Knowledge, Attitude and Practice of Surgical Nurses on Enhanced Recovery after Surgery (ERAS) protocols: Multicentre Cross-sectional study

doi:10.21203/rs.3.rs-5191118/v1

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Knowledge, Attitude and Practice of Surgical Nurses on Enhanced Recovery after Surgery (ERAS) protocols: Multicentre Cross-sectional study

https://doi.org/10.21203/rs.3.rs-5191118/v1

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Introduction:

Enhanced Recovery after Surgery (ERAS) protocols have been widely adopted in surgical practice to improve patient outcomes and optimize recovery. These protocols are evidence-based and focus on minimizing the physiological stress of surgery, promoting postoperative recovery, and reducing the length of hospital stays

Objective

The primary aim of this study was to assess knowledge, attitude and practice of surgical nurses on Enhanced Recovery after Surgery (ERAS) protocols.

Methods

A multicentre cross-sectional study was conducted from May 05/2024 to August 20/2024.

Result

A total of 462 surgical nurses were participated in the study. The study found that most participants (64.1%) had a strong understanding of ERAS protocols. Among participants, 51.9% showed positive attitudes towards ERAS protocol. However, when it came to actually applying the protocols, only 30.1% engaged in good practices. Level of education (AOR = 32.748, AOR = 5.023, AOR = 4.070), work experience (AOR = 6.408, AOR = 8.086), hospital type (AOR = 16.545, AOR = 2.121, AOR = 2.637), and on-the-job training (AOR = 6.525, 2.474, 1.974) were found to be highly associated with surgical nurses' knowledge, attitudes and practice of ERAS protocols with respective AOR.

Conclusion

The result this study emphasizes that age, education, work experience, hospital type, and on-the-job training play key roles in shaping surgical nurses' knowledge and attitudes towards ERAS protocols. It highlights the need for specialized educational and training programs designed for various nursing groups to improve their understanding and application of ERAS. Moreover, these factors also impact the effectiveness of ERAS protocol implementation in clinical settings.

Enhanced recovery after surgery

ERAS Protocol

surgical nurses

knowledge

attitude and practice

The Enhanced Recovery after Surgery (ERAS) protocol was created in 2001 by a group of academic surgeons in Europe. Although the term "fast-track surgery" had already been introduced, the primary focus of ERAS was on improving the overall quality of surgical care (1). Enhanced Recovery After Surgery (ERAS) protocols have become common in surgical care to help patients recover faster and improve overall outcomes. These protocols are based on research and are designed to reduce the physical stress of surgery, support quicker recovery, and shorten hospital stays (2, 3). ERAS takes a team-based approach, making changes to care before, during, and after surgery, all with the goal of helping patients recover better and faster (4).

Surgical nurses are key to making ERAS protocols work effectively. Their understanding and approach can greatly impact how successful these protocols are in practice. However, research shows that nurses' knowledge and use of ERAS principles can vary (5). This inconsistency is often due to limited formal training on ERAS, emphasizing the need for better education and targeted training programs (6).

The attitude of surgical nurses toward ERAS can also affect how likely they are to use these protocols in their day-to-day work. When nurses have a positive outlook, they tend to follow the guidelines more closely, which leads to better patient outcomes (7). On the other hand, negative attitudes or misunderstandings can get in the way of implementing ERAS successfully. This shows how important it is to address these issues for smooth integration into surgical care (8).

This paper focuses on examining the knowledge, attitudes, and practices of surgical nurses regarding ERAS protocols. By identifying areas where understanding and application are lacking, we can create better strategies to improve how ERAS is implemented in surgical care.

Study design, area, period and population

A multicentre cross-sectional study was conducted from May to August 2024 in Ethiopia, which has a population of around 112.1 million, making it the second most populous country in Africa (9). The study was conducted at selected governmental teaching and non-teaching hospitals located in Amhara Regional State and Addis Ababa City Adminstartion. The source population for this study consisted of surgical nurses in Ethiopia, while the study population included surgical nurses working at selected hospital. Participant were randomly selected from certified surgical nurses who have at least 1 year minumum experience and was included in the study. Surgical nurse who were not currently on their work place, who have a history of work-related disciplinary actions or malpractice, who are currently on a leave of absence or unavailable during the study period, and refused to participate are excluded from the study.

Sample size and Sampling Procedure

The sample size was calculated based on 50% professionals will have good knowledge, attitude and practice on ERAS protocol at a 5% margin of error due to the absence of reliable previous study in the study area.

n = (Z _α/2)² P (1-P)/d ²

n = (1.96) ² 0.5 (1-0.5)/ (0.05)²

n = 385 with a 20% Estimated attrition rate, n = 462

Where

n = sample size

d = desired a degree of precision

To determine number participant from each hospital, proportionate stratification technique was applied based on the total number of surgical nurses employed at respective hospitals. Finally, individual participants were selected using random lottery method.

Operational definitions

High knowledge

the study participants who answer above the mean of Knowledge questions are considered as having good knowledge.

Low knowledge

the study participants who answer below the mean of the Knowledge questions are considered as having poor knowledge.

Positive attitude

the study participants who answer above the mean of attitude questions are considered as having positive attitude.

Negative attitude

the study participants who answer below the mean of the attitude questions are considered as having Negative attitude.

Good practice

the study participants who answer above the mean of practice questions are considered as having good practice.

Bad practice

the study participants who answer below the mean of practice questions are considered as having poor practice.

Data Collection

Google form online questioner was used to collecte the data for the study. To ensure transparency and clarity, the data collection began with an intoroductory page that provided participants with important information including the study's purpose, the different topics covered in the survey, considerations regarding informed consent, how the results would be reported, the approval received from the ethical committee, and information about the research team. Once participants accessed the questioner, clear instructions were given to guide them through each section. These instructions were placed at the beginning of each section and aimed to explain the type of information required. They also provided an understanding of the response options available, ensuring participants knew how to provide accurate and relevant answers. The intention was to make the questioner as user-friendly as possible, enabling participants to navigate through it with ease.

All questioner items were made mandatory in order to lessen the risk of missing data. Data collection tool was designed the questioner used by previous studies (10–12).

The questioner contained four parts. Part I demographic variables, part II questions related to knowledge about ERAS protocol, part III questions related to attitude on ERAS protocol and part IV questions related to practice of ERAS protocol by surgical nurses.

To determine level knowledge, attitude and prctice of surgical nurses on ERAS protocol, the mean score in each domain was used as a cut point for classification. Score above mean value leveled as high knowledge, positive atitude and good practice and score below mean value considered as low knowledge, negative atitude and poor practice.

Data Quality Control

In order to assess the effectiveness of the study and identify any potential issues, online pretest was conducted at two hospitals that did not included in the main study. During the pretest, participants were asked to provide feedback on the questionnaire regarding the appropriateness, logical flow, and consistency of the questions. Their comments were invaluable in helping us improve and refine the final version of the questionnaire. To ensure the security and confidentiality of the filled questionnaires, we implemented measures such as using a unique password to protect the data and restricting access to only the data analyst. During the data analysis phase, we carefully examined the data for consistency and performed necessary cleaning and transformations of variables to ensure accurate results.

Data processing and analysis procedure

Data was checked for completeness; consistencies then coded, and imported to SPSS. Then the data was cleaned and analysed using SPSS version 20. Descriptive statistics were computed to determine frequencies and summary statistics (frequency and percentage). Data is presented using tables and graphs. All variables with P ≤ 0.2 in the bivariable logistic regression analysis were included in the final model of multivariable logistic regression analysis to control all possible confounders. Multi-collinearity was checked to see the linear correlation among the independent variables by using the standard error. Variables with a standard error of > 0.2 were dropped from the multivariable logistic regression analysis. Model fitness was checked with the Hosmer-Lemeshow test. The adjusted odds ratio with 95% CI was estimated to identify the factors associated with adherence status using multivariable logistic regression analysis. The level of statistical significance will be declared at p-value < 0.05.

Socio-demographic Characteristics of Surgical Nurses

The study included 462 participants, with the majority being male (68%) and the rest female (32%). Age-wise, 39% were under 30, 37% were between 30–40, and 24% were over 40. In terms of marital status, 60.4% were single, and 39.6% were married.

When it comes to education, 52.2% had a Bachelor's degree or lower, while 47.8% held a Master's degree or higher. As for work experience, 44.2% had less than five years of experience, while 55.8% had five years or more.

The participants worked in both teaching hospitals (53.2%) and non-teaching hospitals (46.8%). Half of them (50.4%) had received on-the-job training, while the remaining 49.6% had not (Table 1).

Overall knowledge, attitude and practice of surgical nurses towards ERAS protocol

The study found that most participants (64.1%) had a strong understanding of ERAS protocols. Attitudes were more evenly split, with 51.9% showing a positive view of ERAS and 48.1% having a negative attitude. However, when it came to actually applying the protocols, 69.9% reported poor practice, and only 30.1% engaged in good practices. These results point to key areas for improvement, especially in putting the protocols into practice, despite the overall good knowledge and generally positive attitudes among the nurses (Fig. 1).

Knowledge of Surgical Nurses about ERAS Protocol and associated factors

Different factors have been found to associated knowledge of surgical nurses. Nurses aged 30–40 had significantly higher knowledge (COR = 2.270, AOR = 20.449), while those over 40 had moderate levels (AOR = 4.518). Single nurses showed notably higher knowledge (75.3%) compared to married nurses, with married nurses having a strong negative association with higher knowledge in both univariate (COR = 0.167) and multivariate (AOR = 0.332) analyses.

Nurses with a Master's degree or higher had much higher knowledge (COR = 5.728, AOR = 32.748) than those with a Bachelor's degree or lower. Similarly, nurses with five or more years of experience demonstrated significantly greater knowledge (COR = 4.221, AOR = 6.408) compared to those with less experience. Those working in teaching hospitals had a much higher likelihood of strong knowledge (COR = 8.818, AOR = 16.545) than those in non-teaching hospitals. Additionally, nurses who received on-the-job training showed significantly higher knowledge levels (COR = 21.824, AOR = 6.525) compared to those without training (Table 2)

Attitude of Surgical Nurses Towards ERAS Protocol and associated factors

Different factors have been found to associated atittude of surgical nurses. Nurses under 30 had the highest rate of positive attitudes. Those aged 30–40 showed a moderate increase in positivity (COR = 1.527, AOR = 1.974), while nurses over 40 had a lower likelihood (AOR = 1.851), showing mixed results. Single nurses were significantly more likely to have positive attitudes (77.1%) compared to married nurses, who were strongly associated with negative attitudes (COR = 0.218, AOR = 0.247).

Nurses with a Master's degree or higher had much more positive attitudes (COR = 3.161, AOR = 5.023) compared to those with a Bachelor's degree or lower. Similarly, nurses with five or more years of experience were far more likely to have positive attitudes (COR = 6.866, AOR = 8.086) than those with less experience. Those working in teaching hospitals were also more likely to have positive attitudes (COR = 5.270, AOR = 2.121) compared to those in non-teaching hospitals. Nurses who had on-the-job training were much more likely to report positive attitudes (COR = 8.717, AOR = 2.474) than those who had not received training (Table 3).

Practice of Surgical Nurses Towards ERAS Protocol and associated factors

Different factors have been found to associated practice of surgical nurses. Nurses under 30 had the highest rate of good practice (64.7%), while those aged 30–40 had a significantly greater likelihood (COR = 2.828, AOR = 4.385). Single nurses were much more likely to practice well (85.6%) compared to married nurses, who had a strong negative association with good practice (COR = 0.165, AOR = 0.221).

Nurses with a Master's degree or higher were more likely to engage in good practice (COR = 3.706, AOR = 4.070) compared to those with a Bachelor's degree or lower. Those working in teaching hospitals were significantly more likely to practice well (COR = 4.199, AOR = 2.637) than those in non-teaching hospitals. Nurses who received on-the-job training were much more likely to follow good practices (COR = 7.817, AOR = 1.974) compared to those without training (Table 3).

Strength of the study

It is the first study on this specific topic in Ethiopia. This study provides a thorough assessment of the knowledge, attitudes, and practices of surgical nurses regarding ERAS protocols, offering valuable insights into their implementation and impact.

Limitation

There is a possibility of response bias, as participants might have given answers they felt were more socially acceptable rather than their true practices and attitudes. Additionally, the cross-sectional design of the study captures data at just one point in time, which makes it challenging to establish causal relationships or observe changes over time. Variations in how different hospitals implement ERAS protocols could also influence the consistency of responses and practices among nurses.

The findings on what influences high knowledge, positive attitudes, and good practices regarding ERAS protocols among surgical nurses offer useful insights that match what previous research has shown.

The finding that males initially showed a higher likelihood of having better knowledge about ERAS protocols (COR = 2.092), but this difference disappeared when adjusting for other factors (AOR = 1.947), aligns with previous research suggesting that gender alone might not be a strong predictor of healthcare knowledge. Similarly, although males seemed to have a higher chance of positive attitudes and good practice initially, these differences diminished when accounting for other variables like experience and education. This suggests that while gender might play a role, it's not the sole factor, and other variables are more influential in shaping knowledge, attitudes, and practices (13). This is consistent with studies that have found gender differences in confidence but not in actual attitudes or practices when other factors are considered (14).

The study found that nurses aged 30–40 had significantly higher knowledge (COR = 2.270, AOR = 20.449) about ERAS protocols, which matches previous research showing that mid-career professionals often combine enthusiasm with practical experience. Younger nurses (under 30) showed the highest proportion of positive attitudes and good practices, reflecting their adaptability and recent training. The moderate increase in positive attitudes among those aged 30–40 suggests they balance innovation with experience, while the lower likelihood of positive attitudes among those over 40 indicates possible resistance to change. These patterns align with findings from studies showing younger and mid-career professionals are generally more open to new practices.(15, 16). (17).

The study found that single nurses had significantly better knowledge (COR = 0.167, AOR = 0.332) more positive attitudes, and better practices compared to married nurses. This is consistent with research by Chen et al., which suggested that single healthcare workers often have more time and flexibility for education and professional development (17). Single nurses' higher likelihood of positive attitudes and good practice reflects their greater capacity to engage with new initiatives, while married nurses may face additional responsibilities that limit their professional growth. (18). (17).

The study found a strong link between higher education levels and greater knowledge (COR = 5.728, AOR = 32.748), positive attitudes, and good practices related to ERAS protocols. This aligns with research by Patel et al. (2023), which showed that nurses with advanced degrees are more likely to adopt evidence-based practices and exhibit better professional behaviors. Higher education enhances both the understanding and acceptance of new protocols, highlighting the crucial role of educational programs in developing favorable attitudes and effective practices (19).

The study found that nurses with five or more years of experience had significantly higher knowledge (COR = 4.221, AOR = 6.408), which aligns with research by Morales et al., suggesting that experienced nurses are more likely to continue learning and applying clinical guidelines. This experience also correlates with more positive attitudes (AOR = 8.086 toward ERAS protocols, as supported by Morales et al., who found that experienced nurses are generally more engaged in professional development and thus more open to new practices. (20). However, while experience was linked to better practices, it was not statistically significant in the adjusted model, indicating that experience alone does not always predict the adoption of new practices, especially if ongoing education is lacking, as noted by Thompson et al. (18)

The study found that nurses in teaching hospitals were more likely to have better knowledge (COR = 8.818, AOR = 16.545), positive attitudes, and good practices regarding ERAS protocols. This is consistent with research by Robinson and Grant, who found that teaching hospitals offer more resources and opportunities for professional development, which supports knowledge acquisition and fosters a positive attitude. Additionally, the enhanced support and training available in teaching hospitals contribute to better implementation of best practices (21).

The study found a strong link between on-the-job training and higher knowledge levels (COR = 21.824, AOR = 6.525 which aligns with Thompson et al., who highlighted the effectiveness of practical training in boosting healthcare workers' knowledge and skills. This finding emphasizes the value of structured training programs for improving understanding of ERAS protocols. Similarly, on-the-job training was associated with more positive attitudes and better practices, consistent with research showing that practical training enhances staff engagement and adherence to clinical guidelines. These results underscore the importance of ongoing professional development in promoting best practices among surgical nurses (22).

We recommend to act on the following three areas. 1). Develop and launch targeted educational programs to enhance ERAS knowledge and practices among different nursing groups. 2). Expand training opportunities and support systems, particularly in non-teaching hospitals, to improve ERAS implementation and standards. 3). Customize training and support to account for factors like age, education, and experience, ensuring that all nurses are well-prepared to apply ERAS protocols effectively.

ERAS Enhanced Recover after surgery

Ethics approval and consent to participate

We obtained approval for the study from the Ethical Review Committee at Asrat Woldeyes Health Science Campus and Debre Berhan University (Ref. AWHSC/CSS/06/03/2021/2017, dated May 10, 2024). All participants gave written informed consent, with full assurance of their right to refuse participation and the guarantee of confidentiality.

Consent for publication

This article does not include any personal information about the participants.

Availability of data and materials

The data and materials used in this study are available from the corresponding author upon reasonable request.

Competing interests

The authors have declared that they have no competing interests.

Funding

The authors declare that this study was conducted without any financial funding.

Authors’ contributions

A.A.A. conceptualized the study, set the objectives, and developed the proposal. M.A.T. and F.S.K. reviewed and provided feedback on the proposal. All authors contributed to data management and statistical analysis. M.A.T., F.S.K., and M.B.F. prepared the manuscript. The final version was approved by all authors.

Acknowledgments

We would like to express our sincere gratitude to Debre Berhan University Asrat Woldeyes Health Science Campus for its invaluable support throughout this study. Our heartfelt thanks also go to the participants, whose time and cooperation made this research possible.

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Tables 1 to 4 are available in the Supplementary Files section.

No competing interests reported.

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You are reading this latest preprint version

Knowledge, Attitude and Practice of Surgical Nurses on Enhanced Recovery after Surgery (ERAS) protocols: Multicentre Cross-sectional study

Status:

Version 1

Abstract

Introduction:

Objective

Methods

Result

Conclusion

Figures

1. Introduction

2. Methods

3. Result

4. Discussion

5. Conclusion and Recommendation

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors’ contributions

Acknowledgments

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1