a really clear way of, erm, expressing their support for it we may be able to move forward faster and better, you know, and some of that translating, then, into reality on the ground as well, and it's not, it's not left - just our fine words. What does that mean in terms of the teams getting what they need, and I guess, you know, senior managers getting what they need? (CLINMAN/MAN-CC-2)
Patient involvement and education
Education of the patient, through face-to-face clinical contact and the provision of good quality information, was viewed as a key facilitator to this change by most of the participants interviewed:I think it's just a culture change … and empowering our patients much more. That, actually, it's okay to go home after four or five days. You know, it's not because we don't care, and it's not because we're a bad organisation or [provide] shoddy care… Actually, it's the right thing for you to be recovering in your own home (CLINMAN/MAN-CC-1)
For example, the palatability of the nutritional drinks that patients were required to drink before and after their operation was reported as a challenge. Healthcare professionals across the specialties and disciplines described patients finding the nutritional drinks difficult to “tolerate” (NUR/AHP-CO-24) especially in the post-operative phase. Encouragement and education from ward staff was considered important for patients to consume the drinks:... patient expectations of coming into hospital and being poorly aren’t what we want them to have. We want to re-educate their expectations … (NUR/AHP-CO-24)So, it’s actually listening to patients and, um, changing their expectations and not institutionalising people. (SUR/ANS-HN-6)
The pre-operative assessment unit was reported to be integral to educate the patient. Providing patients with information about carbohydrate loading, nutritional supplementation, nutrition post-surgery and early mobilisation was part of a process of ‘patient optimization’ so that they would be in the best possible condition on the day of surgery and also aid their recovery post-surgery. However participants were concerned about the volume of information provided to patients prior to surgery, the problems of information retention and ERAS-specific information getting lost:If they are day two or day three post-op and you do a drug round and you say, “You are due for your nutritional drink.” They will say, “Actually I don’t want it.” They’ve had enough of it by then … And I think they are quite difficult to tolerate if you’re not feeling brilliant. (NUR/AHP-CO-24)I think initially, people were wondering why they had to have … the Fortisip drinks three times a day, especially when they didn’t like them. Um, so it’s just educating people that, you know, although they’re eating well, there’s just a little bit of a nutritional boost because post-surgery they need a little bit of extra. So once they knew that it wasn’t just something we wanted to give them like a gimmick, that it was actually- they were a lot happier to take it on board. (NUR/AHP-TH-18)
ERAS diaries were given to patients which set out the steps they should aim to achieve as preparation for surgery and throughout their recovery. Many providers thought they facilitated implementation as they were a tool to educate, empower and motivate the patient to take an active role in their care, including their nutritional intake:There’s significant variation with individuals as to how well they’re able to retain that information, as well. You know, they’ll be given such an enormous amount of information prior to coming in … that the enhanced recovery side of things is something that can sometimes get a little bit overlooked. (NUR/AHP-CC-4)
Some reported the problem of patients failing to bring their ERAS diaries on admission to the ward, and a few had “mixed feelings” (NUR/AHP-HN-9) towards them because some patients might be discouraged if they were not making good progress along the pathway.My view is the patient diaries are a way to motivate the patients to keep on track and to remind everybody else like the nursing staff and the doctors “Well, shouldn't my catheter be coming out today?” “Shouldn't my drain, I've got a drain, why have I got a drain?” “Shouldn't my epidural be coming down?” “Why aren't I allowed to eat, why aren’t I eating, where's my nutritional drinks?” “I need to do my 50 yard walks”…It's them to motivate the patients and them to question if it's not happening which I think is the best way, it's empowering and motivating a patient. (SUR/ANS-CO-20)
Environment/organisational structure
Space was important; having bathrooms that were large enough to turn around with a drip encouraged early mobilisation. The positioning of fridges stocked with nutritional drinks was an issue for some:We’ve concentrated patient care to their bedside and so there needs to be an encouragement to move away from that. So you need communal areas, you need areas where the patients can meet in the corridor and they can chat in the corridor, you need access to extra nutrition so for example when we went to [name of city] …, the wards had occasional tables down the ward with two chairs at each table and a bowl of fresh fruit, there was a buffet area so if the patients could get up, then they got up and ate in the buffet area and relatives were allowed on the ward to eat with them …everything was aimed at trying to create an environment which wasn’t like being on a long-haul flight, it was more like being at home … that’s what you need …to get you better quicker. (SUR/ANS-TH-15)
Participants reported that homogeneity of patients on a ward, and having protected beds for non-emergency ERAS patients facilitated implementation.Twice a day, up you get, you go walking … with your nurse and you go and help yourself to your drinks. But you see on here we got a fridge here, I’ve got a fridge in one of our store rooms. There’s no space, the corridors are meant to be clear, where do you put the fridges? (CLINMAN/MAN-CO-22)
During the fieldwork period for the colorectal ward, environmental changes were taking place in the Trust with the merging of wards across the specialisms. This was considered to have tested the implementation and embedding of ERAS. One of the biggest challenges for staff was aligning different ward cultures as wards merged. Nurses and ward managers reported the merger had created greater diversity on the wards for them to navigate in terms of the conditions and ERAS-status of the patient (whether the patient was on ERAS), and the paperwork and systems in use:…the sort of golden standard would be to have ring fence protected beds. And like I said, it worked for a couple of months I think, and then just with the pressures of beds in general and the capacity it went by the wayside. So a decision was made to change. It was made at senior management level. It was nothing to do with us, um, at ward level, but it was just that the hospital had to look at the bigger picture rather than just the enhanced recovery picture, which is a shame. (NUR/AHP-TH-17)
Another of the major challenges to implementing ERAS reported across the three specialities was patients being admitted via the intensive care unit (ICU) where the culture was for patients to not be provided with early nutrition, thus delaying ERAS implementation:It has been a big challenge really in getting the two teams to mix, you know, two different wards, they work very differently, different consultants, different specialties, different managers, different teams, lot of staff on set shifts. Erm, my staff don’t work set shifts, so the expectations of the staff … (MAN-CO-22)
…when the patients want they can have something to drink in recovery. Er, recovery generally aren’t that happy with that but we’re happy with that, but as soon as they get out to the ward they can eat and drink. Er, we find that falls down if they go to HD or ICU where there is not the, that same philosophy to get patients eating and drinking earlier. (SUR/ANS-TH-15)
Spread
An ERAS lead described how although they had particular links within their own department which made it easier to engage and mobilise staff, they felt an outsider in other specialties and so had less leverage to request change:It can be very difficult to appreciate within the trust …how we’re perceived by the outside world, because we are seen as a beacon nationally and internationally in enhanced recovery, but sometimes you get the impression within the Trust that we’re just seen as annoying because we keep wanting to implement change. (SUR/ANS-TH-15)Our main challenge has been moving on outside of thoracic surgery to other specialities, and we have had some successes, and we’ve had some failures. (SUR/ANS-TH-16)
The stumbling block is when everybody says, “Well, you’re the lead now. Go and do it in other specialties.” But that’s not my specialty … I don’t have the same ability to change people’s opinions of what we should do, because they don’t see me on a day-to-day basis, doing the clinical work. (SUR/ANS-TH-16)
Participants also reported that the irregularity of its use brought up difficulties of staff remembering to use the programme, and identifying those patients that were on the programme:I think, even now, people aren’t great with it ‘cause they were only doing flap patients. So, we’ll have one and then nothing … There’s a blob next to the board [to denote ERAS], but I don’t think anyone is really taking it onboard. I think, I’ve tried to, sort of, with the Senior Nurse, tell [them] what it’s about. But then you find the paperwork, it might be completed, but then it’s a bit halfhearted. (NUR/AHP-HN-10)
The limited number of patients on ERAS was also considered challenging because it reduced the amount of feedback about the programme. One individual stated, “…if there was more patients, I could see more change.” (NUR/AHP-HN-10). Staff perceived that a greater number of patients on an ERAS pathway would facilitate implementation embedding it in day-to-day practice:So then because it’s not a common thing … people forget it so you can have patients that don’t come for three weeks and there’s no enhanced recovery at all, and then another one comes and it’s on enhanced recovery and then they go, “What does that mean again?” (NUR/AHP-HN-12)
It should be that you walk onto the head and neck ward, and everybody is on the enhanced recovery programme. I think one of the things that we’ve got wrong, as I say, is you almost have this guy in different coloured pyjamas with a hat on, that is the enhanced recovery patient … (SUR/ANS-HN-7)I think if we roll it out for more patients, we’ll see the staff using it better. But at the moment I can’t really honestly say that it’s been that useful… (NUR/AHP-HN-10)
Health issue
This was in contrast to the characteristics of the thoracic population which was felt to better suit ERAS implementation:I was keen that head and neck didn’t get left behind really, erm, and it’s a bit difficult because they’re a difficult group because what people are fixated on is length of stay, and some of the things that cause head and neck patients to stay in are not easily changeable. Things like their tracheostomies, erm, but I still thought that, you know, that the quality aspects and the rest of ERAS would be very applicable, erm, to our patients and, er slightly challenging for some of them (Laughter). (SUR/ANS-HN-8)
The type of speciality challenged the early post-operative feeding element of ERAS. The site of operation in the thoracics specialty allowed for minimal consideration when adopting the early feeding element of ERAS as the digestive tract is less affected. In contrast, health care professionals in the head and neck specialty felt they had greater complexities (e.g. anastomosis) to consider before feeding their patients post-surgery.Particularly with thoracic patients; you need to get them up and about and Enhanced Recovery is about getting the patients up and about. Erm, so I think it just suited that population really, really well. (NUR/AHP-TH-19)
Of course, all these other things and different surgical specialties, it has different impacts, so that for a thoracic surgeon it’s less likely to be a problem, feeding is less likely to be a problem, whereas, if you’ve got an anastomosis through which food is likely to go, then that is worrying…(SUR/ANS-HN-6)
Reflective monitoring – Gaining ownership of the ERAS programme
Data - collection and feedback
Data collectors were considered to be crucial in this process, and participants reported that it was challenging when this resource wasn’t available (due to project specific funding ending and posts not being filled), and data analysis tasks fell to them:Because we could get some realistic data month on month back about length of stay, about patient experience, about compliance with nutritional drinks, about every kind of aspect of the enhanced recovery programme. And that started to focus it and really embed it into practice. (NUR/AHP-CO-24)
A few participants reported having used locally-generated data to challenge embedded behaviours and encourage practice to be in line with the ERAS programme:I would like to be able to produce the feedback for people ‘cause people have put a lot of effort in … on the other hand, you know, I don’t have the time to personally go and trawl through and get all that data. (SUR/ANS-HN-8)
So we wanted to change the pain protocol and put them on a different style of pain relief, and that was hugely difficult to do in the anaesthetic department. It was really difficult, and the only way we could do it is by some of us doing it and auditing our data, getting a pain team involved and developing a protocol and comparing our data, new and old, and slowly, over two to three years, most people have moved away from epidurals. But that was a big challenge, and you can’t, to an anaesthetist who’s trained for 15 years of his life, go up to them and say, “You will stop using epidurals now. You will do it this way.” Because the evidence base doesn’t necessarily exist. (SUR/ANS-TH-16)
Adapting the care pathway
Staff reported that numerous subsequent adjustments or ‘tweaks’ to the pathway had been necessary, as had the conduct of audits to prove programme effectiveness:The way that we developed the pathway was to look at the generic enhanced recovery pathway produced by the NHS in their document from 2010 and I took out parts of that pathway which were truly generic, erm so applicable to all specialties including ours, erm, so used those … as the skeleton of the, pathway, and then took other … evidence-based measures from the literature and also from what we were already doing, and incorporated them into our pathway. (SUR/ANS-TH-15)
We’ve tweaked um, the laxatives. That’s a big part of it. Um, the regime we started on wasn’t that effective so we changed it a bit. We spoke with pharmacists and people like that, um, to get to where we are now. (NUR/AHP-TH-17)