Keywords
Health professionals, elective surgical case cancellations, public hospitals, South Africa
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Maake K, Chitha W, Nomatshila S and Mabunda S. Protocol for health professionals’ perspectives on elective surgical case cancellations in selected public hospitals: A quantitative cross-sectional study in South Africa’s Eastern Cape and Mpumalanga provinces [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:802 (https://doi.org/10.12688/f1000research.169011.1)
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Study Protocol
Protocol for health professionals’ perspectives on elective surgical case cancellations in selected public hospitals: A quantitative cross-sectional study in South Africa’s Eastern Cape and Mpumalanga provinces
[version 1; peer review: awaiting peer review]
PUBLISHED 19 Aug 2025
OPEN PEER REVIEW
REVIEWER STATUS
This article is included in the Public Health and Environmental Health collection.
Abstract
Corresponding author:
Kedibone Maake
Competing interests:
No competing interests were disclosed.
Grant information:
This research will be funded by a grant from the South African Medical Research Council, grant number: HDID6032_SB2021.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2025 Maake K et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Maake K, Chitha W, Nomatshila S and Mabunda S. Protocol for health professionals’ perspectives on elective surgical case cancellations in selected public hospitals: A quantitative cross-sectional study in South Africa’s Eastern Cape and Mpumalanga provinces [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:802 (https://doi.org/10.12688/f1000research.169011.1)
First published: 19 Aug 2025, 14:802 (https://doi.org/10.12688/f1000research.169011.1)
Latest published: 19 Aug 2025, 14:802 (https://doi.org/10.12688/f1000research.169011.1)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Introduction
Efficient functioning of surgical services within public hospitals is fundamental to healthcare delivery, impacting not only operational performance but also patient outcomes and system-wide resource utilisation.1–3 Elective surgical case cancellations pose a persistent and multifaceted challenge in healthcare systems globally, often signifying systemic inefficiencies and limitations in resources.1 Defined as the non-performance of scheduled surgeries on the intended date, these cancellations not only disrupt clinical workflows but also lead to wasted operating theatre time, increased healthcare costs, prolonged patient waiting periods, and a decline in trust toward the healthcare system.2–4 Elective surgical case cancellation remains a prevalent challenge in healthcare systems globally, particularly in low to middle-income countries (LMICs) like South Africa, with prevalence rates reaching as high as 34 percent, significantly exceeding the global average of approximately 18 percent.1,5,6 These cancellations contribute to reduced operating theatre efficiency, financial losses, and psychological distress among patients and families.7,8 In LMICs, high cancellation rates exacerbate existing strains on public hospitals, where resource constraints, staff shortages, and systemic inefficiencies are prevalent.9
Literature identifies various factors contributing to the cancellation of theatre cases, categorised into patient-related, systemic inefficiencies, and clinician-related reasons.10,11 Patient-related factors may comprise non-attendance, lack of pre-operative preparation, medical comorbidities, and logistical concerns such as inadequate resources.1,12 Systemic inefficiencies, such as insufficient resources like operating rooms or staff, scheduling conflicts due to poor coordination, and administrative errors like incorrect patient information, are also significant contributors to surgical case cancellations.1,12 Clinician-related factors may include inadequate communication among team members, surgeons’ availability, and various procedural inefficiencies.4,13 In a study by Sukwana et al. (2023), cancellations were distributed based on their preventability, with 52.6% classified as avoidable, 6.2% as potentially preventable, 25.2% as difficult to avoid, and 16% as unavoidable. In LMICs with limited resources, cancelling elective surgical operations for various preventable reasons is common in many hospitals, and this situation is also prevalent in most African countries.15 Cancellations of scheduled elective operations significantly strain health resources in LMICs; in addition to hospital inpatient costs, the government also incurs substantial expenses in transporting patients to and from referring hospitals.16 Realistic strategies to reduce cancellations cannot be established without understanding the underlying reasons for these occurrences in LMICs.1,17
The South African healthcare system faces multiple systemic challenges, contributing to frequent surgical cancellations, further exacerbating backlogs, and further straining an already overburdened healthcare system.4,17,18 For public sector hospitals in South Africa, where resources are already strained and healthcare inequities persist, understanding the drivers and consequences of surgical cancellations is crucial to enhancing service quality and equity.4,17,18 International benchmarks suggest that cancellation rates should not exceed 5%, yet studies in South African public hospitals report rates as high as 14.4%–39%, far surpassing this threshold.4,9 Public hospitals, particularly those in rural and under-resourced provinces like the Eastern Cape and Mpumalanga, face unique challenges that intensify the burden of surgical cancellations.4,19 These include inadequate staffing, equipment shortages, logistical inefficiencies, and weak interdepartmental coordination.17–19 While much of the global literature has focused on quantifying cancellation rates and categorising causes from institutional data,1–4 there is a relative paucity of research capturing the firsthand perspectives of healthcare professionals who are directly involved in perioperative care and theatre management.
The consequences of cancellations extend beyond operational inefficiencies.2 Healthcare workers, already operating under stress, experience demoralisation and burnout due to recurrent workflow disruptions.2 While prior research has quantified cancellation rates and their causes in South Africa,4,9,14 few studies have centered on healthcare professionals’ perspectives, despite their frontline role in identifying and mitigating cancellations. Therefore, this study aims to fill that gap by examining healthcare professionals’ perspectives on elective surgical case cancellations within selected public hospitals in the Eastern Cape and Mpumalanga provinces. The findings from this study will not only contribute to the national discourse on health system strengthening but also offer practical guidance for hospital administrators, policymakers, and healthcare teams aiming to reduce cancellations and improve surgical care delivery.
Protocol
Study setting
The study will be conducted in two mostly rural provinces of South Africa, the Eastern Cape and Mpumalanga, both characterised by high levels of poverty, unemployment, and socioeconomic inequality, which significantly affect healthcare outcomes.20,21 A large portion of the population depends on public health facilities for their healthcare needs.20 Despite substantial interventions, strategies, and investments by the Department of Health aimed at strengthening the health system’s capacity to deliver quality healthcare services, both provinces continue to exhibit poor health outcomes.22,23 The study will take place in four hospitals: Nelson Mandela Academic Hospital and St Elizabeth Hospital in the Eastern Cape, and Rob Ferreira Hospital and Themba Hospital in Mpumalanga. These selected hospitals serve as referral facilities within their respective provinces, offering various levels of specialised healthcare services. To ensure an unbiased and representative sample, a simple random sampling technique was employed in the selection of hospitals for the study.
Study design
This study will employ a quantitative, cross-sectional survey design to systematically investigate the factors contributing to surgical theatre case cancellations in selected public hospitals in the Eastern Cape and Mpumalanga provinces, South Africa. The cross-sectional nature of the design allows for data collection at a single point in time, providing insights into the current state of factors influencing theatre cancellations from the perspectives of healthcare providers. The survey will target healthcare professionals in surgical wards and theatres, specifically doctors and nurses, to explore their perspectives and experiences. By using structured surveys, this research aims to produce findings that are generalisable, which can guide targeted interventions to reduce cancellations and improve surgical efficiency in settings with limited resources.
Population and sampling
A convenient non-probability sampling technique will be utilised.24 This technique will allow data collection from healthcare professionals who are readily available and willing to participate during the study period. This is particularly useful in busy environments like surgical wards and theatres where time and availability can be limited. The technique ensures that the study can include enough participants without disrupting essential duties. The study population will comprise all healthcare professionals in the surgical wards and theatres of the selected public hospitals in the Eastern Cape and Mpumalanga provinces. This will include nurses (professional nurses, enrolled nurses, nursing assistants) and doctors (surgeons, anesthetists, and other relevant medical practitioners) involved in surgical care who fulfill the study’s inclusion criteria during the designated period.
Data collection
Data will be collected using a structured questionnaire designed to capture the perspectives and experiences of healthcare providers regarding the factors contributing to the cancellations of theatre cases. The research questionnaire was designed based on the formats provided in previous empirical literature4,25 and validated for this study by two public health physicians. The questionnaire will include sections on demographic information, including age, gender, professional role, and years of experience. Institutional factors such as the availability of resources and scheduling practices. Patient-related factors, such as patient preparedness and cancellations due to patient conditions. Systemic factors, such as administrative issues and policy-related factors. Data collection will involve distributing structured questionnaires to selected surgical wards and theatre healthcare professionals. Participation will be voluntary, and informed consent will be obtained from all participants before completing the survey. To enhance response rates, reminders will be sent, and participants can complete the survey in either paper format or electronically via a secure online platform, depending on the hospital’s resources and preferences.
Validity and reliability
To ensure validity, researchers invested careful consideration in designing a questionnaire that would only measure what it intended to measure. To further strengthen the reliability of the data collection instruments, tools used in previous research were adapted to align with the study’s specific research questions and objectives. Additionally, the participation of trained researchers in the data collection process will further enhance the reliability of the information gathered.
A pilot study will be conducted to evaluate whether the data collection tools effectively measure the intended concepts.26 A pre-test questionnaire26 will be administered to ten participants at a referral hospital in the Eastern Cape province who share similarities with the target sample population. The questionnaires will undergo this pre-testing to identify potential problem areas, minimise measurement error, ascertain if participants interpret questions correctly, and confirm that the sequence of questions does not influence participants’ responses. The questionnaire will only be finalised after the researcher completes the pre-testing and makes necessary modifications based on feedback from the pre-test.
Data management and analysis
Quantitative data analysis will involve entering survey data into Microsoft Excel 2021 for Windows and subsequently exporting it to STATA version 18.5 for advanced analysis. Descriptive and categorical data will be compared using frequencies, percentages, and graphical representations. The normality of numerical data will be evaluated using the Shapiro-Wilk test. The mean, range, and standard deviation will be reported for data that meets the normal distribution criteria. In contrast, the median and interquartile range (IQR) will be utilised for non-normally distributed data. Statistical comparisons will rely on the Chi-squared or Fisher’s exact test based on the expected frequencies. A significance level of p-value ≤ 0.05 will be adopted, along with a 95% confidence interval to ensure the precision of estimates.
Dissemination
Research findings will be communicated through various dissemination methods, including workshops, media releases, seminars, and conferences, as well as publications in peer-reviewed journals. This approach will ensure that the findings reach the appropriate stakeholders and can effectively inform decisions, policies, and future research initiatives.
Study status
Participant recruitment and data collection will be conducted concurrently from 01 October 2025 to 28 November 2025. During this timeframe, eligible healthcare professionals will be sampled to participate in the study. Data analysis and interpretation are set to begin on 12 January 2026, with completion anticipated by 28 March 2026. As of this submission, none of the study phases, including recruitment, data collection, or analysis, have been initiated.
Discussion
This study aims to identify the key determinants of theatre cancellations, reflecting findings from similar contexts in LMICs, where resource shortages, administrative inefficiencies, and patient-related issues often disrupt surgical workflows.1 Institutional constraints, such as insufficient equipment, staffing shortages, and poor scheduling, are expected to be significant barriers, aligning with prior research that has highlighted systemic weaknesses within South Africa’s public health sector.4 Additionally, patient-related factors, such as late arrivals, inadequate preoperative preparation, or acute clinical deterioration, may further exacerbate cancellations, as observed in comparable studies in LMICs.1
The perspectives of healthcare professionals will provide invaluable insights into operational inefficiencies that are often overlooked in top-down policy evaluations. Their firsthand experiences may uncover gaps in hospital management, including fragmented communication between surgical teams and administrative staff, which can exacerbate delays. By quantifying these factors, this study will add to the growing body of literature advocating for the enhancement of surgical systems in under-resourced settings. If, as expected, resource scarcity and logistical inefficiencies emerge as significant contributors, targeted interventions such as improved supply chain management, predictive scheduling algorithms, and enhanced preoperative patient assessment protocols could help reduce cancellations.
While the study design provides robust quantitative data collection, several limitations warrant consideration. The cross-sectional nature of the study limits causal inference, capturing only a snapshot of healthcare professionals’ perceptions at a single point in time. Employing a longitudinal approach could offer deeper insights into trends and contextual variation. Future research could benefit from the inclusion of qualitative interviews to explore the underlying systemic barriers in greater depth. Despite these limitations, the study results are expected to inform policy and operational improvements. By clarifying the multifactorial causes of cancellations from resource deficiencies to administrative shortcomings, the research will provide actionable evidence for enhancing surgical efficiency. Addressing these challenges is essential not only for reducing procedural delays but also for promoting equitable access to timely surgical care in alignment with global health equity goals.
Ethics and consent statement
Ethical clearance was obtained from the Research Ethics Committee of the Faculty of Health Sciences at Walter Sisulu University, Ref: WSU HREC 051/2025. Approval to access the research sites was obtained from the Provincial Health Research Committees of both the Eastern Cape (Ref: EC_202505_029) and the Mpumalanga (Ref: MP_202506_003) Department of Health. Before data collection, entry to the study sites will be further negotiated with the hospital CEOs. The study will abide by the 4 ethical principles of autonomy, beneficence, non-maleficence, and justice.
Informed consent forms will be signed by all participants in the study. These forms will be clearly explained, outlining the study’s purpose, objectives, participant expectations, and any potential risks and benefits associated with participation. Participants will be reassured that their involvement in this study is completely voluntary and that their confidentiality will be maintained throughout the research process. They will also be informed that they can withdraw from the study at any time and choose not to answer any questions they find uncomfortable without facing any negative repercussions. All identifying information will be removed, and all electronic records will be securely encrypted with a password, accessible only to the researchers.
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how to cite this article
Maake K, Chitha W, Nomatshila S and Mabunda S. Protocol for health professionals’ perspectives on elective surgical case cancellations in selected public hospitals: A quantitative cross-sectional study in South Africa’s Eastern Cape and Mpumalanga provinces [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:802 (https://doi.org/10.12688/f1000research.169011.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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