This study has provided important baseline insights into the current state of ERAS perceptions across Australia and has described clinicians’ preferences for education and learning that can inform future ERAS implementation efforts. Overall, clinicians reported perceiving ERAS protocols in a largely beneficial light, with most also indicating they were ‘knowledgeable’ and had previously cared for a patient who was on an ERAS protocol. However, there were several key results and significant differences between professions that warrant further discussion.

All anaesthetist and most surgeon respondents indicated that they had previously participated in the care of a patient who was on an ERAS protocol. This is greater than the adoption found in a previous survey of colorectal surgeons and perioperative care in Australia and New Zealand, where 55% of 76 respondents did not care for patients using an ERAS protocol, 37% routinely did, and 8% did ‘sometimes’ [35]. More recently, researchers have reported ERAS implementation and/or use in Australian facilities [e.g. 36,37,38], along with the establishment of a local ERAS Centre of Excellence [22]. These resources, and our more contemporary results, suggest that ERAS uptake may be increasing.

It has been estimated that evidence takes up to 17 years to be translated into clinical practice [39], and support for the benefits of ERAS protocols has now been building for over a decade. The lag or gap between what is known and what is done, or the diffusion of innovation into the system and its members, has long been acknowledged as a challenge across many fields [40]. In other areas of health care, use of clinician practice guidelines may be lost across a four-stage pipeline: awareness, to agreement, to adoption, to adherence, and the simple ‘availability’ of a guideline does not result in complete uptake [26, 27]. To overcome the recognised evidence to practice gap [26, 39], translational efforts must support implementation into real-world contexts, particularly in the complex health care environment [41].

Our results suggest that nurses’ perceived knowledge level was also lower than that reported by anaesthetists and surgeons. Nurses play a pivotal role across all phases of the patient’s surgical journey including contributing to and coordinating care directly related to ERAS components [42]. Their lack of awareness and knowledge of ERAS may suggest that protocols are often only partially or selectively implemented locally, which is a controversial approach to implementation not isolated to Australia [20, 21]. In a systematic review and meta-analysis of trials testing ERAS versus usual care for colorectal surgery in adults, protocols from 25 trials included a variation of between 4 and 18 elements [20]. Similarly, some of our survey respondents indicated that there is a need to be able to adapt interventions to individualise care. However, this contrasts with the multimodal, multidisciplinary principles of ERAS in which the intended approach is to include all elements as they have supporting evidence of improving patient outcomes [21]. The exclusion of certain evidence-based ERAS elements may limit patient benefit, and facilities should include as many as possible [21].

Respondents rated their beliefs around ERAS positively, although nurses less so, which may suggest limited knowledge rather than disagreement. Similarly, Beal and colleagues [32] found that most perioperative clinicians surveyed in their United States tertiary medical centre ‘strongly’ or ‘very strongly’ agreed that ERAS protocols were important for patient care, that their colleagues and administration felt the same, and that having patients involved in ERAS improved care. However, while our results indicate clinicians largely understand the benefits of ERAS overall, there are variations in support for ERAS.

In other areas, disagreement with clinical guideline components may result in failed adoption and adherence [26], and this may also limit ERAS uptake. A recent survey of Australian and New Zealand colorectal surgeons (n = 95) attitudes towards the effectiveness of 18 ERAS protocol components on short-term outcomes found that, for five interventions, 50–57% of surgeons felt they were ‘definitely’ or ‘very likely’ to be effective, but the remaining interventions had < 50% support to as low as 1–2% support [28]. Wide variations in implemented ERAS protocol components have been reported elsewhere [20], and there is a need to focus on the benefits of implementing ERAS protocols in their entirety in future research and educational strategies.

Our survey also provided insights into the educational and learning preferences of respondents, which may be used to target and nuance implementation strategies. Our results suggest that Australian clinicians value patient-focused outcomes, with respondents most interested in learning about minimising perioperative complications versus least interested in improving perioperative efficiency (i.e., improving operational processes, while maintaining quality and safety, to optimise productivity and minimise costs and resource requirements [43]). Our results accord with Hughes and colleagues’ [44] multinational survey of patient and care provider attitudes to ERAS after major abdominal surgery across three centres in Scotland, Norway, and The Netherlands. All respondents rated outcomes highly on an 11-point Likert scale (0 not important to 11 very important; medians ≥ 7/11), with care providers and patients rating nausea control and the absence of pain at rest the most important. ERAS strategies were also rated highly, with preoperative counselling rating highly for providers and patients, and promoting and scheduling early mobilisation and avoiding hospital-acquired infection considered the most important for each cohort, respectively. However, higher support for all tested components contrasts with the results of Toh et al.’s [28] survey of Australian and New Zealand colorectal surgeons, where there was little support for the effectiveness of some. Given that some clinicians rated themselves as unknowledgeable about ERAS or commented that their colleagues had limited awareness of ERAS protocols in our survey, education is important and has been credited as a contributor to successful ERAS implementation elsewhere [45].

ERAS protocols are complex to implement, given that full adherence involves the simultaneous implementation of all components and interventions among many healthcare providers across healthcare services [46]. While education is important, this alone will not bridge the knowledge to practice gap, and the effort required to appropriately implement ERAS protocols should not be underestimated [21]. Barriers identified in our survey are congruent with those experienced internationally [19], where resistance to change, limitation in resources, and external factors such as patient complexity and rural location have been highlighted.

In the Australian-based context, larger centre health services may face greater challenges in implementing ERAS compared to smaller single site facilities where there may be greater familiarity with surgical care pathways. Other barriers we have identified include the lack of interest and support from seniority and the inability to adapt content; similar to other older Australian studies [35, 47, 48]. Based on our own experience, gaining support from senior management to implement ERAS protocols into policy and source funding for coordinators and multidisciplinary support are significant barriers, while frontline clinicians are unable to be heavily involved due to workloads, despite their interest. Conversely, engaging support from clinicians and hospital leadership is a recognised facilitator for ERAS implementation, along with adaption to fit the local context, demonstrating early achievements, establishing a strong and regularly meeting ERAS team, and utilising ERAS supporters and dedicated staff [19]. These international facilitators are relevant to the Australian context and similar to those identified by our respondents, with the addition of compliance monitoring using quality indicators and improvement feedback, which is an important strategy for implementing and sustaining ERAS system-wide [49, 50].

From a patient perspective, our consumer investigators indicated they felt that implementation of ERAS was important for future patient care and safety. Inclusion of patients as stakeholders in future ERAS implementation and design is important to give patients agency in their own care, while patient experiences and perceptions shape the surgical care journey and influence compliance. Co-design with stakeholders, from senior management to patients, may be key to gaining insight into addressing these issues.