1.1 Implementation Theory

However, recognising the distinct organisational levels of individual/team, unit and organisation is important to the implementation process in evidence-based practice. The general theory of implementation posits that understanding these levels and their interactions is fundamental to successfully translating research into practice [16]. Components of the theory include capacity, potential, capability and contribution, which can be used to co-design an implementation plan. Capacity refers to the social and structural resources available for the individual/team to enact the new practice [16] (i.e., ERAS), potential indicates the social and cognitive resources that allow the strategy to be translated into action, and capability suggests the possibility of integrating the strategy into daily clinical routines. Assumptions based on the individual's ability to perform specific activities or tasks related to ERAS reflect capability. These three mechanisms influence individual/team contribution, including what individuals will do to implement the strategy in daily practice. Contribution is derived from Normalisation Process Theory which comprises four elements: coherence, cognitive participation, collective action and reflexive monitoring [16]. In this study, we focused on the capacity, potential and capability to co-design an implementation strategy with consumers and healthcare professionals to improve the adoption of ERAS protocols across the preoperative, intraoperative and postoperative periods.

At the individual or team level, strategies can be tailored to address personal motivations and barriers, fostering engagement and accountability [17]. Unit-level strategies focus on optimising workflows and enhancing team dynamics, ensuring cohesive and collaborative interventions. Meanwhile, organisational-level strategies must align with broader institutional goals and policies, promoting a unified approach to implementation. To maximise the effectiveness of evidence-based interventions, it is essential to select and develop strategies that are informed by a comprehensive assessment of the specific context and determinants of implementation gaps [17]. By incorporating these levels and contextual considerations, co-design enhances the relevance and actionability of interventions, ultimately improving communication and collaboration among stakeholders and supporting more effective and sustainable implementation outcomes.

This study aimed to co-design an evidence-based implementation strategy with consumers and healthcare professionals to improve the adoption of ERAS protocols across the preoperative, intraoperative and postoperative periods of surgical care.

2.1 Study Setting and Sample

Co-designers included health consumers with experience in surgery, perioperative nurses, surgical ward nurses, anaesthetists and surgeons. Healthcare professionals were from one tertiary hospital in Queensland, Australia. Health consumers were members of an advisory group at a nursing research centre of excellence that partnered with the hospital. The inclusion criteria were that a co-designer identified as one of the groups above and consented to be a member of the co-design groups. There were no exclusion criteria.

Recruitment of health consumers occurred through an expression of interest process. Health consumers were informed that the next project advisory group meeting would be a co-design session to gain consumer perspectives on their experiences with ERAS; they were sent information sheets and consent forms prior, allowing them to decide whether to participate or not. For perioperative and surgical ward nurses, educators on the units provided study information to the nurses. Due to the nature of shift work, nurse co-designers differed across co-design meetings. Research team members who were anaesthetists and surgeons utilised their networks, providing study information to their colleagues. All participants provided written consent before participating in co-design meetings.

2.2 Co-Design Process

The study was guided by the Generative Co-Design Framework for Healthcare Innovation, which involves three stages: (1) pre-design, (2) co-design and (3) post-design [18]. This framework offers a practical approach to engaging end-users seeking to change a specific healthcare process or system. The framework is divided into seven steps within three stages. Supporting Information File 1 provides descriptions of each stage within each step, including the activities undertaken at each step, summarised briefly below.

2.3 Data Analysis

For data analysis, audio-recording transcriptions, activity sheets, photos and meeting notes were uploaded into NVivo for inductive content analysis [20]. This process involved one researcher with extensive experience in qualitative data analysis, including coding and thematic interpretation. They read all materials in their entirety to become immersed. Next, they assigned codes to each line of materials that explained the substance of that line. Initially, health consumers, nurses (perioperative and ward nurses) and medical professionals were handled separately and assigned distinct codes. The codes across co-design groups were compared, and it became evident that different groups had many similar ideas, suggesting data sufficiency. We considered the broader concept of data sufficiency [21], that is, whether the collected data adequately addressed the research question, accounting for the depth and credibility of the data in answering the study's objectives. Complete data saturation was infeasible, given the exploratory nature of this study. Subsequently, codes across all groups were built into sub-categories. These sub-categories were then combined into categories based on commonalities. These final categories represented a list of implementation strategies for ERAS. To ensure rigour, we employed strategies such as reflexivity, peer debriefing and regular discussions with other researchers to validate coding decisions and interpretations.

Following the inductive analysis process, subcategories were deductively mapped to the level they primarily target, individual or team, unit and organisation. While strategies may cross organisational levels, they were classified according to the level they most closely aligned with.

3.1 Implementation Strategies

Analysis of data generated from the post-design stage with healthcare professionals resulted in 16 implementation strategies. These strategies were then classified according to the intended organisational level they were primarily directed towards (Table 2). Half of the strategies (eight) were aimed at the organisational level, while six targeted the unit level, and the remaining two focused on the individual or team levels. However, these strategies overlapped across categories, highlighting the interdependence and high level of interaction required for successful implementation through a whole-of-organisation approach.

Analysis of post-design data from health consumers identified one implementation strategy only: patient education. Consumers gave detailed feedback about the information they wanted about ERAS, including risks and benefits, why ERAS was being adopted compared to the usual approach to care, how staff will monitor patients on an ERAS pathway, and what ERAS components entail and how patients can enact them. It was motivating for patients to know that some elements of care may not be required as part of an ERAS pathway (e.g., NG tube insertion). For health consumers, it was critical to tailor ERAS to patients' individual needs, especially for complex patients who might require changes to ERAS components to meet their needs. Including these details in ERAS education was expected. Finally, health consumers highlighted that they wanted the opportunity to communicate during education sessions, to ask further questions and to discuss their options.

The top two common implementation strategies prioritised by each professional group are presented in Table 3.

4.1 Capacity

Capacity is about having available resources such as time, personnel, infrastructure and organisational support [16] for successful ERAS implementation. Fifty percent of the strategies identified fell into the remit of being implemented at the organisational level. Members of our co-design groups identified the need for adequate staffing to manage increases in additional work processes required to support ERAS implementation, for example, ERAS nurses to coordinate processes. Many others have identified workload issues as a major issue curtailing ERAS implementation [8, 10, 14, 22]. Resource constraints are the most commonly described barrier across different clinical settings with the implementation of clinical practice guidelines [23], delirium prevention [24], the Surgical Safety Checklist [25, 26] and surgical site prevention programmes [27]. Our co-design participants also identified integrating ERAS with existing processes and care pathways, leading to improvements in the organisation's infrastructure and increasing protocol adherence. For ERAS to be sustainable, healthcare organisations must ensure they have sufficient staffing and access to necessary technology such as electronic dashboards and checklists.

Practitioner co-designers agreed that support through audit and feedback mechanisms enables MDT to identify gaps and where areas of improvement are needed, as well as enhance collaboration across units and departments within the organisation. Without appropriate resourcing, ERAS may fail to be adopted. There is a clear need to develop knowledge translation capacity and capability-building programmes to enable experiential and collaborative learning and target participation at all levels [28]. Findings from a recently published scoping review [28] suggest that practice sustainability can only be achieved with the active involvement of senior and middle managers in mediating and supporting practice change and in building staff capacity within their teams. Increasing the capacity of individuals and teams to implement any programme will be influenced by organisational infrastructures and processes [29].

4.2 Potential

Potential focuses on the readiness and alignment of the organisation to adopt a system or practice change [16] like ERAS protocols. This involves assessing whether HCPs recognise the value of ERAS and whether there is organisational buy-in for the care pathway. Our surgeon and anaesthetist co-designers believed that for successful implementation using a phased roll-out of ERAS, starting with one surgical speciality was necessary to showcase its potential to be scaled up. ERAS protocols trialled with a limited group of patients or specific clinicians before widespread adoption successfully showed local effectiveness [8]. Collecting pilot data to confirm the feasibility of implementing ERAS protocols in the local setting supports their broader application beyond the initial launch phase. The multicomponent nature of ERAS protocols and the increased complexity associated with surgical care coordination in using ERAS has been identified as a barrier to its broader implementation [8]. Starting implementation on a small scale allows implementation processes to be fine-tuned, can build momentum through the ‘early wins’ of success [8] and may lead to a gradual culture change.

4.3 Capability

Capability involves the skills, knowledge and expertise required to implement a programme [16] like ERAS effectively. For instance, clinicians must be trained in ERAS protocols, including preoperative, intraoperative and postoperative care pathways. In other literature, education has been identified as the most frequently implemented strategy [28] used in the implementation of practice change programmes. Our HCP co-designers identified that education was key to building capability in ERAS implementation, while our consumers believed it was important to give patients agency in their care underpinned by the knowledge of the expectations that come with receiving ERAS care. These findings echo those of previous studies examining ERAS implementation [10, 30]. While co-design group members described education initiatives targeted at the individual level, education strategies need to address diverse stakeholder groups across all levels of the organisation. For instance, the implementation of strategies at the organisational level could include establishing MDT training and learning environments, supporting workplace education and enhancing procedural knowledge and practical skills [14]. These education programmes would also include training on reviewing and improving current clinical pathways to align them with ERAS protocols.

4.4 Lessons Learned

The literature often underrepresents the inherent complexities involved in convening co-designers from various stakeholder groups within healthcare. In our study, we encountered significant logistical challenges in coordinating the presence of all stakeholders at a single event, given the diverse demands on their time and resources. These complexities are compounded by the multifaceted nature of healthcare, where differing priorities, institutional cultures and individual perspectives can create barriers to effective collaboration. Despite the logistical challenges associated with gathering all stakeholders, their commitment to the co-design process was evident. Participants engaged actively, contributing a range of insights shaped by their respective experiences and areas of expertise. Although the diversity of perspectives initially posed challenges in reaching consensus, it ultimately facilitated a convergence of ideas and solutions. This collaborative effort demonstrated that inclusive dialogue, while complex, can yield innovative and comprehensive outcomes.

4.5 Strengths and Limitations

While this study has some strengths, we also acknowledge its limitations. The study was conducted in a single site; therefore, implementation strategies developed through the co-design process may be context-specific and may only apply to this local context. To mitigate this, we documented the co-design process and outcomes comprehensively, highlighting context-specific elements and identifying implementation strategies applicable at the different levels of the organisation. Despite our best efforts, it was infeasible to have all groups of co-designers in the same room at the same time. The surgeons and anaesthetists could only meet in the evenings (after completion of elective surgical lists), either online or in person (hybrid meetings). Co-design meetings with perioperative and ward nurses were conducted opportunistically in person during in-service meetings. Nevertheless, all participants were highly engaged in the co-design process; in post-design meetings, ideas across groups were fed back to the different groups, allowing groups to consider each other's ideas during the prioritisation of implementation strategies. Finally, the research team underwent intensive training in co-design, by an expert in the field before starting the study. The expert helped develop co-design activities we used during meetings.