Introduction
Enhanced Recovery After Surgery (ERAS) was one of the major developments in perioperative care to improve surgical outcomes through multimodal, interdisciplinary approaches. In general surgery or neuro-spinal surgery, ERAS pathway strongly emphasizes the coordinated contribution from surgeons, anesthesiologists, nutritionists, rehabilitation specialists and especially nurses (Ljungqvist, Francis, and Urman 2020).
However, in Vietnam, despite the wide involvement of nurses in day-to-day patient care, their role in ERAS protocol is rarely described in detail. While international ERAS guidelines are available for several neuro-spinal surgery procedures, these guidelines tend to emphasis clinical interventions rather than clearly defining the nurse responsibilities, leadership domains or their accountability in preoperative-intraoperative and postoperative periods (Balfour et al. 2022, Bansal, Sharan, and Garg 2022).
Nursing activity might bring more benefit to overall ERAS programs if their role is clearly defined, accountable and measurable enough to support training, implementation, and further research. Given this perspective, the authors highlight some current limitations associated with nursing role within ERAS pathway for neuro-spinal surgery in Vietnam and proposed a framework for role clarification, accountability, measurement.
Current Challenges
Limited nurse role specification in ERAS guidelines
Existing international ERAS guidelines for neuro-spinal surgery consistently place the nurses as a key contributor to successful ERAS implementation. However, in comparison to surgeons and anesthesiologists, nurses’ responsibility is usually described in board terms such as monitoring, documentation, or execution of medical orders. This descriptive gap leads to ambiguity regarding:
The extent of nursing autonomy
The scope of nurse’s decision making.
Leadership role within each ERAS intervention
As a result, many aspects of nursing remain task-oriented in practice rather than pathway driven in most Vietnamese neuro-spinal surgery units. Although noting that various elements are naturally related to nursing activities such as perioperative education, nutrition or pain relief.
Lack of conceptual clarity in research
There is a growing number of clinical reports about the positive effects of ERAS pathway implementation in nursing aspect of neuro-spinal surgery in Asia (Zhang et al. 2025). However, many sources describe nursing interventions in general terms such as:
“Basic” vs “Comprehensive”
“Routine” vs “ERAS-specific”
Descriptions such as these fail to sufficiently explain what exactly changes in nursing practices under ERAS pathway. Without precise operational definitions, ERAS-based nursing practices are difficult to compare and replicate the positive outcome across different clinical neuro-spinal surgery units. It is difficult to compare relevant studies and attribute outcomes to specific components of nursing care.
Limitations of current outcome measures for nursing role
The impact of ERAS pathway implementation is frequently measured using unifying clinical outcomes such as:(Ljungqvist, Francis, and Urman 2020)
Length of stay (LOS)
Opioid consumption (MME)
Pain scores (VAS)
Time to first ambulation
While these metrics are standard and essential, it reflects the combined effort of multidisciplinary team rather than the individual contribution from a single element in pathway. Therefore, in nursing focus literature, the contribution from the nurse remains under-characterised and sometimes leads us back to the previous concern.
The Cross-Relationship Between MISS, ERAS Pathway and Nursing Practice in Neuro-Spinal Surgery
In neuro-spinal surgery practice in Vietnam, minimally invasive spine surgery (MISS) has long been promoted by neuro-spinal surgeons as a major surgical concept for its potential to enable effective multimodal analgesia, reduce tissue trauma, postoperative pain, and length of hospital stay while supporting faster mobilisation (Castillo-Calcáneo Del et al. 2018). These characteristics closely resemble the goals of ERAS pathway: to achieve faster and effective patient recovery.
However, the full effect of MISS cannot be realised with surgical techniques alone without effective nursing activity. In ERAS pathway, the nurse can provide important recovery platform for MISS by providing effective patient education, pain surveillance, patient mobilisation support, nutrition management, wound care, and timely escalation of clinical concerns.
Therefore, a clearer definition of nursing responsibility within ERAS workflow is essential to link the technical advantage of MISS with measurable patient outcomes. MISS creates surgical conditions for advanced recovery; ERAS pathway provides the ground for nursing practice consistently implemented in day-to-day care.
Proposed Framework for Nursing Roles in Neuro-Spinal Eras Pathway Practice in Vietnam
We propose a conceptual framework to address the gaps above, shifting nursing role from task implementers to coordinators and taking leadership roles of specific ERAS domains in training, in practice and especially in literature research. Those domains represent role-based responsibilities, not just interventions:
ERAS counselling coordinator: Nurses provide the patient structured education session about perioperative care at key recovery milestones (e.g., preoperative consultation, resuming solid diet, postoperative ambulation…)
Metabolic preparation and nutrition oversight: initiate and monitor carbohydrate loading protocols, ensuring patient adherence.
Pain assessment leadership: provide regular bedside pain surveillance, pain documentation, and escalate pain care pathway. The nurses should provide initiative-taking pain assessments by identifying pain early, communicating promptly, and initiating appropriate escalation rather than simply recording pain scores.
Early mobilisation: Nurses may lead the first postoperative ambulation with physician authorisation, provide guiding patients during mobilisation, and ensure safety throughout the process. This role positions nurses as operational leaders in the implementation of patient mobilisation within ERAS pathway.
Resumption of early oral feeding postoperative: Nurses may provide monitoring patient solid feeding including tracking tolerance and adjusting the suitable pacing in collaboration with the team.
Wound care and pressure injury prevention: Nurses may take an active role for the incision healing through proactive surveillance, early identification of wound dehiscence or SSI through dressing change and all the necessary action to avoid complications such as pressure injury.
Rethinking How We Measure Nursing Impact
To better capture nursing contributions within ERAS in neuro-spinal surgery, we suggest two additional considerations for evaluating nursing impact in practice as well as in review literature:
Implementation of structured audit systems
Reliable evaluation requires a functional audit framework: continuous data collection, compliance tracking for each ERAS component and team-specific performance indicators (Perinel and Adham 2020). Available tools (e.g., REDCap-based databases or dedicated paid ERAS audit platforms) can support this process. Without functional audit systems, outcome attribution may remain imprecise and partly speculative.
Development of nursing-specific metrics
In addition to standard ERAS clinical outcomes, we propose further investigation and incorporating the suitable nursing metrics into localised ERAS pathway:
Protocol adherence rates for the nurse-led domains explained above (Baimas-George et al. 2020).
Process indicators (timeliness of mobilisation, feeding progression...)
Patient-reported experience measures, particularly for: satisfaction with nursing care, clarity of nurse–patient communication and the perceived support during recovery.
These indicators should be initiated as complementary measures, not replacements for clinical outcomes.
Implication For Nursing Education and Training
Clearly defined roles of the nurse might bring corresponding changes in training models (Wainwright, Jakobsen, and Kehlet 2022). Traditional Vietnamese nursing training often focuses on skills and task execution, should evolve toward pathway-driven training, structure communication, and excellent patient counselling skills. Bedside mentoring, interdisciplinary coordination training with competency checklists tied to each nursing ERAS domains will play higher importance. It represents a shift from task-based care to pathway-driven and ERAS domain-oriented practice.
Conclusion
ERAS will continue to play a bigger role in general surgery and neuro-spinal surgery. However, to successfully implement the pathway in Vietnam, it requires further nursing role clarity, accountability, and measurement within the multidisciplinary team. Defining nursing roles in terms of coordination, leadership, and accountability— rather than task execution alone—is essential. It allows meaningful implementation, better clinical research, and nursing training. Future work is required for standardising nurse role definitions, developing measurable frameworks, and integrating audit systems into routine practice. Only by closing this gap, the contribution of Vietnamese nurses within ERAS pathway can be more accurately recognised and strengthened.