Nurses Know ERAS. So Why Aren’t They Always Practicing It?

Enhanced Recovery After Surgery, better known in hospital corridors as ERAS, has become one of the most influential care philosophies of modern operative medicine. Built on decades of evidence that patients recover faster when hospitals abandon outdated rituals—prolonged fasting, aggressive bowel preparation, excessive intravenous fluids, and rigid bed rest—ERAS protocols now span nearly every surgical specialty. Yet a new study from China suggests that knowing what works and actually doing it are two very different things, even among the nurses who stand at the bedside of recovering patients every day.

The research, published in BMC Health Services Research, examined a question that has long frustrated implementation scientists: how well do urology nurses translate their knowledge of ERAS principles into the actual care of patients recovering from surgery for benign prostatic hyperplasia, or BPH? BPH, a non-cancerous enlargement of the prostate gland, is one of the most common conditions affecting aging men, and surgical treatment—whether transurethral resection, laser enucleation, or open prostatectomy—remains a mainstay when medications fail. Because these patients often recover quickly, the quality of perioperative nursing care can make an outsized difference in their experience and outcomes.

Between January and May 2026, a team led by Xuefei Liang of Yangjiang Hospital of Traditional Chinese Medicine surveyed 106 registered urology nurses working across seven wards in five hospitals in Yangjiang, a city in Guangdong province in southern China. The multicenter cross-sectional design allowed the researchers to capture a snapshot of ERAS knowledge and self-reported practice across a range of institutional settings, from larger hospitals to smaller district facilities. Each nurse completed validated instruments measuring their ERAS knowledge, their self-reported ERAS practice, and—crucially—their capacity to translate knowledge into action, a construct the researchers treated as distinct from knowledge itself.

The headline finding was deceptively reassuring: on average, the nurses’ overall practice scores actually exceeded their knowledge scores, with practice at 71.8 percent and knowledge at 68.7 percent, a mean gap of just 3.1 percentage points. In other words, these nurses were not simply failing to apply what they knew. But when the researchers dissected the data by individual ERAS domains, a striking exception emerged. Perioperative thermal management—keeping patients warm before, during, and after surgery—showed the largest knowledge-to-practice gap of any domain, at 13.4 percentage points. Nurses knew that maintaining normothermia reduces complications, yet they reported doing it far less consistently than their knowledge would predict.

That gap matters more than it might sound. Perioperative hypothermia is a well-established driver of surgical complications: even mild drops in core body temperature can impair blood clotting, increase the risk of surgical site infection, trigger cardiac events, and prolong recovery by forcing the body to spend energy rewarming. For BPH patients, many of whom are older and may have diminished thermoregulatory capacity, the stakes are real. Operating rooms are kept cool for the comfort of surgical teams, irrigation fluids used during prostate surgery can cool the body from within, and general or spinal anesthesia blunts the shivering response that normally defends core temperature. Thermal care is one of the cheapest and simplest ERAS elements to deliver—warm blankets, fluid warmers, forced-air warming devices—yet it is precisely the element slipping through the cracks.

To understand what actually drives ERAS practice, the researchers built a multivariable linear regression model. The outcome was the total self-reported ERAS practice score, and the candidate predictors included hospital level, formal ERAS training, monthly BPH surgical volume, ERAS knowledge score, and knowledge-to-practice translation capacity. Three factors emerged as independently associated with better practice. Hospital level carried a regression coefficient of 9.02 (95 percent confidence interval, 4.72 to 13.32), meaning nurses at higher-level hospitals reported substantially better ERAS practice than their peers elsewhere. Knowledge score was independently associated with practice at B = 1.63 (95 percent CI, 0.79 to 2.47), and translation capacity—the ability to convert what one knows into what one does—was the strongest single predictor, at B = 10.38 (95 percent CI, 5.33 to 15.42).

Perhaps the most provocative result was what did not matter. Formal ERAS training showed no independent association with practice, with a coefficient of −1.59 (95 percent CI, −6.12 to 2.95), a range that comfortably includes zero. This finding cuts against the intuitive assumption that sending nurses to training courses will automatically change bedside behavior. The study’s authors concluded that ERAS nursing practice is not determined by knowledge or training alone, and that organizational context and the ability to translate knowledge into action may be more important targets for strengthening ERAS implementation in BPH surgery. In plain terms: a certificate on the wall does not guarantee a warm blanket on the bed.

The hospital-level effect offers a clue about why. Higher-level hospitals typically command greater resources—more staff per patient, better equipment such as forced-air warming units and fluid warmers, established quality-improvement infrastructure, and institutional cultures in which protocol adherence is monitored and rewarded. A nurse in a well-resourced tertiary ward may want to deliver evidence-based thermal care and simply be able to, while a nurse in a smaller district hospital may face staffing shortages, missing equipment, or workflow pressures that make the same care impractical. This is the classic terrain of implementation science: behavior change in healthcare is rarely a simple function of education, because clinicians operate within systems that either enable or obstruct good practice.

The study’s emphasis on knowledge-to-practice translation capacity as the strongest predictor is especially noteworthy. This construct captures something beyond textbook knowledge—the practical judgment, confidence, autonomy, and environmental support that allow a nurse to act on what they know in the moment a patient needs it. Interventions designed around this insight look different from traditional continuing education. They might include bedside decision-support tools, protocol checklists embedded into electronic records, peer champions who model ERAS behaviors on the ward, audit-and-feedback cycles that show nurses how their unit’s practice compares with benchmarks, and organizational commitments to supplying the equipment that protocols assume. The finding that training alone was not associated with practice suggests that such system-level supports, rather than more lectures, may be where investment pays off.

There are limits worth keeping in mind. The study was cross-sectional, capturing a single moment in time, so it can identify associations but cannot prove that translation capacity causes better practice—though the biological and organizational plausibility is strong. The sample of 106 nurses from five hospitals in a single Chinese city, while multicenter, may not generalize to other regions or health systems. And because practice was self-reported, social desirability bias could inflate scores; nurses may report delivering care they believe they should deliver. Still, the consistency of the pattern—practice broadly tracking knowledge except where systems fail, with organizational level and translation capacity dominating the statistical model—gives the findings weight.

For the millions of men worldwide who undergo prostate surgery each year, the practical message is encouraging in an unexpected way. The barrier to better recovery care is not primarily a knowledge deficit among nurses, which would demand years of curriculum reform. It is a delivery problem, and delivery problems can be fixed faster. Hospitals that invest in warming equipment, streamline ERAS protocols into daily workflow, and empower nurses to act on their training could close the thermal management gap quickly. As ERAS continues to expand across surgical specialties, this study from Yangjiang is a reminder that the last mile of evidence-based medicine is walked not by guidelines but by nurses at the bedside—and that health systems must equip them for the walk.

Subject of Research: The gap between ERAS knowledge and nursing practice in postoperative care of benign prostatic hyperplasia patients

Article Title: Gap between ERAS knowledge and practice among urology nurses caring for postoperative benign prostatic hyperplasia patients: a cross-sectional study

Article References: Liang, X., Gao, X., Liang, P., Xiao, R., Zhang, N., Tan, M., Huang, R., Wu, P., & Li, X. (2026). Gap between ERAS knowledge and practice among urology nurses caring for postoperative benign prostatic hyperplasia patients: a cross-sectional study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15672-y

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15672-y

Keywords: ERAS, enhanced recovery after surgery, urology nursing, benign prostatic hyperplasia, knowledge-practice gap, perioperative thermal management, postoperative care, cross-sectional study, nursing education, implementation science, hospital level, China