Institutionalizing Enhanced Recovery After Surgery and Changes in Patient Safety Culture: A 5-Year Longitudinal Study of Multidisciplinary Colorectal Surgical Teams

In the high-stakes environment of a hospital operating room, the success of a surgery depends on more than just the skill of the surgeon. It relies on a complex web of coordination between anesthesiologists, nurses, physical therapists, and nutritionists, all working in sync to guide a patient from the operating table to a full recovery. For decades, hospitals have tried to improve this process using a model called Enhanced Recovery After Surgery, or ERAS. This approach is not a single drug or device, but a carefully choreographed set of rules that standardizes how different medical teams talk to each other and care for a patient before, during, and after an operation. The goal is to reduce stress on the body and speed up healing, but for this system to work, the people running it must trust one another, feel supported by their workplace, and be able to bounce back when things go wrong. This human element is known as safety culture. While we know ERAS helps patients recover faster, it has remained unclear whether turning this voluntary, enthusiastic effort into a strict, hospital-wide rule actually improves the way medical teams feel about their work and their ability to handle pressure over time.

A team of researchers at Cathay General Hospital in Taiwan decided to investigate this question by looking at the five-year journey of their own colorectal surgery program. They wanted to see what happened to the morale and resilience of the medical staff as they moved from a loose, voluntary group of volunteers into a rigid, standardized system. From 2019 to 2023, they tracked the feelings of hundreds of professionals across five different departments: anesthesiology, the operating room, the surgical ward, nutrition, and physical therapy. Instead of asking individual doctors or nurses to fill out surveys every year, the researchers looked at the aggregated, anonymous results of a national safety survey that the hospital already collected as part of its routine quality checks. They focused on four specific areas: how well the teams felt they worked together, how satisfied they were with their jobs, how good their working conditions were, and how resilient they felt in the face of stress.

The story that emerged from five years of data was not a simple straight line of improvement. If one had expected that making the ERAS program a strict rule would instantly make everyone happier and more united, the results would have been a surprise. Instead, the researchers found a landscape of mixed signals, where some departments improved in certain areas while others struggled, and where feelings shifted dramatically from year to year. In the anesthesiology department, for instance, the staff's sense of resilience—their ability to recover from setbacks—jumped from a low of 11.9 percent in 2019 to 41.2 percent in 2023. Their satisfaction with working conditions also rose significantly, moving from 59.3 percent to 84.0 percent over the same period. However, this progress was not steady; in the middle years, these numbers dipped and rose again, showing that the path to a better culture is rarely smooth.

The experience of the operating room staff told a different, more turbulent story. While their sense of working conditions eventually improved from 30.4 percent to 39.7 percent by 2023, their feelings about teamwork and job satisfaction took a sharp dive in 2022 before recovering slightly. In that same year, the surgical ward saw a massive, temporary spike in resilience, where 58.6 percent of staff felt resilient, a number that had been as low as 4.6 percent just three years prior. Yet, by 2023, that number had fallen back down to 8.3 percent. This volatility suggests that the culture of a hospital unit is not a static thing that gets fixed once and for all; it is a living system that reacts to the specific pressures of each year, including the global disruptions of the pandemic.

The allied health teams, who provide essential support like nutrition and physical therapy, showed their own unique patterns. The nutrition team saw their sense of teamwork grow from 60.4 percent to 89.2 percent, suggesting that the new standardized rules helped them feel more connected to the rest of the surgical team. However, their satisfaction with working conditions actually declined over the five years. Similarly, the physical therapy team started with perfect scores for teamwork and job satisfaction in 2019, but by 2023, those numbers had dropped, even though their teamwork remained high. These contrasting trends highlight a crucial point: you cannot look at just one number to understand how a team is doing. A department might feel like a tight-knit family while simultaneously feeling overworked and unsupported.

The researchers were careful to explain that these numbers describe a pattern of change, not a guaranteed cause-and-effect relationship. They could not prove that the ERAS program itself caused these shifts, because many other things were happening at the same time, such as changes in staffing, the stress of the pandemic, and new hospital policies. The data did not allow them to track the same individual doctors or nurses over time, so they could not say if a specific person became happier or more resilient. Instead, the study offers a snapshot of how the collective mood of different units shifted as the hospital tried to turn a good idea into a standard rule. The findings suggest that while institutionalizing a new way of working can create opportunities for better teamwork and resilience, it does not automatically solve every problem. In fact, the transition can be messy, with some areas improving while others struggle, and with feelings swinging wildly from year to year.

Ultimately, this five-year look into the heart of a surgical team reveals that building a safer, more resilient hospital is a complex, ongoing process. It is not enough to simply write down a new set of rules and expect everyone to feel better. The human side of medicine—how teams communicate, how they support each other, and how they handle stress—requires constant attention and adjustment. The study shows that while the move toward standardized care can help break down barriers between different medical professions, it also introduces new challenges that shift and change over time. For hospital leaders, the lesson is that measuring success requires looking at the whole picture, not just the final score, and understanding that the culture of a medical team is as dynamic and unpredictable as the patients they care for.