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Patient involvement in enhanced recovery

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Empowering patients to help themselves through an enhanced recovery care pathway is key to achieving optimal recovery in the shortest possible time


There are proven benefits of encouraging patients to play a more active role and take responsibility for their recuperation after all surgical procedures. This article explores the concept of enhanced recovery and the development of tools to support patients and health professionals in using an enhanced recovery pathway.

Citation: Cottle S, Lewis W (2013) Patient involvement in enhanced recovery. Nursing Times; 109: 13, 24-25.

Authors: Sue Cottle is national improvement lead; Wendy Lewis is nurse adviser, enhanced recovery partnership and national improvement lead; both at NHS Improving Quality.

  • This article has been double-blind peer reviewed
  • Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)


Enhanced recovery is an evidence-based integrated pathway consisting of a range of clinical care elements that, when brought together, enable patients to get better sooner, get fitter sooner and return home to normal life sooner. This increases the efficiency of the NHS, improves patient outcomes and reduces complications.

Enhanced recovery involves a multi-disciplinary team approach starting in the community, carrying on while in hospital and continuing after the patient is discharged home. The four core principles underpinning the pathway are:

  • All patients should be on a pathway to enhance their recovery;
  • Health professionals should make preparations to ensure patients are in the best possible condition;
  • Active patient management components are embedded across the whole pathway - before, during and after the operation/treatment;
  • Patients play an active role and take responsibility for enhancing their own recovery.

This approach has already been widely used across a range of specialties including colorectal, gynaecological, orthopaedic and urological care. More recently, it is being tested and adopted in lung, pancreatic, upper GI and liver surgery, breast reconstruction and elective Caesarean section. There is also an increasing interest in using enhanced recovery in emergency pathways and episodes of acute illness, both medical and surgical.

A survey of enhanced recovery patients in 2012 demonstrated that providers following the enhanced recovery pathway scored significantly higher in terms of general inpatient experience compared with the latest National Inpatient Survey undertaken in 2011 (Department of Health 2011). At the same time, the length of stay for eight surgical procedures reduced with no change in readmission rates.

NHS Improvement has been working closely with the Department of Health, healthcare organisations, clinical experts and patients to develop strategies and practice that can help health professionals to educate and encourage patients on the pathway.

Enhanced Recovery Partnership

To support the spread and delivery of enhanced recovery, an enhanced recovery partnership (ERP) was established between the Department of Health, NHS Improvement, the National Cancer Action Team, clinical experts, patient representatives, strategic health authorities and networks.

Its objectives are to improve the quality of the patient experience and reduce length of stay by sharing good practice principles. Significantly, the ERP has identified nurses and patients as key players in communicating enhanced recovery, maintaining its benefits and ensuring it remains sustainable.

The ERP set up a patient group to review the enhanced recovery pathway through the eyes of the patient. The group drew on their collective experience of “traditional” and “enhanced recovery” techniques and concluded that many patients did not realise they had a role to play in optimising their recovery.

They also found a gap in resources from the patient perspective - patients were given information telling them what was going to happen to them and about enhanced recovery, but nothing about the role they could play and their responsibilities in this. The vast majority of the information had been developed and written by professionals with little patient input.

Communications to aid patient involvement

The work of the ERP group, supported by NHS Improvement, has given patients an opportunity to develop materials that can help patients and professionals understand the patient perspective. These materials include a patient video story, a generic patient leaflet entitled My Role and My Responsibilities in My Recovery, and further information for professionals, all designed to improve awareness of what “getting better sooner” actually involves.

The patient story on video

Patient stories provided the foundation for the ERP patient group to identify what materials were needed and develop them. These stories identified key messages:

  • Patients do not always know they have a role to play;
  • Preparation starts before patients get to hospital;
  • 30% of recovery is in the patients’ own hands;
  • At home patients should measure progress weekly, not daily;
  • All patient information should communicate clear messages.

A DVD that tells the story of a patient’s experience is helping to get people more actively involved in their recovery. The DVD can be used online by professionals to raise awareness of enhanced recovery practice and support key messages.

Generic patient information leaflet

My Role and My Responsibilities in My Recovery was designed, tested and evaluated by patients to ensure it offered practical step-by-step advice before, during and after surgery. Critically, it has enabled patients who have gone through the pathway and those starting on it to share experiences. The design and content of the leaflet reflect patient need for simple, user-friendly information that is not overwhelming.

NHS organisations that have requested the leaflet, report that it helps in conversations with patients about their involvement in their recovery. The leaflet prompts patients to ask questions about their role and is being used in primary care during outpatient consultations, pre-operative assessment and education, as well as on admission to hospital, while in hospital and when discharged.

“Patients have found it useful in preparing for their journey, reminding them especially that the role is shared. It is not only a one-way process.” Nurse, NHS Improvement Provider Evaluation survey, 2012

A quantitative and qualitative evaluation of the leaflet was used to check it was addressing the intended needs. All the patients surveyed said the leaflet helped them to feel more confident in their role, and in understanding their responsibilities in getting better sooner. Some reported that did not know they had a role to play. Patients also reported that they felt they had more control over their care after being informed.

“I felt that I could contribute to my own recovery. This helped me to adopt the right mental attitude towards the hospital and recovery experience.” Patient, NHS Improvement Patient Evaluation survey, 2012.

The leaflet has been tremendously successful and to date over 100,000 copies have been distributed across the NHS in England.


The patient voice is essential in supporting the wholesale adoption of enhanced recovery principles. The enhanced recovery pathway tools discussed here have had a positive impact in responding to the needs originally identified by patients.

If the expectations of patients and professionals are aligned at the earliest stage in the enhanced recovery pathway, the whole journey is less stressful for patients; in turn, they feel more in control and better able to play their part in their recovery. The value of involving patients in improving both their own experience and outcomes must not be underestimated.

Box 1. Involving patients in their recovery

  • Having ownership of the decision to opt for surgery: enable patients to make an active decision in electing for surgery
  • Good communication from the GP at the time of referral about what to expect from enhanced recovery: align expectations to make the patient feel more in control and better able to play a part
  • Quality assured information soon after referral: ensure the patient understands what will be involved and has the opportunity to ask questions
  • Practical support in advance to make postoperative recovery less difficult: invite patients and involve others to meet staff and learn coping and recovery techniques for surgery
  • Peer and/or family support: reinforce positive messages of support around self-management via helplines and written information, and encourage the use of supportive networks
  • Positive reinforcement of messages: reassure that patient before and during admission that enhanced recovery is normal in getting the best outcome
  • Knowing who to ask: one of the most empowering things of all is to feel confident that you know where you can turn to for answers, advice or support
  • Anticipating a rapid recovery positively: ensure patients know what will be involved at an early stage and what they can access to deal with the unexpected

Source: NHS Improvement (2012)

Key points

  • An enhanced recovery pathway aims to help patients get back to their normal life sooner
  • Involving patients in their care can reduce recovery times
  • Patients are often unaware of how they can be involved in their own recovery
  • Recovery should be ongoing, starting before patients are admitted to hospital and continuing after discharge
  • Involving families can help patients to learn how to manage their condition
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