Table 1 Thematic categories.

Theme	Meaning unit	Content-related category
Collaboration and communication	Staff find the information-rich nature of enhanced recovery after surgery (ERAS) confusing. Many staff feel that they do not understand it well enough and/or that they have not received sufficiently clear or consistent information or training. Information about ERAS is not always disseminated between staff—and between staff and patients—in a coherent and consistent way. Collaborative multidisciplinary team (MDT) work is hindered by high staff turnover and a lack of coordination across different departments.	Providing staff and their patients with a comprehensive education about and introduction to ERAS improves understanding and helps to mitigate confusion. Strong team communications help to ensure the effective dissemination of information. Building good relationships within the MDT helps to encourage dialogue between staff, and to improve their willingness and ability to collaborate. The appointment of a dedicated ERAS ‘champion’ improves staff engagement and collaborative working.
Resistance to change	Staff are reluctant to implement or engage with new and unfamiliar working practices. Some staff—especially those who are older or more well established in their role—tend to dislike change more generally and are disinclined to engage with ERAS.	Appointing and ERAS champion helps to encourage more positive attitudes among staff.
Role and significance of protocol-based care	Staff recognise the usefulness of evidence-based protocol guidelines as a means of reducing variations and standardising practice, but have mixed feelings about whether ERAS facilitates this well. ERAS is not definitively prescriptive, and therefore, allows for too much variability in local implementation. Some staff feel conflicted about having to compromise their capacity for and confidence in providing individualised care for patients.	The incorporation of standardised order sets and basing ERAS practices on best evidence increases staff willingness to implement it as a complex intervention. Having a local ERAS champion helps to improve consistency in implementing and operationalising the pathway into existing systems at local sites. Clearer guidance about when it is acceptable to deviate from ERAS protocols would improve staff confidence.
Knowledge and expectations	Staff feel that they need a broader knowledge and understanding of ERAS, that is, beyond protocol guidelines. Staff are sceptical about the usefulness and value of ERAS prior to its implementation. Managing the expectations of staff and patients is recognised as being crucial to the successful implementation of ERAS. Differing professional perspectives, which are sometimes based on incorrect assumptions, can create ambivalence and uncertainty among staff. Staff use tacit knowledge and a ‘common sense’ approach to overcome this.	Belief in the value and potential positive impact of ERAS improves the willingness of staff to engage with the pathway and its guidelines. Staff feel more positive about and favourable towards ERAS when they have seen it work successfully in practice. Setting clear and realistic expectations about ERAS helps to improve staff and patient experiences of the pathway.