clinical

Ward nurses experience of enhanced

recovery after surgery: a grounded
theory approach
Abstract
Many studies looking at enhanced recovery after surgery (ERAS) examine the clinical outcomes and patient
satisfaction of the programme. This article reports on the findings of a qualitative study employing a
grounded theory approach to explore the experiences of ward nurses involved in the postoperative stage of
the ERAS programme with colorectal patients. Data were collected in 2012 using semistructured interviews.
The basic social process that emerged from the analysis describes how ward nurses adapted their delivery
of care in order to meet patient need. This process also explains why variance in individual patient recovery,
lack of resources, and an inconsistent adherence to protocols necessitated the adapting of the ERAS nursingcare protocol. ERAS can provide a framework for nurses to deliver care but protocol-led care can have
limitations. This study also developed the theory of adaptation, which describes how ward nurses adapt in
certain situations to deliver care.

2014 MA Healthcare Ltd

n the late 1920s, Biochemist David

Cuthbertson researched the link between
injury and the disturbance of metabolism.
He then questioned the significance of this
disturbance on patients recovering from
bone fractures by undertaking metabolic
examinations on participants (Cuthbertson,
1930). This research marked the beginning of
an understanding of the bodys physiological
stress response.
Henrik Kehlet further developed this research
in the 1990s, and commented that surgical
outcomes were not solely related to the
expertise of the surgical and anaesthetic team
since complications could occur regardless of
the level of skill. Kehlet (1997) questioned if
modifications to the bodys pathophysiological
responses to surgery would improve surgical
outcomes and progress patient recovery. On the
basis of this hypothesis, programmes to enhance
patient care were developed using terminology

Gastrointestinal Nursing

vol 12 no 4 May 2014 

such as fast track, multimodal optimisation, and

rapid recovery.
The programme consists of a number of
strategies to ensure the patients condition
is optimised at all phases. The programme
includes elements such as reduced fasting,
preoperative carbohydrate loading, avoidance
of mechanical bowel preparation, drains and
nasogastric tubes, goal-directed intra-operative
fluid therapy, shorter incisions, and patient
information and goal setting. It was adopted
as a key clinical quality indicator with an aim
to standardise care through an evidence-based
protocol (Khan et al, 2009).
The move from conventional care to enhanced
recovery after surgery (ERAS) requires a
multidisciplinary team (MDT) approach (Khan
et al, 2009). Kahokehr et al (2009) commented
on the dynamics of the team and how experience
and attitudes can affect both the implementation
and adherence to the ERAS protocols. Mitchell

Angela Jeff is Colorectal

Macmillan Nurse Specialist
at East Cheshire NHS Trust,
Cheshire, England.
Claire Taylor is Macmillan
Team Leader in Colorectal
Cancer at St Marks Hospital,
London, England.
Email: angela.jeff@nhs.net

Key words

Ward nurse
Enhanced recovery
after surgery
Multidisciplinary team
Colorectal
Grounded theory

This article has been subject

to double-blind peer review

23

clinical

Study aim
The studys aim was to explore and describe the
experiences of the ward nurses involved in the
ERAS programme. The research was oriented to
the postoperative phase, since this phase has the
potential to improve recovery, clinical outcomes,
and both patient and staff satisfaction during
the programme.
A rigorous method of grounded theory (GT)
was chosen because the topic is preliminary and
relatively unexplored, and the study sought to
understand nurses experiences in a challenging
phase of the programme as there are no existing
theories. GT is a qualitative approach that adds
depth to the enquiry through a systematic break
down of data, rebuilding it in new ways to
allow the discovery of a theory. The GT research
approach is a methodological tool that offers a
framework for qualitative analysis and is used to
generate new theory on the basis of collected data
(Glaser and Strauss, 1967). Ethical approval was
sought from relevant research ethics committee.
No theory was developed at the beginning of
the study; therefore, purposeful sampling was
used (Draucker et al, 2007). Nurses with the most
experience and knowledge about the research
topic and who had been involved in both the
traditional and ERAS programmes were selected.
This guided the researcher to participants who
would provide detailed data (Coyne, 1997).
Theoretical sampling was then used to develop
the analysis as concepts emerged.

Data collection and analysis

The data collection and analysis for this
study followed a cyclical process typical for
GT, and early findings shaped the ongoing
24

data collection. Data were collected using a

combination of semistructured interviews, in
which questions were structured to be broad
and open-ended to allow discussion to emerge
(Charmaz, 2006), and documentary evidence
using memos and a reflective journal. This varied
collection method allowed the demonstration
of any variation and verified, connected, and
determined the next course of action; it also
helped to develop the conceptual framework
(Glaser and Strauss, 1967). Data collection took
place between February and May 2012.
All interviews were recorded using a digital
dictaphone and transcribed verbatim. Moreover,
self-transcription allowed the researcher to keep
the data close (McGee et al, 2007). As discussed
by Poland (1995), a written transcription does
not capture the nonverbal communication and
emotional aspect of the interview; in order to
combat this, a reflective journal and memos
were used to help capture the essence of the
interview. To assist in the management of the
large quantity of data collected, the software
program NVivo 9 was used.
Analysis was performed in parallel with data
collection using the iterative process of constant
comparison. By comparing ideas, the strength
of explanation supported the development of
theory (Hollowayand Todres, 2006).
Coding was used to analyse the data, which
were broken down into concepts and categories
and rebuilt to establish theories that were
grounded in the findings and consistent with the
Strauss and Corbin (1990) framework for GT. The
final analysis linked all the categories to the central
category of adapting to the road to recovery,
thus capturing the overall conceptualisation of
the research.

Findings
Eight of a possible 30 participants were recruited
for the study. All participants had nursed patients
on the ERAS programme for at least 1 year.
Further characteristics of the sample can be
found in Table 1. A total of four experienced
participants, with knowledge of both the
traditional method of recovery and ERAS, were
in post as the ERAS programme was introduced.
Four newer participants were only familiar with
the ERAS programme.
Following analysis of three interviews, it was
apparent that differences in experience levels
Gastrointestinal Nursing vol 12 no 4 May 2014

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(2011) considered that the role of the ward nurse

should not be driven by medical protocols, but
nursing staff should focus on care compatible
with the nursing role involving an holistic
approach, such as psychosocial care, information
giving, discharge planning, and the management
of common complications.
The authors investigated the general surgery
wards of a district general hospital that was an
adopter of ERAS back in 2008. Implementation
of ERAS on the two surgical wards was
conducted with an MDT approach led by two
nurse practitioners, alongside their normal work
schedule; they were not ward based.

clinical

Table 1. Participant characteristics

Age

Number of years qualified

Time employed on the

surgical unit

Shift Pattern

Education

Number of participants
20 - 29

30 - 39

40 - 49

50+

0-3

3-6

6-9

10 - 20

20+

Less than 2 months

2 months to 1 year

1 yr to 3 years

3 years to 5 years

5 years to 10 years

10 years to 20 years

More than 20 years

Day shifts only

Night shifts only

Day and night shifts but mainly day shifts

Day and night shifts but mainly night

shifts

Registered nurse training only

Diploma

Degree

Masters

1 Studying for

led to the differences in the data. As a result of

the analysis, theoretical sampling was performed
after the first three interviews to explore the
experiences of the less experienced nurses.
Analysis with open coding broke down the
data and yielded 41 initial themes. Of these,
29 developed after the first 3 interviews
with the more experienced participants,
and a further 12 developed after analysis
of data from the newer participants. No
further themes developed on analysis of the
final two interviews. The new themes were
compared to the previous interviews. Overall,
12 subcategories were developed from the
emerged themes to form concepts of similar
content. These concepts were then grouped
to form four categories using the same coding
framework used during earlier analysis. These
categories were then linked and an overall
category relating to the basic social process
of adapting was identified. A tentative
26

explanation of participants experiences with

ERAS of adapting to the road to recovery was
developed (Figure1).
The participants experiences can be categorised
into four stages:
1. Believing in the programme
To develop belief in ERAS and feel confident
that the associated nursing care is appropriate,
the participants described the factors that
enabled adjustment to this new way of working.
Participants involved in the implementation
described the change as big and dramatic.
Reasons for not liking change included the
identification of feelings of comfort and being
comfortable in processes that were familiar
to them. Experienced participants referred to
negativity expressed as the programme was
introduced, as the following example shows:
I think a lot of the negativity was the fact
that we didnt know any better and I think
Gastrointestinal Nursing vol 12 no 4 May 2014

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Question

iStock/Dean Mitchell, track5, Ninevian, graphixel

clinical

Overcoming
negativity
When it works
Gaining
knowledge

Believing in the
programme

Gaining
confidence
Adapting to
change
Barriers to getting
the job done

The working
programme

Getting the
job done

Nurses experiences
Change in
workload
Support

Identifying ward
nurse role in the
programme

Aspects of
the role

Adapting to the
road to recovery

Shutterstock/michaeljung

Developing
programme

Adapting

Figure 1. Development of main categories from subcategories to produce overall central category in ERAS experience.

2014 MA Healthcare Ltd

again its historical[:] weve done it like this

for so many years.
Negativity in this context meant that some
senior staff, both medical and nursing, did not
want to follow all aspects of the programme.
The negativity voiced by one or two of the senior
nurses created some unease among those who
were less experienced and confusion about how
rigidly to implement the programme.
Some
participants
approached
the
implementation of ERAS with caution and
scepticism. The need for this cautious approach
was revealed by both experienced and newer
participants to include:
Gastrointestinal Nursing

vol 12 no 4 May 2014 

The lack of confidence in following ERAS

Being indecisive over when to progress the
patients recovery
Experiences of being challenged on the medical
wards rounds.
A few participants reported having to seek
clarification from the medical team. Here is one
participants comment:
Its confidence in yourself, if there is a
doctor you always feel the need to say well
can I do this and can I do that.
The participants caution meant they took
patients more slowly through the ERAS
27

clinical

I think peoples attitudes need to change

I dont think people necessarily believe in it
and I dont think that helps the programme
to be successful because if people dont
believe in it then they are not going to
promote it.
A number of participants recognised how
long it had taken them to adjust to the ERAS
programme. By adjusting to working within the
programme, they now saw care as routine,
second nature, and automatic, and reflected
on the degree of change, either believing in or
coming around to the change.
All participants strongly emphasised ERAS
experiences with successful results and that
28

when it works it is fantastic. The participants

perceived the indicators of ERAS success to
be the patients not developing complications
in the postoperative period and achieving an
earlier discharge. Some participants appeared
to have realistic expectations of the programme,
recognising that a few patients would be
unable to achieve recovery within the expected
timeframes. Others saw nonachievement of goals
as a failure of the programme.
2. Identifying the ward nurse role in the
programme
Experienced participants described the alterations
in their role with the introduction of ERAS; in
comparison, newer nurses could only describe
how they viewed their role within the programme
as they had not worked on the ward prior to
implementation.
Participants identified their role within ERAS
in different ways. The role included encouraging
patients to achieve key postoperative goals
relating to mobility and feeding, thereby ensuring
compliance with the ERAS protocol. Education
and recovery promotion were seen as important
aspects to the role. Encouraging and pushing
were used to describe the role in moving forward
the patients recovery. All participants felt that
care needed to be individualised rather than have
one protocol for all. In addition, assessment and
monitoring of patient progress was a concurrent
theme from the interviews. A participant made
reference to this fact as follows:
Standards will not always be met and you
will have to reset and you will have to drive
those standards forward.
All participants felt that their role involved
coordinating all aspects of the postoperative
phase of ERAS. Patients not recovering as expected
might necessitate a referral to another health
professional, such as occupational therapists and
social workers. It was also identified that not only
should the patient and nurse work together to
achieve these goals, but a team approach was
essential as well to enable an early recovery.
A change in the pace of patient recovery was
identified by some nurses who had worked
in other specialities and for whom this was a
familiar concept, but the others were still in the
process of adapting to the concept. Reflections
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recovery protocol. They felt this would

improve the patients recovery and prevent
complications. They revealed that progression
of the patients recovery could have adverse
consequences: something might go wrong and
they feared being challenged by the medical
team. To ensure the progression of ERAS, both
experienced and newer nurses expressed how
confidence had to be gained to achieve a new
level of comfort.
All nurses pointed out that knowledge of
the programme was important for a number
of reasons, such as being able to adjust to the
change, understand the reasoning behind
aspects of the programme, and helping patients
to comply and recover.
Previously with experienced participants, the
surgical nursing of patients involved more physical
hands-on care as opposed to rehabilitation, and
the participants did not always feel sufficiently
experienced with the ERAS programme; they
would often be cautious in delivering the ERAS
protocol. Newer participants felt that some of the
experienced nurses were resistant to change and
described them as being stuck in old ways. Since
newer participants had not delivered care on
the traditional recovery pathway, it was difficult
for them to appreciate the changes in care now
required. Both sets of participants identified that
newer nurses adjusted to and believed in the
programme quicker than experienced participants.
A number of participants commented on how
attitudes needed to change as disbelief in the
programme did have an effect on the programme
functioning:

clinical

on how ERAS had affected the nursing workload

was commented on positively by experienced
participants. Patients on the programme
were no longer viewed as recovering from a
major surgical procedure, and by somehow
shortening the length of stay, the severity of
the surgery was diminished.
Numerous suggestions were identified for the
further development of ERAS. These were derived
from journal articles and from visiting other areas.
Many of the elements are in line with the ethos
of ERAS by providing a rehabilitation environment
for the patient and promoting self-care and
encouragement for other patients. There was a
general consensus among participants that several
factors, such as a lack of autonomy, experience,
and resources and being unable to articulate
suggestions, would hinder the development of
the programme. One comment is below:
Maybe it takes somebody from up above to
say lets do this because I feel that Im just
a little staff nurse [who] doesnt really have
much power.
This example highlights that the participants
did not perceive themselves as having ownership
and development of the postoperative phase of
the programme. They appeared to feel relatively
powerless in promoting the rehabilitative aspects
of the programme. The participants who had
visited other hospitals delivering ERAS had
compared the levels of support and considered
that additional support from a designated wardbased ERAS nurse was necessary to achieve
further cultural change.

2014 MA Healthcare Ltd

3. The working programme

Mixed views were obtained about how the ERAS
programme was currently working. Experienced
participants felt that the negativity from some staff
at the beginning of the programme affected the
other staff and development of the programme.
One participant made the following comment:
It didnt help with consultants not all
agreeing on how things are done, I think
that probably hindered a lot of it to begin
with.
At times, care of the patient with the ERAS
programme appeared to become routine
Gastrointestinal Nursing

vol 12 no 4 May 2014 

practice at the research site, as the following

comment suggests:
They [nurses] just get on with it and get
the job done and get the patients home.
Current practice identified inconsistencies
between teams following the protocol for ERAS.
Participants cited examples of taking the initiative
to drive patients forward as per the protocol and
described how they felt they were doing wrong
because they were questioned on the ward
round by the consultant as to why these actions
had been taken and were getting into trouble.
The individual trends determining the teams
interpretation of the ERAS protocol meant that
the participants knew which patients they could
drive through the recovery process and which
patients needed to wait for instructions or, owing
to a lack of clarity, the participants needed to
precede with caution.
The participants described the concept
of enabling as ensuring all conditions are
maximised to the best of the nurses ability so
that patient recovery/goals can be achieved.
The key drivers behind compliance with the
programmes delivery were thought to be both
the consultants and ward nurses themselves. All
participants identified that, sometimes, achieving
the ERAS protocol was dependant on whether
the patient recovery was parallel to the protocol.
They felt that goals can be set, but in reality, not
every patient is going to meet the goals within
the expected timeframe. While it was generally
the participants experience that patients made a
positive attempt to achieve the set ERAS goals,
some would not be able to achieve them owing
to factors such as nausea, poor appetite, and
pain control. Nonetheless, several participants
emphasised that enablement to achieve goals
was part of their nursing role.
The barriers affecting the effectiveness of the
programme included team inconsistencies, lack
of individual confidence, and lack of resources
to provide a rehabilitative environment. Nurses
developed strategies to adapt and overcome
these problems.
4. Adapting to the road to recovery
For some participants, the ERAS experience was
significant, and they needed a considerable
amount of change in their approach to their
29

postoperative care to adapt to this programme.

The underlying theory of adaptation in the recovery
programme was based on the participants
descriptions of how they had to adapt their role
within ERAS to suit each circumstance. As a result,
it appeared as if ERAS was not as protocol-driven
as intended or as recommended by its originators.
The participants considered that compliance
with the programme was determined by the
medical team, patient, and other ward nurses.
They described how an adaptation of ERAS
was necessary at times. The absence of clear
guidance created conflict for nurses as they tried
to find a balance between their own intuition,
the protocol, and instructions given. They
reported taking a cautious stance, defaulting
from ERAS to allow the progression of patient
recovery. This adaptation by participants was
described as we do our own enhanced recovery
and I think, postoperatively, we just adhere to
our own things.
Participants were able to make clinical decisions
when they saw that patients were not achieving
recovery goals. By reassessing and resetting new
goals agreed with the patient, they achieved a
satisfactory adjustment in care:
Our patient will drive it, we will assess and
we will monitor and yes it would be good
if we did a textbook timescale like with
anything else if you propose standards,
standards will not always be met and you
will have to reset and you will drive those
standards.
Participants gave many examples of adapting
their care to patient recovery by stepping the
patient off the protocol when they experienced
severe nausea and reintroducing the protocol
as and when the patients condition dictated.
A common sense approach was required
when delivering care and setting patient goals.
These situations were reported with a sense of
confidence and pride in their clinical autonomy.
Overall, all participants could describe the
experiences of ERAS working well.

Discussion
Working to stipulated protocols is endorsed by
the Department of Health (DH) as it provides a
framework to optimise patient flow by examining
what should be done, when, and by whom,
30

thereby reducing delays for patients (NHS Institute

for Innovation and Improvement, 2008). Ilott et al
(2010) explored the literature on how nurses are
involved in the development, implementation,
and audit of protocolised care, and discovered
that the role and activities of the nurse were
unclear and vastly underestimated.
Changes to organisational culture and delivery
of care are continually ongoing and can lead to
resistance as key stakeholders understand how
change will affect their roles and responsibilities
(McConnell, 2010). Salmond (1998) described the
gap between the current position to the proposed
and how this can be narrowed by providing
information and training. Significant changes to
care delivery with the ERAS programme required
structured organisation and cooperation between
the health professionals involved in all stages of
the programme (Zonca et al, 2008).
The basic social process that developed from
the nurses experiences was adapting, which in
this setting, meant how nurses adjusted to the
specific situations encountered that were in
conflict with the protocol. It is therefore important
to understand both the processes that preceded
this adaptation as well as the consequences.
Protocols for ERAS are described in numerous
contexts such as guidelines, algorithms, and
care pathways. Protocol-based care is aimed
at standardising care to improve the quality of
patient care. Adherence to protocols therefore
reduces any variation in the treatment of
patients. The consequence of protocol conflict
with expected and actual patient recovery left
nurses feeling confused as to which course of
action to take. Lyon et al (2012) debate that
even if a one size fits all regime can be applied
in ERAS, owing to the variety in procedures and
patients, some degree of individualised care is
required. Recognition that not all patients are
able to meet the protocol standards results in
reassessment of the patient and delivery of
individualised care. This involved monitoring
progress and resetting patient goals when
required (Baker et al, 2001), and being
challenged on the medical ward rounds was
often expressed as a result of this.
Protocol-based care can provide a safety net
for some nurses with a reluctance to veer from
the set standard. Gerrish et al (2008) discussed
that modern nurse education places more
emphasis on evidence-based practice engaging
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2014 MA Healthcare Ltd

clinical

clinical

junior nurses, but the knowledge and experience

of senior nurses gives greater autonomy to deliver
evidence-based care. When delivering protocolbased care, tacit knowledge and experience
allows nurses to know when to deviate from
the strict regimen of protocols and guidelines,
to modify patient care according to individual
patient recovery (Benner, 1982).
If nurses are to be given the clinical freedom
to deliver care that is based on an integration of
the nurses knowledge of patients conditions
and recovery to date alongside what is expected
of the protocol, they need to have strong clinical
leadership, feel empowered to make informed
decisions about what they believe is the best care
for a particular patient, and provide justification
if challenged.

Limitations
This study was performed at a single research site
and only involved registered nurses.

Conclusion
The central difficulty experienced by nurses was
trying to adapt the protocol to the demands
of patient care delivery within the constraints
of their role and organisational culture. The
variance between what the nurses felt they
were meant to be delivering, as indicated on
the ERAS protocol, and what they found they
were on many occasions actually delivering
created conflict, confusion, and clarification
seeking. The problem arose because of
the standardisation, which could provide
nurses with the guidance and parameters
for the delivery of patient care. Nevertheless,
nurses still require the autonomy to adapt
standardised protocols to individualise patient
care dependant on patient recovery.
GN

2014 MA Healthcare Ltd

Declaration of interest The authors have no conflicts of

interest to declare.

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