Table 2.

Table of included studies

Study	Study design	Surgical population	Methodology and methods	No and type of participants	Country	Key findings
Alawadi et al 22	Qualitative study to assess the perceived barriers and facilitators before enhanced recovery after surgery (ERAS) adoption.	Colorectal surgery	Qualitative interviews with multidisciplinary team (MDT) staff and patients. Content analysis.	8 anaesthesiologists, 5 surgeons, 6 nurses and 18 patients.	USA	Conclusion: ‘Although limited hospital resources are perceived as a barrier to ERAS implementation… there is strong support for such pathways and multiple factors were identified that may facilitate change’ (2016: 700).
Sjetne et al 26	Pre–postintervention prospective design, to monitor changes in workload and work environment of ward nursing staff when ERAS was introduced.	Gynaecological surgery	Questionnaires and qualitative interviews. Quantitative data analysed using SAS Version 9.1.13 (t-tests and differences in means), qualitative data used to elaborate the topics studied.	34, 33 and 32 nurses returned questionnaires in phases 1, 2 and 3, respectively (100% survey response rate). 9 interviews with 4 different nurses.	Norway	Conclusion: ‘expected clinical gains achieved by introducing ERAS are achieved without compromising the work environment of ward nurses’ (2009: 239).
Pearsall et al 19	Qualitative study to understand barriers and enablers in perioperative implementation of ERAS.	Colorectal surgery	Qualitative semistructured interviews. Thematic analysis.	19 general surgeons, 18 anaesthesiologists, 18 nurses.	Canada	Conclusion: ‘participants supported the need for implementation of an ERAS programme… (but) felt there remained major barriers to (its) successful implementation’ (2015: 96).
Wagner et al 24	Exploratory and descriptive qualitative study to gather knowledge about staff and patient experiences of the Accelerated Recovery Programme (ARP).	Abdominal hysterectomy	Qualitative individual interviews and focus groups with staff, observation of and interviews with patients. Thematic analysis.	Observation of 17 patients, 10 of whom were interviewed twice. Interviews with 15 staff, who all participated in focus groups.	Denmark	Conclusion: patients underwent ARP without significant problems, but identified a need for greater psychological support. Staff data showed a positive change in opinion and an understanding of ARP. Recommendations made for better information to be provided to staff and patients, in consultation rooms and outpatient clinics.
Jeff and Taylor23	To explore and describe ward nurses’ experience of ERAS in the postoperative phase.	Gastrointestinal surgery	Semistructured interviews and documentary evidence (memos and reflective journals). Thematic analysis.	Interviews with 8 (of a possible 30) nurses.	UK	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’ (2014: 31).
Gotlib Conn et al 20	Process evaluation of ERAS champions’ experiences. To understand enablers and barriers to the successful implementation of ERAS.	Colorectal surgery	Qualitative semistructured interviews. Normalisation process theory framework analysis.	5 surgeons, 14 anaesthesiologists, 15 nurses and 14 project coordinators.	Canada	Conclusion: successful implementation of ERAS is achieved by a ‘complex series of cognitive and social processes… (the study demonstrates the importance of) champion coherence, external and internal relationship building, and the strategic management of a project’s organisation-level visibility’ (2015: 1).
Lyon et al 21	Qualitative study to assess barriers to ERAS implementation, conducted at postoperative stage.	Colorectal surgery	Qualitative semistructured interviews. Grounded theory analysis.	18 interviews with MDT staff.	Australia	Conclusion: there are four key areas that present barriers to successful ERAS implementation: (1) patient-related factors, (2) staff-related factors, (3) practice-related issues and (4) resources. For ERAS to be implemented successfully and function efficiently with high levels of compliance, these key areas need to be addressed (ideally) before launching an ERAS programme, and then carefully managed throughout.
Berthelsen and Frederiksen25	Qualitative study to illuminate orthopaedic nurses’ perceptions and experiences of providing individual nursing care for older patients in standardised fast-track programmes.	Orthopaedic surgery (hip and knee replacement)	Semistructured interviews. Manifest and latent content analysis.	10 interviews with orthopaedic nurses.	Denmark	Conclusion: nurses felt they had to compromise their nursing care and ethics in order to comply with the fast-track programme and implement the standardised care that it recommends.