Barriers and facilitators to implementation of enhanced recovery after surgery protocols in resource-constrained hospitals: A mixed-methods study from a semi-urban government teaching hospital

Introduction: Enhanced recovery after surgery pathways improve postoperative outcomes, yet consistent implementation remains challenging, particularly in resource-constrained settings. Previous observations identified variability in adherence to key enhanced recovery after surgery components, including delayed mobilisation and prolonged postoperative device use. This study aimed to identify barriers and facilitators influencing enhanced recovery after surgery implementation from the perspective of multidisciplinary perioperative staff. Methods: A sequential explanatory mixed-methods study was conducted in a government teaching hospital providing gastrointestinal surgical services in a semi-urban setting. Perioperative healthcare providers completed a structured questionnaire assessing barriers across workflow, resources, training, communication and documentation domains. Semi-structured interviews with purposively selected participants explored contextual factors affecting protocol delivery. Quantitative data were analysed using descriptive and inferential statistical analysis, while qualitative data underwent thematic analysis. Results: A total of 259 healthcare providers participated across surgical, anaesthesia, nursing, theatre and ward roles. Workflow pressures, staffing shortages and inconsistent training exposure were the most reported barriers. Communication gaps and documentation challenges were also common. Leadership involvement, multidisciplinary collaboration and structured workflows were identified as key facilitators. Conclusion: Enhanced recovery after surgery implementation is primarily influenced by workflow factors rather than knowledge alone. Addressing staffing, training, communication and documentation systems may improve consistency and sustainability of ERAS delivery.