Medical staff's perception of factors contributing to accelerated rehabilitation in patients with cervical spinal cord injury: A qualitative research

To explore the factors affecting the quality of accelerated rehabilitation for patients with cervical spinal cord injury, therefore, to propose targeted improvement strategies and provide reference for promoting the quality of nursing care for accelerated rehabilitation.


Enhanced Recovery After Surgery (ERAS) was first proposed by
Danish surgeon Henrik Kehlet at the American Annual Meeting of Surgery in 1997. It refers to a multidisciplinary collaboration in which healthcare professionals (HCP) implement a series of evidence-based perioperative management measures aiming to reduce traumatic stress reaction and promote the recovery of patients (Merchea& Larson, 2018). At present, ERAS has been carried out in fields including orthopaedic surgery, breast surgery, cardiothoracic surgery, gastrointestinal surgery, obstetrics and gynaecology, and has achieved remarkable results in reducing surgical stress response and perioperative complications, shortening the average length of hospital stay and reducing hospitalization costs (Asklid et al., 2017;Geubbels et al., 2019;Liu et al., 2017). The quality of enhanced recovery is very important for the prognosis, recovery speed and safety of patients (Asklid et al., 2017;Geubbels et al., 2019).
However, quality of the implementation of ERAS is not optimistic, implementation of accelerated rehabilitation in practice is slow, and many clinical teams have not even incorporated the accelerated rehabilitation path into clinical practice (Elhassan et al., 2018;Francis et al., 2018). Studies have shown that during the implementation of ERAS, some medical staffs were not willing to implement accelerated rehabilitation measures, and the opposing colleagues was almost 68%, which needs to be improved (Martin et al., 2018). Keil et al. (2019) found that the compliance rate of the entire ERAS pathway was only about 58%. Nikodemski et al. (2017) found that patients with ERAS protocol did not require routine mechanical bowel preparation, but nearly 85% of patients received mechanical bowel preparation. Lambaudie et al. (2017) noted that only 69% of the HCP give supplement beverages containing sugar 2 h before surgery, and the early feeding was also needed to be improved. Patients with cervical spinal cord injury have severe trauma, high mortality, poor tolerance to surgery and great difficulty in perioperative nursing (Whelan et al., 2020). Early implementation of accelerated rehabilitation for patients with cervical spinal cord injury is very important to shorten the length of hospital stay, reduce hospitalization costs and promote quality rehabilitation for patients (Elsarrag et al., 2019). It is very important to monitor the nursing quality of accelerated rehabilitation for patients with cervical spinal cord injury, regulate behaviour of nursing staff implementing ERAS, ensure the quality of implementation of accelerated rehabilitation measures and promote rapid recovery of patients (Francis et al., 2018). At present, there is a lack of clinical practice guidelines or expert consensus on perioperative accelerated rehabilitation for patients with cervical spinal cord injury, and the quality of accelerated rehabilitation varies greatly.

| BACKG ROU N D
In recent years, some scholars have actively explored the promotion and hindrance factors of enhanced recovery. Pędziwiatr et al. (2018) discussed the factors affecting the implementation of enhanced recovery, and results showed that lack of human resources, insufficient communication and collaboration of multidisciplinary teams and patients' resistance to change were the main reasons hindering the promotion of enhanced recovery. Gramlich et al. (2020) adopted qualitative interview method to investigate causes for enhanced recovery implementation difficulties. Results showed that the causes vary, including the time-consuming nature of enhanced recovery measures, multidisciplinary collaboration difficulties, lack of medical support system and poor compliance of patients. Martin et al. (2018) interviewed the medical staff involved in enhanced recovery and discussed that the most important factors hindering the promotion of enhanced recovery were time restraints, insufficient support from ERAS care providers and insufficient logistical support. Meyenfeldt et al. (2022) used qualitative interview to discuss the reasons for difficulties in promoting enhanced recovery. The study showed that the main factors affecting enhanced recovery were poor compliance of staff, poor communication among members of multidisciplinary team, complexity of patients. At present, factors affecting quality of enhanced recovery are not completely clear. Therefore, it is difficult to improve the quality of enhanced recovery from a system level.
American scholar Donabedian proposed the structure-processresult theoretical model (Donabedian, 1992). Donabedian pointed out that the structural quality evaluation focused on the evaluation of basic working conditions for nursing work provided by the hospital.
The process quality evaluation focused on the feedforward control of implementing medical procedure or treatment. Result quality evaluation was the objectified and datalized reflection of the practice outcome, belonging to the feedback control considered from patients' perspective (Denadai & Lo, 2021). Structure quality, process quality and result quality are closely related and linearly correlated in medical care services. A sound structure can improve process quality, a good process will have important impact on the quality of results, and the evaluation of results can also feedback and control the process of medical care, thus promoting the further improvement of medical care quality (Tossaint-Schoenmakers et al., 2021). Accelerated rehabilitation quality evaluation is an important method to evaluate its effectiveness. It can evaluate the quality of accelerated rehabilitation, also can guide medical staff to standardize the accelerated rehabilitation work. Thus, it will ensure quality implementation of accelerated rehabilitation work (Tossaint-Schoenmakers et al., 2021).

| Design
This study employed a qualitative method with a descriptive and explorative design (Polit & Beck, 2010). Participants were invited to share and reflect on factors affecting quality of ERAS for patients with cervical spinal cord injury. Donabedian's structure-processoutcome theoretical model served as the theoretical framework of this study, as shown in Figure 1 (Donabedian, 1992). Descriptive qualitative research methods are considered useful for obtaining richer descriptions and are more suitable for exploring the factors affecting the quality of accelerated rehabilitation for patients with cervical spinal cord injury by medical staff (Luciani et al., 2019).
Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for qualitative studies (Du et al., 2022) was adopted to report this study.

| Participants and setting
From December 2020 to April 2021, the method of destination sampling was adopted and the principle of difference maximization was followed (Slamet et al., 2022). Medical staff from three ter- • Willing to participate in this research.
We excluded medical staff who were taking a refresher course, on leave or away from clinical duties during the interview period.
The sample size of the interview is based on the principle of data saturation, that is, data collection will stop when there is no more new information or content (Hennink & Kaiser, 2022). A total of 16 interviewees were interviewed in this study, including eight orthopaedic nurses and head nurses, four orthopaedic surgeons, two physiotherapists and two anaesthesiologists. Among them, nine were females and seven were males. Four of the interviewees have a PhD degree and the rest have a bachelor degree. Respondents ranged in age from 29 to 51 years old. Working experience in spinal surgery ranged from 6 to 32 years. The practical experience of accelerated rehabilitation was 4-6 years. A total of five supplementary interviews were conducted with four respondents. General information about respondents is shown in Table 1.

| Data collection
The data were collected in the form of face-to-face semi-structured interviews. The interview outline was preliminarily formulated according to the research purpose and Donabedian's structureprocess-result theoretical model (Donabedian, 1992). Some interviewees were colleagues, and some were introduced by colleagues. Before the interview, time and place of interview were confirmed with the interviewees, and the time period convenient for interviewees were chosen. The interviews took place in a conference room of the hospital ward. Interviews were conducted in a quiet environment, with only the interviewer and interviewee present. Interviewers had systematically learned interview methods and skills before the formal interviews, and a pre-interview was conducted. After each interview, the author kept a reflection diary to reflect on the existing problems and correct them in the upcoming interviews. Interviews were conducted following the interview outline. During interviews, interviewees were carefully listened to and properly responded to, so that they could fully express their views.
Key information of interviews was recorded in time, and non-verbal behaviours such as verbal pauses, facial expressions and actions of interviewees were closely observed and recorded. Researcher maintained a non-biased attitude to maintain objectivity of data collection. After interviews, gratitude for participation was expressed and possibility of follow up encounters was explained in case of further addition of information. Each interview lasted for 30-45 min.

| Data analysis
The interview recording was transcribed into text within 24 h after the interview. Original interview materials were read repeatedly, reviewed with interviewees for verification and consent for application. The data were analysed by theme analysis method (Kiger & Varpio, 2020). The steps were as follows, (1) Repeatedly read the transcript take notes. (2) Extract duplicated points in the data F I G U R E 1 Three-dimensional mass structure model (Donabedian, 1992).

Result
The outcome of the medical care process

Structure
Basic working conditions for care work

Process
The practical process of care service and encode them with phrases or sentences. (3) Further condense the codes with similar contents to generate themes/sub-themes.
(4) Review the themes/subthemes and compare it with the original data repeatedly. (5) Rephrase the themes in simple and easilyunderstandable words. (6) Write data analysis process. To reduce the subjectivity of the study, two researchers analysed the data independently and held regular discussions until the encoded information was agreed upon.

| Credibility
To ensure the credibility of results, data were returned to interviewees for verification after transcription into text. Two researchers reviewed the data repeatedly and independently, and discussed results of data analysis with other members of the research group on a regular basis about inconsistencies in the coding. In case of disagreement, the original data were reviewed immediately with comparison with field notes, reflective diaries and other data to truly reflect the data content from multiple perspectives and improve the credibility of the data. And the decision was made by the third researcher (Cypress, 2017).

| Transferability
According to the principle of difference maximization (Chen, 2000), targeted multidisciplinary HCP with accelerated rehabilitation experience in cervical and spinal cord injury were selected for interviews, to ensure the diversity of participant source. (Chen, 2000).

| Confirmability
In order to ensure the verifiability of this study, entire process of the interview was recorded, so that researchers could check the record at any time (Thompson Burdine et al., 2021).

| Dependability
Inclusion and exclusion criteria, data collection methods and data analysis methods were described in detail (Luciani et al., 2019).

| Ethical consideration
The study was performed following the Helsinki principles of Ethics (Kurihara, et al., 2020). The study was approved by the Ethics Committee of Capital Medical University (batch number: Z2022SY032). Approval date is March 9, 2022. The aim and significance of the research were fully informed to interviewees before the interview. We have also promised to keep the relevant information strictly confidential. Information was to be shared within the research group only. Respondents were told that they could voluntarily participate in this study and were able to withdraw from this study at any time. During the interview, all interviewees participated voluntarily, without any refusal or withdrawal. Each participant has TA B L E 1 General information of respondents (N = 16).

| FINDING S
A total of two themes and nine sub-themes were extracted in this study, among which three sub-themes were related to the structural quality of accelerated rehabilitation and six sub-themes were related to its process quality.

|
Also, some participants emphasized that nurses play an important role in the accelerated rehabilitation team and have a direct impact on the quality of accelerated rehabilitation. In addition, patient participation plays a crucial role in improving the quality of rehabilitation.
It is important for patients to be actively involved.
Nurses play an important role in the evaluation and early identification of rehabilitation and postoperative complications, which is directly related to the overall nursing quality of patients, and is also the inspector of the patients' knowledge of rehabilitation.

| Poor multidisciplinary communication and collaboration
In the process of implementing accelerated rehabilitation, it is necessary for multidisciplinary HCP to reach a consensus on the requirements of implementation of accelerated rehabilitation, so as to carry out homogenized management for patients. Some participants mentioned that providing patients with adequate and consistent information is an important factor affecting the imple- After repeated propaganda and education, patients will form a positive perception of enhanced recovery.
If propaganda and education are not in place, patients will not cooperate actively, and the rehabilitation effect of patients will be poor. (P14)

| The conceptual framework influencing the quality of enhanced recovery
Through the analysis of interview data, we extracted the conceptual framework affecting the quality of accelerated rehabilitation, as shown in Figure 2. Among them, the lack of nursing staff is structural factor, and the lack of training of accelerated rehabilitation members is process factor. Lack of training affects the awareness of HCP of accelerated rehabilitation, hence affects the ability, compliance and multidisciplinary collaboration between HCP. In addition, HCP' perceptions also affect patients' perceptions about accelerated rehabilitation, thus affecting patients' compliance and quality of accelerated rehabilitation.

| DISCUSS ION
In this study, the qualitative descriptive research method was

| Factors related to structural quality of accelerated rehabilitation
In this study, participants reported factors related to structural quality of accelerated rehabilitation, includes construction of mul-  Ljungqvist et al., 2017). Therefore, if the allocation of nursing resources is insufficient, it will affect the implementation and quality of accelerated rehabilitation.
Training of accelerated rehabilitation HCP is an important factor affecting quality of accelerated rehabilitation process. This was consistent with previous studies (Gramlich et al., 2017). addition, due to the contradiction between some accelerated rehabilitation and traditional measures, medical staff did not immediately see the outcome of accelerated rehabilitation, and they were sceptical about the effect of accelerated rehabilitation. Hence, medical staff were not ready to accept the accelerated rehabilitation program. As a result, the implementation of accelerated rehabilitation measures is poor.
Difficulties in communication and collaboration among multidisciplinary members are also important factors affecting the quality of accelerated rehabilitation. This is consistent with previous research results (Gramlich et al., 2017). The timeliness and accuracy of information communicated among multidisciplinary HCP is the key to promote the smooth implementation of accelerated rehabilitation (Rossettini et al., 2021). Strengthening communication and coordination between medical and nursing staff is conducive to promote accelerated rehabilitation (Brown & Xhaja, 2018;Crosson, 2018;Sibbern et al., 2017). Awad et al. (2019) also believed that faceto-face communication among multidisciplinary HCP should be strengthened to facilitate better inter-disciplinary cooperation. Brown and Xhaja (2018) showed that lack of communication among multidisciplinary HCP is one of the factors affecting implementation of ERAS. This study emphasizes that the cognitive difference of medical staff on accelerated rehabilitation is one of the reasons for poor communication among multidisciplinary members during implementation of accelerated rehabilitation. Therefore, consistent training for accelerated rehabilitation HCP is critical.
The lack of adequate health education and lack of awareness of accelerated rehabilitation are important factors affecting the process quality of accelerated rehabilitation. This is consistent with previous studies (Carmichael et al., 2017;Gramlich et al., 2017). Due to deep-rooted traditional concepts and uneven educational levels of patients, some patients do not understand accelerated rehabilitation mode and have doubts about it, leading to their preference for conservative management. Health education is an important way for patients and their families to acquire disease-related knowledge, and directly affects patients' acceptance of accelerated rehabilitation program, psychological state and rehabilitation effect (Inkeroinen et al., 2020). Carmichael et al. (2017) believed that effective health education on accelerated rehabilitation could improve patients' compliance. Only when patients fully realize the importance of accelerated rehabilitation, can they accept this concept, hence actively cooperate with medical staff to implement rehabilitation programs and improve the effect of accelerated rehabilitation.
The lack of competency of the accelerated rehabilitation HCP is also a factor affecting the quality of accelerated rehabilitation.
When the competency of the nurse is low, it will be difficult to personalize the clinical path to ERAS for the patient (Wang et al., 2022).
The general clinical pathway of accelerated rehabilitation cannot meet the individual needs for each patient. The establishment of personalized clinical pathways can help medical staff clarify the specific content and process of implementation of accelerated rehabilitation for individual patient. Therefore, implementation of accelerated rehabilitation measures will be better regulated by medical staff. (Smirk et al., 2018). Smirk et al. (2018) believe that due to the variability in each patient's condition, multidisciplinary team should develop personalized and targeted diagnosis and treatment plan for each patient, so that each patient can receive targeted diagnosis and treatment. This shortens the rehabilitation period for patients, and makes diagnosis and treatment and nursing work more efficient.

| S TRENG TH S AND LIMITATI ON S OF THE RE S E ARCH
In this study, Donabedian's structure-process-result theory model is used as the framework to refine the themes, making the extracted themes more scientific (Donabedian, 1996). The qualitative interview method was used to select orthopaedic nurses, nursing management experts, orthopaedic doctors, anaesthesiologists and physiotherapists of different ages, genders and positions with accelerated rehabilitation experience, reveal their different views on the impact of accelerated rehabilitation quality, and obtain some valuable opinions, which can provide reference for improving the quality of accelerated rehabilitation implementation. This study clearly and comprehensively describes the research process, thus ensuring the validity of the study. The initial citation explains the process of analysis and drawing conclusions from the results, which increases the credibility of the research results.
However, this study also has some limitations. First of all, this study only discussed the views of medical staff on the factors affecting the quality of accelerated rehabilitation, and did not discuss the views of patients. Secondly, although the data in this study reached saturation, interviewees only came from two cities in China.
It may limit the universality of the research results. In addition, most of interviews were conducted face-to-face, but interviewees were all wearing masks due to the epidemic. Thus, it was impossible to observe the facial expressions of the interviewees and record their reactions in detail. Online video interview was conducted with two interviewees, and interview effect may be lower than that in real environment.

| CON CLUS I ON S AND RELE VAN CE TO CLINI C AL PR AC TI CE
This study provided a new insight into the factors influencing the quality of accelerated rehabilitation, and could provide a reference for managers to develop the quality improvement program of accelerated rehabilitation for patients with cervical spinal cord injury during perioperative period, and constructed the evaluation index system for nursing quality.
This study emphasized that before the implementation of accelerated rehabilitation, hospital managers should be equipped with sufficient nursing resources and should allocate nursing resource reasonably according to the workload during implementation of accelerated rehabilitation. At the same time, manager should establish a system related to accelerated rehabilitation and organize training and assessment regularly. This is to ensure HCP to achieve unity of the concept of accelerated rehabilitation. In addition, managers should strengthen leadership, organize HCP to discuss the problems encountered in the work regularly, promote communication and collaboration of accelerated rehabilitation members, in order to reach a consensus on the specific measures of accelerated rehabilitation, and ensure the quality of implementing accelerated rehabilitation.
For HCP, they should actively learn the knowledge of accelerated rehabilitation, improve their own capability, and develop personalized clinical pathways for patients based on their conditions. Secondly, in the process of implementing accelerated rehabilitation, HCP should take the initiative to communicate with other members in order to timely solve the problems in the process of accelerated rehabilitation and reach an agreement. In addition, HCP should learn the up-to-date guidelines for accelerated rehabilitation on regular basis. They should reflect on the implementation of accelerated rehabilitation to continuously improve the quality.

AUTH O R CO NTR I B UTI O N S
Interview, data collection, data analysis and writing-original draft preparation: Qiuxue Li; Data collection, data analysis, proofreading: Qianghuizi Zhang. Design, supervision and review the entire project: Weiwei Liu; the revised version of the manuscript, polish the language: Zheyi Zhou. Discuss the results, provide feedback, Acknowledgement and agreement with the content of the article: All authors.

ACK N O WLE D G E M ENTS
Thanks to the journal of the Chinese Medical Association for its support of this study. The authors thank the respondents for their active participation in this study and for providing sufficient information for the subject.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors declare that they have no conflict of interests.

FU N D I N G I N FO R M ATI O N
There is no funding for this article.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

R E S E A RCH E TH I C S CO M M IT TE E A PPROVA L
Capital Medical University (batch number: Z2022SY032).The purpose and significance of the research were fully informed to the interviewees before the interview.