Exploring barriers and facilitators to implementing enhanced recovery after surgery in total hip arthroplasty: a qualitative study

Exploring barriers and facilitators to implementing enhanced recovery after surgery in total hip arthroplasty: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring barriers and facilitators to implementing enhanced recovery after surgery in total hip arthroplasty: a qualitative study Jiayin Wang, Huiwen Zeng, Congying Yang, Chenxin Hou, Xiaoyan Jin, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6653848/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Enhanced Recovery After Surgery (ERAS) protocols have shown significant promise in improving outcomes for patients undergoing total hip arthroplasty (THA). Yet, the implementation of ERAS in orthopedic clinical settings remains inconsistent, challenged by systemic, organizational, and cultural barriers. Understanding the underlying factors influencing ERAS uptake is critical for improving perioperative care and ensuring consistent, evidence-based practice. Guided by the Social Ecological Model, this study aimed to explore the multi-level influences on ERAS implementation in the perioperative management of THA patients and to inform future strategies for optimizing ERAS integration in orthopedic practice. Methods Face-to-face semi-structured interviews were conducted with 13 healthcare professionals—including orthopedic surgeons, nurses, anesthesiologists, a rehabilitation physician, and a hospital administrator—from three ERAS pilot hospitals in China. Interviews were transcribed verbatim and analyzed using content analysis supported by NVivo 12 software. Results Three overarching categories of influencing factors emerged: (1) health system factors, including hospital management support, infrastructure readiness, policy-driven incentives, and technological advancement; (2) healthcare professional factors, such as ERAS awareness, attitudinal barriers, and the quality of multidisciplinary collaboration; and (3) patient and family-related factors, including perceptions, treatment history, and engagement in recovery decisions. These factors were mapped across individual, interpersonal, organizational, and societal levels, reflecting the complex interactions shaping ERAS implementation. Conclusions The sustainable implementation of ERAS in THA requires a coordinated, multidisciplinary approach supported by hospital leadership, comprehensive staff education, and active patient involvement. Embedding ERAS within a multi-level strategic framework—supported by policy alignment, technological readiness, and cultural change—is essential to advancing its integration from theoretical model to standard orthopedic practice. Enhanced Recovery After Surgery Total Hip Arthroplasty Qualitative Research Multidisciplinary Care Perioperative Management Background Total hip arthroplasty (THA), a type of total joint arthroplasty, has been widely recognized since the 1960s as an effective surgical treatment for severe degenerative joint diseases, osteoarthritis, and post-traumatic hip deformities[ 1 ]. With global population aging, the demand for THA continues to increase[ 2 ]. While THA brings substantial improvements in pain relief and physical function[ 3 ], postoperative recovery remains a significant clinical concern, particularly due to extended hospitalization, high costs, and the risk of complications[ 4 ]. Enhanced Recovery After Surgery (ERAS), introduced by Kehlet in 2001, has emerged as a multimodal perioperative care approach designed to reduce surgical stress and support faster recovery[ 1 , 5 , 6 ]. Evidence from gastrointestinal and colorectal surgeries has demonstrated that ERAS can significantly reduce complications, accelerate discharge, and improve patient satisfaction[ 7 – 9 ]. In recent years, this concept has been increasingly integrated into orthopedic procedures, including THA, where studies have shown improvements in pain control, reduced length of stay, and enhanced early mobility[ 1 , 10 , 11 ]. Despite these promising outcomes, the implementation of ERAS in THA is not without challenges. Existing literature primarily emphasizes quantitative outcomes such as hospitalization duration and complication rates[ 12 ], while qualitative dimensions of ERAS implementation—including healthcare provider perceptions, institutional readiness, and patient engagement—are underexplored. Furthermore, variability in protocol adherence, resource constraints, and heterogeneity in patient populations (e.g., age, comorbidities) raise concerns about ERAS generalizability and sustainability in orthopedic care settings[ 13 ]. Thus, in-depth qualitative research is needed to identify the multifaceted factors that facilitate or hinder ERAS adoption in THA. Given that ERAS implementation is influenced not only by individual-level factors such as healthcare providers’ knowledge and attitudes but also by interpersonal collaboration, organizational resources, and broader sociocultural and policy environments, there is a need for a multi-level analytical lens to comprehensively capture these interrelated influences. To address this complexity, the present study adopts the Bronfenbrenner’s Social Ecological Model (SEM)[ 14 ] as its theoretical framework. The SEM offers a robust, multi-dimensional perspective for examining how individual, interpersonal, organizational, and societal factors interact to shape clinical behaviors and system-level change, making it particularly suited for exploring the layered challenges and facilitators of ERAS integration in orthopedic practice. This study aims to explore the perspectives of multidisciplinary healthcare professionals on the implementation of ERAS in THA perioperative care. Through qualitative interviews, we seek to uncover perceived barriers, facilitators, and contextual considerations that shape ERAS application, with the goal of informing more personalized and sustainable ERAS protocols in orthopedic practice. Methods Theoretical Framework We posit that the successful implementation of ERAS protocols in THA depends on the interplay of multi-level influences spanning individual, interpersonal, organizational, and societal domains. Understanding how these interrelated factors converge to shape perioperative practices, attitudes, and system-level readiness is central to advancing sustainable ERAS integration. To guide this inquiry, we utilize the SEM[ 14 ], originally conceptualized by Urie Bronfenbrenner in the 1970s, as the theoretical framework underpinning this study. Although the SEM was initially developed in the field of child development, it has since been widely applied across public health, healthcare implementation, and organizational research to examine how layered environmental systems affect human behaviors and institutional change[ 15 , 16 ]. The SEM is particularly well-suited for exploring ERAS implementation because it captures the dynamic, context-dependent interactions between individuals and their broader environments—something individual behavior models (such as the Theory of Planned Behavior) or organizationally focused implementation frameworks (such as CFIR) do not fully address. By emphasizing the multi-dimensional nature of behavioral and institutional change, the SEM provides a robust and adaptable scaffold for investigating how ERAS practices are adopted, resisted, or modified within orthopedic settings. The SEM conceptualizes human behavior as nested within five interrelated levels: the individual, interpersonal, organizational, community, and societal systems. In the context of this study, the individual level encompasses the knowledge, attitudes, beliefs, and competencies of healthcare providers and patients toward ERAS protocols, shaping their readiness and capacity to engage in enhanced recovery practices. The interpersonal level involves the quality of interactions, communication, and teamwork among multidisciplinary staff and between providers and patients—elements critical to fostering coordinated, patient-centered care. The organizational level refers to the institutional structures, resources, policies, and leadership support that facilitate or hinder the uptake of ERAS, including hospital management commitment, technological infrastructure, and workflow alignment. The community level captures broader networks and professional affiliations that shape local practice patterns and knowledge dissemination, while the societal level encompasses overarching sociocultural norms, regulatory frameworks, and policy environments that incentivize or constrain ERAS adoption across healthcare systems. By employing the SEM, this study situates ERAS implementation within a comprehensive, multi-layered analytical framework, allowing for an integrated understanding of how systemic, organizational, interpersonal, and individual-level factors interact to shape clinical practice. This framework thus offers both theoretical depth and practical relevance for structuring the data collection and guiding the multi-layered analysis of factors shaping perioperative care, ultimately informing future efforts to optimize ERAS integration in orthopedic surgery. Study Design Guided by the SEM, This study employed a descriptive phenomenological design to investigate the lived experiences and perceptions of healthcare professionals involved in ERAS-based THA. This approach was chosen to obtain rich, contextualized insights into the complexities of ERAS implementation in clinical settings. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Setting and Participant Recruitment Participants were recruited from three hospitals in China that were designated as ERAS pilot institutions. Purposive sampling was used to select individuals directly involved in the perioperative management of THA patients. Inclusion criteria included: (1) holding a valid medical or nursing license; (2) at least 5 years of experience in orthopedic or anesthesiology departments; (3) active involvement in ERAS program implementation; and (4) ability and willingness to articulate their perspectives. Participants were approached via departmental leadership and provided written informed consent. Ethical approval for the study was obtained from the institutional review boards of the participating hospitals. Recruitment continued until data saturation was achieved—defined as the point at which no substantially new codes or themes emerged from successive interviews[ 17 ]. Interview Guide and Data Collection An initial semi-structured interview guide was developed based on a literature review and refined through consultation with experts in orthopedic surgery and qualitative research. The guide was pilot-tested with three clinicians and revised for clarity and relevance. Key questions included: “What steps has your department taken to implement ERAS in THA?”, “What difficulties have you encountered during implementation?”, and “What factors do you believe influence ERAS success?” All interviews were conducted face-to-face in quiet, private hospital meeting rooms. A total of 13 participants were interviewed between September and October 2022. Each interview lasted 25–40 minutes and was audio-recorded with participant consent. An interview assistant took observational notes, including nonverbal cues such as tone, expressions, and body language. Researchers maintained a neutral stance and used reflective probes and clarifying questions to enhance data depth. Throughout the process, the research team engaged in reflexive discussions to examine their own assumptions and potential influences on data collection and interpretation. Data Management and Analysis Audio recordings were transcribed verbatim within 48 hours of each interview. Transcripts were cross-checked against recordings and field notes for accuracy. NVivo 12 software was used for data management and coding. Data were analyzed using qualitative content analysis, following these steps: (1) familiarization through repeated reading; (2) open coding to identify meaningful units; (3) grouping codes into subcategories and themes; (4) refining and defining themes through iterative comparison; and (5) synthesizing findings into a coherent narrative. Two researchers independently coded all transcripts. Coding discrepancies were resolved through discussion, and a third senior researcher was consulted when needed. The research team held regular meetings to discuss emerging themes and ensure analytical rigor. Themes were then organized in alignment with the SEM levels to ensure theoretical coherence between findings and the study framework. A data audit trail was maintained throughout the process. Rigor and Reflexivity To enhance trustworthiness, we employed strategies including triangulation, member checking, and researcher reflexivity. Participants were selected from diverse professional roles to ensure a wide range of perspectives. The research team included members with clinical orthopedic backgrounds and qualitative research training. No prior relationships existed between researchers and participants, minimizing bias. Ongoing reflexivity and regular team debriefings were used to identify and mitigate potential sources of researcher bias. Results Participant Characteristics A total of 13 healthcare professionals participated in the study, representing diverse roles across three ERAS pilot hospitals: 1 administrator (M), 5 nurses (N), 4 orthopedic surgeons (D), 2 anesthesiologists (A), and 1 rehabilitation physician (R). Participants ranged in age from 27 to 54 years (mean 38.85 ± 8.18), with work experience ranging from 8 to 34 years (mean 16.84 ± 8.79). Educational backgrounds included college (1), bachelor’s (6), master’s (2), and doctoral degrees (4). Each interview lasted between 25 and 45 minutes (mean 32.85 ± 6.44). Detailed demographic information is provided in Table 1 . Themes Identified from the Interviews Drawing on the SEM, the interview data were organized across individual, interpersonal, organizational, and societal dimensions to capture the multi-level influences on ERAS implementation. Three overarching themes emerged: (1) health system factors, (2) medical staff-related factors, and (3) patient and family-related factors, each containing several subthemes describing the facilitators and barriers identified by participants. 1. Health System Factors 1.1 Leadership and Management Support Institutional leadership and efficient organizational processes were identified as critical enablers of ERAS implementation. Support from senior administrators helped promote coordination among departments and secure necessary resources. "I think the biggest help comes from the strong support of the leadership." (M1) "Management is the most important and the leaders are very supportive." (N3). 1.2 Infrastructure and Resource Limitations Inadequate hospital infrastructure, limited diagnostic equipment, and human resource shortages were commonly reported as barriers. Participants emphasized how these constraints could delay procedures or discharge timelines."Some examination departments do not have enough instruments or staff, leading to delays." (N3) "Sometimes we have to keep patients longer just because we can’t get an imaging result in time due to equipment scheduling." (D3). 1.3 Policy and Institutional Incentives National healthcare policies promoting shorter hospital stays and cost-effective care provided momentum for ERAS adoption. Institutional endorsement of pilot programs also served as a driving force. "National policy advocacy is particularly important. It encourages hospitals to adopt ERAS." (D4) "Policy support is one of the reasons we’re implementing ERAS. Being a pilot hospital comes with responsibility and expectation." (N1). 1.4 Technological and Material Advancements Advances in surgical techniques and the availability of innovative materials (e.g., absorbable sutures, updated anesthesia protocols) facilitated early mobilization and discharge. "Thanks to improved anesthesia and surgical techniques, the operation is faster and there's no longer a need for urinary catheters." (D1) "Absorbable sutures mean patients don’t have to come back for removal, which supports early discharge." (D4). 2. Medical Staff-Related Factors 2.1 Awareness and Attitudinal Change Successful ERAS implementation depends on a shift in clinical mindsets. While most staff acknowledged the benefits of ERAS, some found it difficult to abandon entrenched traditional practices. Variability in acceptance among departments was also noted. "The traditional philosophy is deeply rooted. It takes time for people to accept a new concept." (A2)"Doctors may embrace ERAS, but sometimes support staff are hesitant and not fully on board." (D1). 2.2 Interprofessional Collaboration Multidisciplinary teamwork was seen as essential but often challenged by departmental silos and inconsistent collaboration. Effective communication among orthopedic, anesthesia, nursing, and rehabilitation teams was emphasized. "ERAS is multidisciplinary; the orthopedic department alone cannot implement it effectively without cooperation from others." (D3) "Different departments have their own leaders and perspectives, and that can make coordination difficult." (N3). 3. Patient and Family-Related Factors 3.1 Previous Treatment Experiences Patients' and families' prior experiences with traditional surgical care influenced their willingness to accept ERAS protocols. Familiarity with older methods often led to resistance, particularly among older patients and caregivers. "Some patients are used to the old process and are less willing to try the new ERAS approach." (N3) "Families who had good outcomes with previous methods tend to stick with what they know." (N4). 3.2 Perceptions and Expectations of Recovery Varied understandings of what constitutes adequate recovery impacted discharge decisions. Some patients preferred longer hospital stays despite meeting discharge criteria. Others misinterpreted early discharge as inadequate care. "Some patients feel they must be 'fully recovered' before discharge, even if they meet all the criteria." (D1)"Some families are anxious about new methods and worry it’s part of a clinical trial rather than proven care." (A2). Overall, participants acknowledged the multifaceted nature of ERAS implementation. While institutional policies and technological progress have created a favorable environment, effective execution still hinges on interprofessional collaboration, resource availability, and active engagement from both healthcare providers and patients. By mapping these findings across SEM levels, this study highlights the complex interplay of systemic, interpersonal, and individual factors, underscoring the need for integrated, multi-level strategies to optimize ERAS adoption in orthopedic care. Discussion Implementing Scientific Management and Maximizing Policy Leverage This study highlights that hospital-level governance is a key determinant in the successful implementation of ERAS, consistent with previous findings[ 18 ]. Adequate allocation of human resources is foundational, ensuring healthcare workers have sufficient capacity to engage in ERAS-related tasks. Moreover, the integration of administrative roles, such as care coordinators and process improvement specialists, is essential for program success[ 19 ]. Participants also emphasized that a lack of physical infrastructure—such as outdated diagnostic tools or insufficient ward space—hinders effective ERAS rollout. Framed within the SEM, these organizational and systemic factors illustrate how institutional conditions shape the capacity and readiness of healthcare teams to adopt evidence-based perioperative innovations. Hospital administrators must respond proactively to national directives by leveraging policy incentives granted to ERAS pilot hospitals. Strategic investments in advanced technologies and surgical materials, alongside system-wide infrastructure renewal, are necessary steps to establish an enabling environment for ERAS. Leadership at the hospital level must be centralized and empowered, guiding multidisciplinary teams through performance-based and duty-oriented management. Dedicated department heads should assume responsibility for ERAS implementation, acting as communication and accountability nodes. Equally important is the establishment of clear, streamlined, and standardized workflows, allowing clinical staff to precisely understand their roles and contribute effectively. This aligns with prior literature emphasizing the need to eliminate redundant or inefficient procedures as a means to facilitate ERAS [ 18 , 19 ]. Importantly, from a socio-organizational perspective, the SEM reminds us that top-down directives must be paired with mechanisms for bottom-up feedback. Rather than imposing rigid compliance metrics, incentive-based strategies—such as performance bonuses, procedural green channels, and research or training platforms—may enhance frontline engagement. Shifting Clinical Mindsets and Enhancing Knowledge Capacity The study reaffirms that medical staff understanding and perception of ERAS are critical to implementation success, consistent with the work of Martin et al.[ 20 ]. ERAS represents a paradigm shift from traditional perioperative management, challenging long-standing practices and emphasizing evidence-based, patient-centered care[ 21 ]. Surgeons, often prioritizing safety and clinical prudence, may be hesitant to abandon familiar methods[ 22 ]. This reluctance is influenced by entrenched beliefs, knowledge gaps, and varying levels of exposure to ERAS education[ 22 , 23 ]. Interestingly, while previous studies suggest that senior clinicians are more likely to adopt ERAS due to their access to academic resources and continuous professional development[ 24 ], our findings suggest otherwise: some experienced specialists may possess more rigid clinical mindsets, presenting a barrier to change. Lyon’s findings echo this perspective, noting the difficulty of behavioral change among seasoned professionals[ 25 ]. Moreover, although most participants reported some familiarity with ERAS, their practical application remained limited—indicating a disconnect between awareness and action. Qiu et al. similarly observed that ERAS adoption often lags behind theoretical promotion[ 26 ]. By situating these observations within the SEM, we underscore the interplay between individual-level knowledge and interpersonal influences such as peer modeling, mentorship, and team norms, all of which co-determine whether awareness translates into sustained practice change. Therefore, hospitals should prioritize structured educational interventions, including multidisciplinary workshops, peer learning platforms, and hands-on field observations, to build foundational understanding and foster enthusiasm for ERAS protocols. Fostering Team Collaboration and Improving Multidisciplinary Efficiency Team-based care emerged as both a facilitator and barrier to ERAS implementation. A cohesive, interdisciplinary approach is vital to achieving holistic perioperative care, aligning with international best practices[ 27 , 28 ]. The formation of collaborative networks among surgeons, anesthesiologists, nurses, dietitians, and rehabilitation experts ensures that the multifaceted needs of THA patients are met. However, in the Chinese context, ERAS multidisciplinary teams (MDTs) remain in early developmental stages, with no standardized models for integration. Participants noted that siloed departmental management often impedes communication and coordination. Effective ERAS management demands well-defined roles, shared goals, and a unified vision for recovery. The SEM helps contextualize these findings by illustrating how interpersonal interactions, team dynamics, and organizational structures mutually reinforce or obstruct cross-functional collaboration. Establishing a culture of open communication and interdependence can help transform interdisciplinary challenges into synergy[ 29 ]. Literature supports the appointment of dedicated communication coordinators or ERAS leads to bridge departmental gaps and reinforce accountability[ 30 , 31 ]. While some models emphasize physician leadership, others advocate for greater involvement from nursing staff, including navigation nurses and ERAS specialists, to facilitate cross-functional communication and follow-through[ 32 , 33 ]. Future work should explore which organizational structures yield the best outcomes in orthopedic ERAS programs. Enhancing Public Knowledge and Patient Engagement Patient and family perspectives significantly influence ERAS adherence, especially in elective procedures like THA. As healthcare models shift toward shared decision-making, it is imperative to align clinical recommendations with patient expectations[ 34 ]. Our findings demonstrate that patients unfamiliar with ERAS protocols, or those accustomed to traditional care pathways, often exhibit skepticism or resistance. This hesitancy may stem from safety concerns, lack of trust in newer interventions, or negative prior experiences. Healthcare professionals must play a proactive role in educating patients about the benefits and rationale of ERAS, using clear, evidence-based communication to dispel myths and foster confidence. Providing educational materials, holding preoperative counseling sessions, and leveraging peer support groups can enhance receptivity. Beyond clinical settings, public education efforts—through community health centers, mass media, and health promotion campaigns—can normalize ERAS concepts and increase societal acceptance. Viewed through the SEM, these patient-level and societal-level interventions highlight the importance of aligning cultural expectations, social trust, and institutional messaging to empower patients and families as active partners in recovery. Moreover, improving continuity of care between hospitals and primary care institutions may reduce perceived risk and reinforce the credibility of ERAS measures. Collectively, these efforts can shift patient and family mindsets from passive care recipients to informed partners in the recovery process. Strengths and Limitations This study offers in-depth qualitative insights into the systemic, interpersonal, and perceptual dimensions of ERAS implementation in THA. The use of a phenomenological approach allowed for rich data collection from multidisciplinary stakeholders, providing a comprehensive view of clinical realities. However, several limitations exist. The sample was confined to three tertiary pilot hospitals, limiting generalizability to other institutional settings or lower-level hospitals. Additionally, the absence of patient perspectives restricts the analysis to provider-side experiences. Furthermore, the study relied solely on self-reported data from healthcare professionals, which may introduce recall bias or social desirability bias, potentially affecting the authenticity or completeness of reported experiences. Future research should incorporate voices from diverse hospital tiers and directly involve patients to capture a fuller spectrum of facilitators and barriers to ERAS implementation in orthopedic surgery. In addition, adopting mixed-methods designs that integrate qualitative and quantitative data could strengthen the robustness of future investigations, providing both depth and breadth in understanding ERAS implementation challenges and outcomes. Conclusion This study employed semi-structured interviews with 13 healthcare professionals from multiple disciplines to explore the multifactorial influences on the implementation of ERAS in the perioperative management of THA. The findings reveal that successful ERAS implementation is shaped by a combination of systemic, professional, and patient-level factors. Anchored in the SEM, the study identified influences operating across multiple levels—including hospital governance and policy environments, infrastructure readiness, healthcare staff knowledge and attitudes, interdisciplinary collaboration, and patient and family engagement. A coordinated, multi-level strategy—supported by institutional leadership and enabled through effective interprofessional communication—is indispensable for realizing the full benefits of ERAS in orthopedic care. Strengthening team-based care, investing in staff training, and addressing logistical barriers such as equipment shortages and workflow inconsistencies are essential to promoting consistent practice. Moreover, enhancing patient education and expanding public awareness of ERAS principles will be crucial in improving acceptance and adherence across diverse patient populations. To ensure the sustainable and scalable implementation of ERAS, hospital administrators, clinical leaders, and policymakers must co-develop tailored strategies that reflect local institutional contexts. By fostering a culture of collaboration and engagement—both within care teams and with patients—healthcare systems can optimize perioperative outcomes and advance the transition toward patient-centered, evidence-based surgical care. Abbreviations ERAS Enhanced recovery after surgery THA Total hip arthroplasty SEM Social Ecological Model Declarations Ethics approval and consent to participate Ethical approval was obtained from the Biomedical Ethics Committee of Peking University (IRB00001052-21127; approved on December 10, 2021). Participants received written and verbal explanations of the study purpose, confidentiality protections, and their rights, including the option to withdraw at any time. All participants provided written informed consent. Clinical trial number Not applicable. Consent for publication Not applicable. Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding Statement This work was supported by Peking University Nursing Discipline Research and Development Fund [grant number LJRC20YB05]. Author Contributions JYW and HWZ played a pivotal role in designing the study, collecting and analyzing the data, and drafting the manuscript. CYY and CXH were instrumental in performing statistical analyses, contributing to data visualization, and critically reviewing the manuscript. XYJ and SMS significantly contributed to the conceptual framework, guided the data analysis, and provided key insights for interpreting the findings. The final draft was reviewed and approved by all authors. Acknowledgements We would like to express our sincere gratitude to the 13 healthcare professionals who participated in the qualitative interviews for this study. References Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, et al. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6653848","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469788570,"identity":"b3071fb7-5373-415f-aa47-68b68ff9418c","order_by":0,"name":"Jiayin Wang","email":"","orcid":"","institution":"Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Jiayin","middleName":"","lastName":"Wang","suffix":""},{"id":469788571,"identity":"9a3f91fe-b673-425a-ac09-66c1c1dc9dc2","order_by":1,"name":"Huiwen Zeng","email":"","orcid":"","institution":"Peking University School and Hospital of Stomatology \u0026 National Center of Stomatology \u0026 National Clinical Research Center for Oral Diseases \u0026 National Engineering Research Center of Oral Biomaterials and Digital Medical Devices","correspondingAuthor":false,"prefix":"","firstName":"Huiwen","middleName":"","lastName":"Zeng","suffix":""},{"id":469788572,"identity":"48254876-ddb9-4305-bff0-6fffa9c052f5","order_by":2,"name":"Congying Yang","email":"","orcid":"","institution":"The Second Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Congying","middleName":"","lastName":"Yang","suffix":""},{"id":469788573,"identity":"067de1a2-4d5c-4c65-99eb-2635e52f0faf","order_by":3,"name":"Chenxin Hou","email":"","orcid":"","institution":"Henan Provincial People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chenxin","middleName":"","lastName":"Hou","suffix":""},{"id":469788574,"identity":"7d49a138-7b64-4c02-8008-9263abd1fca1","order_by":4,"name":"Xiaoyan Jin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArElEQVRIiWNgGAWjYBACxgYGNiBlAyZJ0pJGghYgACk+TIJ65hk5Zo9utp2355NufsDwo2IbEQ7rOWNunNt2O7FN5pgBkHObCC3tPWbSQC0JbBIJBsyMbcRoaeYBaTlnzyaR/oFILRBbDjC2SeQQa0vPsXLjnHPJiUAtBQeJ8ovhjORtj3PK7OzlZ6RvfPCjghgtDRwGcM4BwuqBQJ6B/QFRCkfBKBgFo2AEAwDoujfR+WUG9QAAAABJRU5ErkJggg==","orcid":"","institution":"Peking university school of nursing","correspondingAuthor":true,"prefix":"","firstName":"Xiaoyan","middleName":"","lastName":"Jin","suffix":""},{"id":469788575,"identity":"cb1f1530-b74d-4f62-8731-1f730a57d0da","order_by":5,"name":"Shaomei Shang","email":"","orcid":"","institution":"Peking university school of nursing","correspondingAuthor":false,"prefix":"","firstName":"Shaomei","middleName":"","lastName":"Shang","suffix":""}],"badges":[],"createdAt":"2025-05-13 09:23:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6653848/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6653848/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84497533,"identity":"3e65342c-a5d4-4761-aaa0-d1f04dfe75ec","added_by":"auto","created_at":"2025-06-12 15:52:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":479645,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6653848/v1/88c6bb65-289f-41cd-b867-1ab6067b8266.pdf"},{"id":84496794,"identity":"ccf2ec62-43bc-4e54-bdc0-4c40f2083365","added_by":"auto","created_at":"2025-06-12 15:44:33","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":35541,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6653848/v1/7c9ada13439cc217c5eac991.docx"},{"id":84495296,"identity":"6208ce14-b528-4adf-b41a-7e460023b46f","added_by":"auto","created_at":"2025-06-12 15:28:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":37933,"visible":true,"origin":"","legend":"","description":"","filename":"COREQchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-6653848/v1/9bc6bb091f3a4a40bc6be2e3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring barriers and facilitators to implementing enhanced recovery after surgery in total hip arthroplasty: a qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eTotal hip arthroplasty (THA), a type of total joint arthroplasty, has been widely recognized since the 1960s as an effective surgical treatment for severe degenerative joint diseases, osteoarthritis, and post-traumatic hip deformities[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. With global population aging, the demand for THA continues to increase[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While THA brings substantial improvements in pain relief and physical function[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], postoperative recovery remains a significant clinical concern, particularly due to extended hospitalization, high costs, and the risk of complications[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEnhanced Recovery After Surgery (ERAS), introduced by Kehlet in 2001, has emerged as a multimodal perioperative care approach designed to reduce surgical stress and support faster recovery[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Evidence from gastrointestinal and colorectal surgeries has demonstrated that ERAS can significantly reduce complications, accelerate discharge, and improve patient satisfaction[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In recent years, this concept has been increasingly integrated into orthopedic procedures, including THA, where studies have shown improvements in pain control, reduced length of stay, and enhanced early mobility[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Despite these promising outcomes, the implementation of ERAS in THA is not without challenges.\u003c/p\u003e \u003cp\u003eExisting literature primarily emphasizes quantitative outcomes such as hospitalization duration and complication rates[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], while qualitative dimensions of ERAS implementation\u0026mdash;including healthcare provider perceptions, institutional readiness, and patient engagement\u0026mdash;are underexplored. Furthermore, variability in protocol adherence, resource constraints, and heterogeneity in patient populations (e.g., age, comorbidities) raise concerns about ERAS generalizability and sustainability in orthopedic care settings[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Thus, in-depth qualitative research is needed to identify the multifaceted factors that facilitate or hinder ERAS adoption in THA.\u003c/p\u003e \u003cp\u003eGiven that ERAS implementation is influenced not only by individual-level factors such as healthcare providers\u0026rsquo; knowledge and attitudes but also by interpersonal collaboration, organizational resources, and broader sociocultural and policy environments, there is a need for a multi-level analytical lens to comprehensively capture these interrelated influences. To address this complexity, the present study adopts the Bronfenbrenner\u0026rsquo;s Social Ecological Model (SEM)[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] as its theoretical framework. The SEM offers a robust, multi-dimensional perspective for examining how individual, interpersonal, organizational, and societal factors interact to shape clinical behaviors and system-level change, making it particularly suited for exploring the layered challenges and facilitators of ERAS integration in orthopedic practice.\u003c/p\u003e \u003cp\u003e This study aims to explore the perspectives of multidisciplinary healthcare professionals on the implementation of ERAS in THA perioperative care. Through qualitative interviews, we seek to uncover perceived barriers, facilitators, and contextual considerations that shape ERAS application, with the goal of informing more personalized and sustainable ERAS protocols in orthopedic practice.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eTheoretical Framework\u003c/p\u003e \u003cp\u003eWe posit that the successful implementation of ERAS protocols in THA depends on the interplay of multi-level influences spanning individual, interpersonal, organizational, and societal domains. Understanding how these interrelated factors converge to shape perioperative practices, attitudes, and system-level readiness is central to advancing sustainable ERAS integration. To guide this inquiry, we utilize the SEM[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], originally conceptualized by Urie Bronfenbrenner in the 1970s, as the theoretical framework underpinning this study.\u003c/p\u003e \u003cp\u003eAlthough the SEM was initially developed in the field of child development, it has since been widely applied across public health, healthcare implementation, and organizational research to examine how layered environmental systems affect human behaviors and institutional change[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The SEM is particularly well-suited for exploring ERAS implementation because it captures the dynamic, context-dependent interactions between individuals and their broader environments\u0026mdash;something individual behavior models (such as the Theory of Planned Behavior) or organizationally focused implementation frameworks (such as CFIR) do not fully address. By emphasizing the multi-dimensional nature of behavioral and institutional change, the SEM provides a robust and adaptable scaffold for investigating how ERAS practices are adopted, resisted, or modified within orthopedic settings.\u003c/p\u003e \u003cp\u003eThe SEM conceptualizes human behavior as nested within five interrelated levels: the individual, interpersonal, organizational, community, and societal systems. In the context of this study, the individual level encompasses the knowledge, attitudes, beliefs, and competencies of healthcare providers and patients toward ERAS protocols, shaping their readiness and capacity to engage in enhanced recovery practices. The interpersonal level involves the quality of interactions, communication, and teamwork among multidisciplinary staff and between providers and patients\u0026mdash;elements critical to fostering coordinated, patient-centered care. The organizational level refers to the institutional structures, resources, policies, and leadership support that facilitate or hinder the uptake of ERAS, including hospital management commitment, technological infrastructure, and workflow alignment. The community level captures broader networks and professional affiliations that shape local practice patterns and knowledge dissemination, while the societal level encompasses overarching sociocultural norms, regulatory frameworks, and policy environments that incentivize or constrain ERAS adoption across healthcare systems.\u003c/p\u003e \u003cp\u003eBy employing the SEM, this study situates ERAS implementation within a comprehensive, multi-layered analytical framework, allowing for an integrated understanding of how systemic, organizational, interpersonal, and individual-level factors interact to shape clinical practice. This framework thus offers both theoretical depth and practical relevance for structuring the data collection and guiding the multi-layered analysis of factors shaping perioperative care, ultimately informing future efforts to optimize ERAS integration in orthopedic surgery.\u003c/p\u003e \u003cp\u003eStudy Design\u003c/p\u003e \u003cp\u003eGuided by the SEM, This study employed a descriptive phenomenological design to investigate the lived experiences and perceptions of healthcare professionals involved in ERAS-based THA. This approach was chosen to obtain rich, contextualized insights into the complexities of ERAS implementation in clinical settings. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.\u003c/p\u003e \u003cp\u003eSetting and Participant Recruitment\u003c/p\u003e \u003cp\u003eParticipants were recruited from three hospitals in China that were designated as ERAS pilot institutions. Purposive sampling was used to select individuals directly involved in the perioperative management of THA patients. Inclusion criteria included: (1) holding a valid medical or nursing license; (2) at least 5 years of experience in orthopedic or anesthesiology departments; (3) active involvement in ERAS program implementation; and (4) ability and willingness to articulate their perspectives. Participants were approached via departmental leadership and provided written informed consent. Ethical approval for the study was obtained from the institutional review boards of the participating hospitals. Recruitment continued until data saturation was achieved\u0026mdash;defined as the point at which no substantially new codes or themes emerged from successive interviews[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterview Guide and Data Collection\u003c/p\u003e \u003cp\u003eAn initial semi-structured interview guide was developed based on a literature review and refined through consultation with experts in orthopedic surgery and qualitative research. The guide was pilot-tested with three clinicians and revised for clarity and relevance. Key questions included: \u0026ldquo;What steps has your department taken to implement ERAS in THA?\u0026rdquo;, \u0026ldquo;What difficulties have you encountered during implementation?\u0026rdquo;, and \u0026ldquo;What factors do you believe influence ERAS success?\u0026rdquo;\u003c/p\u003e \u003cp\u003eAll interviews were conducted face-to-face in quiet, private hospital meeting rooms. A total of 13 participants were interviewed between September and October 2022. Each interview lasted 25\u0026ndash;40 minutes and was audio-recorded with participant consent. An interview assistant took observational notes, including nonverbal cues such as tone, expressions, and body language. Researchers maintained a neutral stance and used reflective probes and clarifying questions to enhance data depth. Throughout the process, the research team engaged in reflexive discussions to examine their own assumptions and potential influences on data collection and interpretation.\u003c/p\u003e \u003cp\u003eData Management and Analysis\u003c/p\u003e \u003cp\u003eAudio recordings were transcribed verbatim within 48 hours of each interview. Transcripts were cross-checked against recordings and field notes for accuracy. NVivo 12 software was used for data management and coding. Data were analyzed using qualitative content analysis, following these steps: (1) familiarization through repeated reading; (2) open coding to identify meaningful units; (3) grouping codes into subcategories and themes; (4) refining and defining themes through iterative comparison; and (5) synthesizing findings into a coherent narrative.\u003c/p\u003e \u003cp\u003eTwo researchers independently coded all transcripts. Coding discrepancies were resolved through discussion, and a third senior researcher was consulted when needed. The research team held regular meetings to discuss emerging themes and ensure analytical rigor. Themes were then organized in alignment with the SEM levels to ensure theoretical coherence between findings and the study framework. A data audit trail was maintained throughout the process.\u003c/p\u003e \u003cp\u003eRigor and Reflexivity\u003c/p\u003e \u003cp\u003eTo enhance trustworthiness, we employed strategies including triangulation, member checking, and researcher reflexivity. Participants were selected from diverse professional roles to ensure a wide range of perspectives. The research team included members with clinical orthopedic backgrounds and qualitative research training. No prior relationships existed between researchers and participants, minimizing bias. Ongoing reflexivity and regular team debriefings were used to identify and mitigate potential sources of researcher bias.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipant Characteristics\u003c/p\u003e\n\u003cp\u003eA total of 13 healthcare professionals participated in the study, representing diverse roles across three ERAS pilot hospitals: 1 administrator (M), 5 nurses (N), 4 orthopedic surgeons (D), 2 anesthesiologists (A), and 1 rehabilitation physician (R). Participants ranged in age from 27 to 54 years (mean 38.85\u0026thinsp;\u0026plusmn;\u0026thinsp;8.18), with work experience ranging from 8 to 34 years (mean 16.84\u0026thinsp;\u0026plusmn;\u0026thinsp;8.79). Educational backgrounds included college (1), bachelor\u0026rsquo;s (6), master\u0026rsquo;s (2), and doctoral degrees (4). Each interview lasted between 25 and 45 minutes (mean 32.85\u0026thinsp;\u0026plusmn;\u0026thinsp;6.44). Detailed demographic information is provided in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\n\n\u003cp\u003eThemes Identified from the Interviews\u003c/p\u003e\n\u003cp\u003eDrawing on the SEM, the interview data were organized across individual, interpersonal, organizational, and societal dimensions to capture the multi-level influences on ERAS implementation. Three overarching themes emerged: (1) health system factors, (2) medical staff-related factors, and (3) patient and family-related factors, each containing several subthemes describing the facilitators and barriers identified by participants.\u003c/p\u003e\n\n\u003cp\u003e1. Health System Factors\u003c/p\u003e\n\u003cp\u003e1.1 Leadership and Management Support\u003c/p\u003e\n\n\u003cp\u003eInstitutional leadership and efficient organizational processes were identified as critical enablers of ERAS implementation. Support from senior administrators helped promote coordination among departments and secure necessary resources. \u0026quot;I think the biggest help comes from the strong support of the leadership.\u0026quot; (M1) \u0026quot;Management is the most important and the leaders are very supportive.\u0026quot; (N3).\u003c/p\u003e\n\u003cp\u003e1.2 Infrastructure and Resource Limitations\u003c/p\u003e\n\u003cp\u003eInadequate hospital infrastructure, limited diagnostic equipment, and human resource shortages were commonly reported as barriers. Participants emphasized how these constraints could delay procedures or discharge timelines.\u0026quot;Some examination departments do not have enough instruments or staff, leading to delays.\u0026quot; (N3) \u0026quot;Sometimes we have to keep patients longer just because we can\u0026rsquo;t get an imaging result in time due to equipment scheduling.\u0026quot; (D3).\u003c/p\u003e\n\u003cp\u003e1.3 Policy and Institutional Incentives\u003c/p\u003e\n\u003cp\u003eNational healthcare policies promoting shorter hospital stays and cost-effective care provided momentum for ERAS adoption. Institutional endorsement of pilot programs also served as a driving force. \u0026quot;National policy advocacy is particularly important. It encourages hospitals to adopt ERAS.\u0026quot; (D4) \u0026quot;Policy support is one of the reasons we\u0026rsquo;re implementing ERAS. Being a pilot hospital comes with responsibility and expectation.\u0026quot; (N1).\u003c/p\u003e\n\u003cp\u003e1.4 Technological and Material Advancements\u003c/p\u003e\n\u003cp\u003eAdvances in surgical techniques and the availability of innovative materials (e.g., absorbable sutures, updated anesthesia protocols) facilitated early mobilization and discharge. \u0026quot;Thanks to improved anesthesia and surgical techniques, the operation is faster and there\u0026apos;s no longer a need for urinary catheters.\u0026quot; (D1) \u0026quot;Absorbable sutures mean patients don\u0026rsquo;t have to come back for removal, which supports early discharge.\u0026quot; (D4).\u003c/p\u003e\n\n\u003cp\u003e2. Medical Staff-Related Factors\u003c/p\u003e\n\u003cp\u003e2.1 Awareness and Attitudinal Change\u003c/p\u003e\n\n\u003cp\u003eSuccessful ERAS implementation depends on a shift in clinical mindsets. While most staff acknowledged the benefits of ERAS, some found it difficult to abandon entrenched traditional practices. Variability in acceptance among departments was also noted. \u0026quot;The traditional philosophy is deeply rooted. It takes time for people to accept a new concept.\u0026quot; (A2)\u0026quot;Doctors may embrace ERAS, but sometimes support staff are hesitant and not fully on board.\u0026quot; (D1).\u003c/p\u003e\n\u003cp\u003e2.2 Interprofessional Collaboration\u003c/p\u003e\n\u003cp\u003eMultidisciplinary teamwork was seen as essential but often challenged by departmental silos and inconsistent collaboration. Effective communication among orthopedic, anesthesia, nursing, and rehabilitation teams was emphasized. \u0026quot;ERAS is multidisciplinary; the orthopedic department alone cannot implement it effectively without cooperation from others.\u0026quot; (D3) \u0026quot;Different departments have their own leaders and perspectives, and that can make coordination difficult.\u0026quot; (N3).\u003c/p\u003e\n\n\u003cp\u003e3. Patient and Family-Related Factors\u003c/p\u003e\n\u003cp\u003e3.1 Previous Treatment Experiences\u003c/p\u003e\n\n\u003cp\u003ePatients\u0026apos; and families\u0026apos; prior experiences with traditional surgical care influenced their willingness to accept ERAS protocols. Familiarity with older methods often led to resistance, particularly among older patients and caregivers. \u0026quot;Some patients are used to the old process and are less willing to try the new ERAS approach.\u0026quot; (N3) \u0026quot;Families who had good outcomes with previous methods tend to stick with what they know.\u0026quot; (N4).\u003c/p\u003e\n\u003cp\u003e3.2 Perceptions and Expectations of Recovery\u003c/p\u003e\n\u003cp\u003eVaried understandings of what constitutes adequate recovery impacted discharge decisions. Some patients preferred longer hospital stays despite meeting discharge criteria. Others misinterpreted early discharge as inadequate care. \u0026quot;Some patients feel they must be \u0026apos;fully recovered\u0026apos; before discharge, even if they meet all the criteria.\u0026quot; (D1)\u0026quot;Some families are anxious about new methods and worry it\u0026rsquo;s part of a clinical trial rather than proven care.\u0026quot; (A2).\u003c/p\u003e\n\u003cp\u003eOverall, participants acknowledged the multifaceted nature of ERAS implementation. While institutional policies and technological progress have created a favorable environment, effective execution still hinges on interprofessional collaboration, resource availability, and active engagement from both healthcare providers and patients. By mapping these findings across SEM levels, this study highlights the complex interplay of systemic, interpersonal, and individual factors, underscoring the need for integrated, multi-level strategies to optimize ERAS adoption in orthopedic care.\u003c/p\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eImplementing Scientific Management and Maximizing Policy Leverage\u003c/p\u003e \u003cp\u003eThis study highlights that hospital-level governance is a key determinant in the successful implementation of ERAS, consistent with previous findings[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Adequate allocation of human resources is foundational, ensuring healthcare workers have sufficient capacity to engage in ERAS-related tasks. Moreover, the integration of administrative roles, such as care coordinators and process improvement specialists, is essential for program success[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Participants also emphasized that a lack of physical infrastructure\u0026mdash;such as outdated diagnostic tools or insufficient ward space\u0026mdash;hinders effective ERAS rollout. Framed within the SEM, these organizational and systemic factors illustrate how institutional conditions shape the capacity and readiness of healthcare teams to adopt evidence-based perioperative innovations. Hospital administrators must respond proactively to national directives by leveraging policy incentives granted to ERAS pilot hospitals. Strategic investments in advanced technologies and surgical materials, alongside system-wide infrastructure renewal, are necessary steps to establish an enabling environment for ERAS.\u003c/p\u003e \u003cp\u003eLeadership at the hospital level must be centralized and empowered, guiding multidisciplinary teams through performance-based and duty-oriented management. Dedicated department heads should assume responsibility for ERAS implementation, acting as communication and accountability nodes. Equally important is the establishment of clear, streamlined, and standardized workflows, allowing clinical staff to precisely understand their roles and contribute effectively. This aligns with prior literature emphasizing the need to eliminate redundant or inefficient procedures as a means to facilitate ERAS [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Importantly, from a socio-organizational perspective, the SEM reminds us that top-down directives must be paired with mechanisms for bottom-up feedback. Rather than imposing rigid compliance metrics, incentive-based strategies\u0026mdash;such as performance bonuses, procedural green channels, and research or training platforms\u0026mdash;may enhance frontline engagement.\u003c/p\u003e \u003cp\u003eShifting Clinical Mindsets and Enhancing Knowledge Capacity\u003c/p\u003e \u003cp\u003eThe study reaffirms that medical staff understanding and perception of ERAS are critical to implementation success, consistent with the work of Martin et al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. ERAS represents a paradigm shift from traditional perioperative management, challenging long-standing practices and emphasizing evidence-based, patient-centered care[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Surgeons, often prioritizing safety and clinical prudence, may be hesitant to abandon familiar methods[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This reluctance is influenced by entrenched beliefs, knowledge gaps, and varying levels of exposure to ERAS education[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterestingly, while previous studies suggest that senior clinicians are more likely to adopt ERAS due to their access to academic resources and continuous professional development[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], our findings suggest otherwise: some experienced specialists may possess more rigid clinical mindsets, presenting a barrier to change. Lyon\u0026rsquo;s findings echo this perspective, noting the difficulty of behavioral change among seasoned professionals[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Moreover, although most participants reported some familiarity with ERAS, their practical application remained limited\u0026mdash;indicating a disconnect between awareness and action. Qiu et al. similarly observed that ERAS adoption often lags behind theoretical promotion[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. By situating these observations within the SEM, we underscore the interplay between individual-level knowledge and interpersonal influences such as peer modeling, mentorship, and team norms, all of which co-determine whether awareness translates into sustained practice change. Therefore, hospitals should prioritize structured educational interventions, including multidisciplinary workshops, peer learning platforms, and hands-on field observations, to build foundational understanding and foster enthusiasm for ERAS protocols.\u003c/p\u003e \u003cp\u003eFostering Team Collaboration and Improving Multidisciplinary Efficiency\u003c/p\u003e \u003cp\u003eTeam-based care emerged as both a facilitator and barrier to ERAS implementation. A cohesive, interdisciplinary approach is vital to achieving holistic perioperative care, aligning with international best practices[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The formation of collaborative networks among surgeons, anesthesiologists, nurses, dietitians, and rehabilitation experts ensures that the multifaceted needs of THA patients are met. However, in the Chinese context, ERAS multidisciplinary teams (MDTs) remain in early developmental stages, with no standardized models for integration.\u003c/p\u003e \u003cp\u003e Participants noted that siloed departmental management often impedes communication and coordination. Effective ERAS management demands well-defined roles, shared goals, and a unified vision for recovery. The SEM helps contextualize these findings by illustrating how interpersonal interactions, team dynamics, and organizational structures mutually reinforce or obstruct cross-functional collaboration. Establishing a culture of open communication and interdependence can help transform interdisciplinary challenges into synergy[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Literature supports the appointment of dedicated communication coordinators or ERAS leads to bridge departmental gaps and reinforce accountability[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. While some models emphasize physician leadership, others advocate for greater involvement from nursing staff, including navigation nurses and ERAS specialists, to facilitate cross-functional communication and follow-through[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Future work should explore which organizational structures yield the best outcomes in orthopedic ERAS programs.\u003c/p\u003e \u003cp\u003eEnhancing Public Knowledge and Patient Engagement\u003c/p\u003e \u003cp\u003ePatient and family perspectives significantly influence ERAS adherence, especially in elective procedures like THA. As healthcare models shift toward shared decision-making, it is imperative to align clinical recommendations with patient expectations[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Our findings demonstrate that patients unfamiliar with ERAS protocols, or those accustomed to traditional care pathways, often exhibit skepticism or resistance. This hesitancy may stem from safety concerns, lack of trust in newer interventions, or negative prior experiences.\u003c/p\u003e \u003cp\u003eHealthcare professionals must play a proactive role in educating patients about the benefits and rationale of ERAS, using clear, evidence-based communication to dispel myths and foster confidence. Providing educational materials, holding preoperative counseling sessions, and leveraging peer support groups can enhance receptivity. Beyond clinical settings, public education efforts\u0026mdash;through community health centers, mass media, and health promotion campaigns\u0026mdash;can normalize ERAS concepts and increase societal acceptance. Viewed through the SEM, these patient-level and societal-level interventions highlight the importance of aligning cultural expectations, social trust, and institutional messaging to empower patients and families as active partners in recovery. Moreover, improving continuity of care between hospitals and primary care institutions may reduce perceived risk and reinforce the credibility of ERAS measures. Collectively, these efforts can shift patient and family mindsets from passive care recipients to informed partners in the recovery process.\u003c/p\u003e"},{"header":"Strengths and Limitations","content":"\u003cp\u003eThis study offers in-depth qualitative insights into the systemic, interpersonal, and perceptual dimensions of ERAS implementation in THA. The use of a phenomenological approach allowed for rich data collection from multidisciplinary stakeholders, providing a comprehensive view of clinical realities. However, several limitations exist. The sample was confined to three tertiary pilot hospitals, limiting generalizability to other institutional settings or lower-level hospitals. Additionally, the absence of patient perspectives restricts the analysis to provider-side experiences. Furthermore, the study relied solely on self-reported data from healthcare professionals, which may introduce recall bias or social desirability bias, potentially affecting the authenticity or completeness of reported experiences. Future research should incorporate voices from diverse hospital tiers and directly involve patients to capture a fuller spectrum of facilitators and barriers to ERAS implementation in orthopedic surgery. In addition, adopting mixed-methods designs that integrate qualitative and quantitative data could strengthen the robustness of future investigations, providing both depth and breadth in understanding ERAS implementation challenges and outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study employed semi-structured interviews with 13 healthcare professionals from multiple disciplines to explore the multifactorial influences on the implementation of ERAS in the perioperative management of THA. The findings reveal that successful ERAS implementation is shaped by a combination of systemic, professional, and patient-level factors. Anchored in the SEM, the study identified influences operating across multiple levels\u0026mdash;including hospital governance and policy environments, infrastructure readiness, healthcare staff knowledge and attitudes, interdisciplinary collaboration, and patient and family engagement.\u003c/p\u003e \u003cp\u003eA coordinated, multi-level strategy\u0026mdash;supported by institutional leadership and enabled through effective interprofessional communication\u0026mdash;is indispensable for realizing the full benefits of ERAS in orthopedic care. Strengthening team-based care, investing in staff training, and addressing logistical barriers such as equipment shortages and workflow inconsistencies are essential to promoting consistent practice. Moreover, enhancing patient education and expanding public awareness of ERAS principles will be crucial in improving acceptance and adherence across diverse patient populations.\u003c/p\u003e \u003cp\u003eTo ensure the sustainable and scalable implementation of ERAS, hospital administrators, clinical leaders, and policymakers must co-develop tailored strategies that reflect local institutional contexts. By fostering a culture of collaboration and engagement\u0026mdash;both within care teams and with patients\u0026mdash;healthcare systems can optimize perioperative outcomes and advance the transition toward patient-centered, evidence-based surgical care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eERAS \u0026nbsp; Enhanced recovery after surgery\u003c/p\u003e\n\u003cp\u003eTHA \u0026nbsp; \u0026nbsp;Total hip arthroplasty\u003c/p\u003e\n\u003cp\u003eSEM \u0026nbsp; \u0026nbsp;Social Ecological Model\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e \u003cstrong\u003eapproval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Biomedical Ethics Committee of Peking University (IRB00001052-21127; approved on December 10, 2021). Participants received written and verbal explanations of the study purpose, confidentiality protections, and their rights, including the option to withdraw at any time. All participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Peking University Nursing Discipline Research and Development Fund [grant number LJRC20YB05].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJYW and HWZ played a pivotal role in designing the study, collecting and analyzing the data, and drafting the manuscript. CYY and CXH were instrumental in performing statistical analyses, contributing to data visualization, and critically reviewing the manuscript. XYJ and SMS significantly contributed to the conceptual framework, guided the data analysis, and provided key insights for interpreting the findings. The final draft was reviewed and approved by all authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to the 13 healthcare professionals who participated in the qualitative interviews for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced recovery after surgery (ERAS\u0026reg;) society recommendations. 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Results of a colorectal enhanced recovery after surgery (ERAS) programme and a qualitative analysis of healthcare workers\u0026rsquo; perspectives. Asian J Surg. 2021;44:307\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eMorrell AT, Layon DR, Scott MJ, Kates SL, Golladay GJ, Patel NK. Enhanced recovery after primary total hip and knee arthroplasty: A systematic review. J Bone Joint Surg Am. 2021;103:1938\u0026ndash;47.\u003c/li\u003e\n\u003cli\u003eTan Y-Z, Lu X, Luo J, Huang Z-D, Deng Q-F, Shen X-F, et al. Enhanced recovery after surgery for breast reconstruction: Pooled meta-analysis of 10 observational studies involving 1,838 patients. Front Oncol. 2019;9.\u003c/li\u003e\n\u003cli\u003ePritchard MG, Murphy J, Cheng L, Janarthanan R, Judge A, Leal J. Enhanced recovery following hip and knee arthroplasty: A systematic review of cost-effectiveness evidence. BMJ open. 2020;10:e032204.\u003c/li\u003e\n\u003cli\u003eZhang Z, Song Y. Enhanced recovery after surgery in nursing care of elderly patients undergoing coronary artery bypass grafting. Asian J Surg. 2024. https://doi.org/10.1016/j.asjsur.2024.07.328.\u003c/li\u003e\n\u003cli\u003eBronfenbrenner U. The ecology of human development: Experiments by nature and design. Harvard University Press; 1979.\u003c/li\u003e\n\u003cli\u003eMadsen KG, Mosgaard JS, Oshosen M, Swai P, Mwaiselage J, Rasch V, et al. Barriers and facilitators for implementation of HPV-based cervical cancer screening in tanzania: A qualitative study among healthcare providers, stakeholders, and tanzanian women. Glob Health Action. 2025;18:2491852.\u003c/li\u003e\n\u003cli\u003eEriksson M, Sundberg LR, Santosa A, Lindgren H, Ng N, Lindvall K. Health behavioural change \u0026ndash; the influence of social-ecological factors and health identity. Int J Qual Stud Health Well-being. 2025;20:2458309.\u003c/li\u003e\n\u003cli\u003eWang T, Yan X, Li CY, Sun H, Jiang H. A qualitative study on the experience of related donors of allogeneic hematopoietic stem cell transplantation. Chin J Nurs. 2020;55:1785\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eSalenger R, Morton-Bailey V, Grant M, Gregory A, Williams JB, Engelman DT. Cardiac enhanced recovery after surgery: A guide to team building and successful implementation. Semin Thorac Cardiovasc Surg. 2020;32:187\u0026ndash;96.\u003c/li\u003e\n\u003cli\u003eBeal EW, Reyes J-PC, Denham Z, Abdel-Rasoul M, Rasoul E, Humeidan ML. Survey of provider perceptions of enhanced recovery after surgery and perioperative surgical home protocols at a tertiary care hospital. Medicine (baltimore). 2021;100:e26079.\u003c/li\u003e\n\u003cli\u003eMartin D, Roulin D, Grass F, Addor V, Ljungqvist O, Demartines N, et al. A multicentre qualitative study assessing implementation of an enhanced recovery after surgery program. Clinical Nutrition (Edinburgh, Scotland). 2018;37 6 Pt A:2172\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eHuang H, Zhang Y, Shen L, Huang Y. Level of ERAS understanding affects practitioners\u0026rsquo; practice and perception of early postoperative resumption of oral intake: A nationwide survey. BMC anesthesiology. 2021;21:279.\u003c/li\u003e\n\u003cli\u003eBalfour A, Burch J, Fecher-Jones I, Carter FJ. Understanding the benefits and implications of enhanced recovery after surgery. Nursing Standard (Royal College of Nursing (Great Britain): 1987). 2019;34:70\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eBalfour A, Amery J, Burch J, Smid-Nanninga H. Enhanced recovery after surgery (ERAS\u0026reg;): Barriers and solutions for nurses. Asia-Pac J Oncol Nurs. 2022;9:100040.\u003c/li\u003e\n\u003cli\u003eWang D, Liu Z, Zhou J, Yang J, Chen X, Chang C, et al. Barriers to implementation of enhanced recovery after surgery (ERAS) by a multidisciplinary team in China: A multicentre qualitative study. BMJ open. 2022;12:e053687.\u003c/li\u003e\n\u003cli\u003eLyon A, Solomon MJ, Harrison JD. A qualitative study assessing the barriers to implementation of enhanced recovery after surgery. World J Surg. 2014;38:1374\u0026ndash;80.\u003c/li\u003e\n\u003cli\u003eQiu ST, Zhang XR, Che GW, Li Chuan, Gong RR. The opinion of operating room nurse on the enhanced recovery after surgery (ERAS): A survey questionnaire. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery. 2017;24:543\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eCrosson JA. Enhanced recovery after surgery-the importance of the perianesthesia nurse on program success. Journal of Perianesthesia Nursing: Official Journal of the American Society of PeriAnesthesia Nurses. 2018;33:366\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eGramlich LM, Sheppard CE, Wasylak T, Gilmour LE, Ljungqvist O, Basualdo-Hammond C, et al. Implementation of enhanced recovery after surgery: A strategy to transform surgical care across a health system. Implementation science: IS. 2017;12:67.\u003c/li\u003e\n\u003cli\u003eDu N, Guo C, Yang M, Ji Y, Wang W, Li J, et al. [assessing the current status of enhanced recovery after surgery in the usage of web-based survey questionnaires by thoracic surgeons and nurses attending the meeting in mainland China]. Zhongguo Fei Ai Za Zhi = Chinese Journal of Lung Cancer. 2017;20:157\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eAyinde BO, Chokshi P, Adhikari S, Jaimalani A, Yeritsyan A, Surve AV, et al. Challenges and elements hindering the adoption of enhanced recovery after surgery (ERAS) protocols in colorectal surgery and their resolutions: A systematic review. Cureus. 2024;16:e63222.\u003c/li\u003e\n\u003cli\u003ePereira J, Paduraru M. Multimodal rehabilitation in geriatric emergency surgery. Chirurgia (Bucharest, Romania: 1990). 2017;112:558\u0026ndash;65.\u003c/li\u003e\n\u003cli\u003eBalfour A, Burch J, Fecher-Jones I, Carter FJ. Exploring the fundamental aspects of the enhanced recovery after surgery nurse\u0026rsquo;s role. Nursing Standard (Royal College of Nursing (Great Britain): 1987). 2019. https://doi.org/10.7748/ns.2019.e11437.\u003c/li\u003e\n\u003cli\u003eMiralpeix E, Nick AM, Meyer LA, Cata J, Lasala J, Mena GE, et al. A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol. 2016;141:371\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eSiebinga VY, Driever EM, Stiggelbout AM, Brand PLP. Shared decision making, patient-centered communication and patient satisfaction - a cross-sectional analysis. Patient Educ Couns. 2022;105:2145\u0026ndash;50.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Enhanced Recovery After Surgery, Total Hip Arthroplasty, Qualitative Research, Multidisciplinary Care, Perioperative Management","lastPublishedDoi":"10.21203/rs.3.rs-6653848/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6653848/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEnhanced Recovery After Surgery (ERAS) protocols have shown significant promise in improving outcomes for patients undergoing total hip arthroplasty (THA). Yet, the implementation of ERAS in orthopedic clinical settings remains inconsistent, challenged by systemic, organizational, and cultural barriers. Understanding the underlying factors influencing ERAS uptake is critical for improving perioperative care and ensuring consistent, evidence-based practice. Guided by the Social Ecological Model, this study aimed to explore the multi-level influences on ERAS implementation in the perioperative management of THA patients and to inform future strategies for optimizing ERAS integration in orthopedic practice.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFace-to-face semi-structured interviews were conducted with 13 healthcare professionals\u0026mdash;including orthopedic surgeons, nurses, anesthesiologists, a rehabilitation physician, and a hospital administrator\u0026mdash;from three ERAS pilot hospitals in China. Interviews were transcribed verbatim and analyzed using content analysis supported by NVivo 12 software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree overarching categories of influencing factors emerged: (1) health system factors, including hospital management support, infrastructure readiness, policy-driven incentives, and technological advancement; (2) healthcare professional factors, such as ERAS awareness, attitudinal barriers, and the quality of multidisciplinary collaboration; and (3) patient and family-related factors, including perceptions, treatment history, and engagement in recovery decisions. These factors were mapped across individual, interpersonal, organizational, and societal levels, reflecting the complex interactions shaping ERAS implementation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe sustainable implementation of ERAS in THA requires a coordinated, multidisciplinary approach supported by hospital leadership, comprehensive staff education, and active patient involvement. Embedding ERAS within a multi-level strategic framework\u0026mdash;supported by policy alignment, technological readiness, and cultural change\u0026mdash;is essential to advancing its integration from theoretical model to standard orthopedic practice.\u003c/p\u003e","manuscriptTitle":"Exploring barriers and facilitators to implementing enhanced recovery after surgery in total hip arthroplasty: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-12 15:28:28","doi":"10.21203/rs.3.rs-6653848/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"51939019562067321211235430025111117853","date":"2026-05-10T19:01:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-12T15:43:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283205887664025947733571328418041303364","date":"2025-06-12T15:26:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-10T17:57:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-16T09:08:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-16T08:27:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-16T08:24:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-05-13T09:21:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cc8ba723-8984-46dc-b061-d757b773f13e","owner":[],"postedDate":"June 12th, 2025","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"51939019562067321211235430025111117853","date":"2026-05-10T19:01:52+00:00","index":84,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-12T15:28:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-12 15:28:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6653848","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6653848","identity":"rs-6653848","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}