[version 2; peer review: 1 approved]
No competing interests were disclosed.
The efficient functioning of surgical services in public hospitals is a cornerstone of effective healthcare delivery, influencing not only operational performance but also patient outcomes and the overall utilisation of resources within the health system. Elective surgical case cancellations represent a persistent and complex challenge faced by healthcare systems globally, often reflecting systemic inefficiencies and resource limitations. While existing research has predominantly focused on quantifying cancellation rates and categorising causes through retrospective institutional data, few studies have explored the insights of healthcare professionals, key frontline stakeholders who play a critical role in identifying and addressing cancellations. This study seeks to address this gap by examining healthcare professionals’ perspectives on elective surgical case cancellations within selected public hospitals in South Africa. This study will employ a quantitative cross-sectional survey to identify and understand the factors contributing to the cancellations of theatre cases from healthcare professionals’ perspectives. A convenience non-probability sampling technique will be utilised to collect data using a structured questionnaire from healthcare professionals who are readily available and willing to participate during the study period. 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. Ethical clearance has been granted by the Human Research Ethics Committee of the Faculty of Medicine and Health Sciences at Walter Sisulu University, Ref: WSU HREC 051/2025. Approval to access the research sites has been obtained from both the Provincial Health Research Committees of the Eastern Cape (Ref: EC_202505_029) and Mpumalanga (Ref: MP_202506_003) departments. Results will be shared with key stakeholders through public presentations, conferences, and published in peer-reviewed journals.
This revised version addresses the reviewer’s comments and enhances the clarity of the study protocol's methodology. The title has been shortened for improved clarity and readability while still reflecting the study's population, topic, setting, and design. The methods section has been updated to clarify the pragmatic convenience sampling approach, noting that no predetermined minimum sample size was established. The revised manuscript specifies that all eligible and available healthcare professionals working in surgical wards and operating theatres during the data collection period will be invited to participate. The questionnaire description has been expanded to enhance transparency. The Data collection section now provides illustrative example items for each of the four questionnaire domains (demographic/professional, institutional, patient-related, and systemic factors) to improve methodological transparency and allow appraisal of instrument content validity. Additionally, example questionnaire items have been included. The scope of surgical cancellations has also been broadened to encompass cancellations that occur during preoperative preparation, after patient admission to the operating theatre, and immediately before anaesthesia induction.
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.
Literature identifies various factors contributing to the cancellation of theatre cases, categorised into patient-related, systemic inefficiencies, and clinician-related reasons.
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.
The consequences of cancellations extend beyond operational inefficiencies.
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.
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. For this study, an elective surgical cancellation is defined as the failure to perform a scheduled elective procedure on the intended day of surgery. The study specifically includes cancellations that occur at any point along the perioperative pathway. This encompasses cancellations that arise during preoperative preparation and ward-level workup, as well as those that happen after the patient has been admitted to the operating theatre, including cancellations that occur immediately before anaesthetic induction. By considering both preoperative and theatre-admission cancellations, the study aims to provide a more comprehensive and nuanced understanding of their timing and underlying causes from the perspectives of frontline healthcare professionals. 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.
A convenience non-probability sampling technique will be utilised.
In survey-based research utilising nonprobability sampling, the determination of sample size is guided by the need to achieve adequate statistical power for the planned analyses, while also considering practical constraints of the study environment.
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 literature
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.
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.
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.
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.
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.
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.
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.
No data is associated with this article.
The authors wish to thank the Eastern Cape and Mpumalanga Department of Health for allowing this study to be conducted in their healthcare facilities.
At first impression, the title is excessively long. It could be changed to a clear, informative, and concise title. Overall assessment:
Sample size and power analysis: The planned sample size has not been specified. Including a power calculation or at least an estimated minimum number of participants would substantially strengthen the scientific robustness and credibility of the protocol.
Although the authors clearly defined the study population and indicated that a convenience sampling approach would be used, the protocol does not specify the target sample size and does not provide any power or precision calculations to verify the adequacy of the proposed sample. This omission limits the ability to assess whether the study will achieve sufficient statistical power to detect meaningful differences or estimate proportions with an acceptable level of precision. Questionnaire content: While the authors mention that the questionnaire was adapted from previous studies, the specific items or domains to be assessed are not detailed. Providing examples of key questions or constructs would improve methodological transparency and allow readers to better evaluate the validity of the instrument. Group comparisons:
Is the study design appropriate for the research question?
Yes
Is the rationale for, and objectives of, the study clearly described?
Yes
Are sufficient details of the methods provided to allow replication by others?
Partly
Are the datasets clearly presented in a useable and accessible format?
Not applicable
Reviewer Expertise:
I am an anesthesiologist with substantial clinical and academic experience in preoperative evaluation, operating theatre management, and surgical case cancellations. My team and I have recently conducted research in this area, yielding notable findings. Given this background, I consider this topic particularly relevant and am pleased to contribute my perspective to the review of this important study.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
• At first impression, the title is excessively long. It could be changed to a clear, informative, and concise title.
• Overall assessment: Surgical case cancellations represent a critical health system challenge with implications for both resource utilisation and patient safety. The manuscript offers an original perspective on an important healthcare issue and addresses a notable gap in the literature, particularly within the context of low- and middle-income countries (LMICs). Conducting the study across two provinces and multiple public hospitals enhances the potential generalisability of the findings. The manuscript is generally well-structured, with clearly defined objectives, appropriate ethical approvals, and a transparent description of the study procedures. Although no outcome data are yet presented, the methodological planning appears rigorous and comprehensive for a study protocol.
• Sample size and power analysis: The planned sample size has not been specified. Including a power calculation or at least an estimated minimum number of participants would substantially strengthen the scientific robustness and credibility of the protocol.
o Although the authors clearly defined the study population and indicated that a convenience sampling approach would be used, the protocol does not specify the target sample size and does not provide any power or precision calculations to verify the adequacy of the proposed sample.
o This omission limits the ability to assess whether the study will achieve sufficient statistical power to detect meaningful differences or estimate proportions with an acceptable level of precision.
• Questionnaire content: While the authors mention that the questionnaire was adapted from previous studies, the specific items or domains to be assessed are not detailed. Providing examples of key questions or constructs would improve methodological transparency and enable readers to better assess the instrument's validity. Please provide these examples
• Group comparisons: It is not clearly indicated whether differences between subgroups, such as years of professional experience, role, or hospital setting, will be analysed. Clarifying whether such comparative analyses are planned would enhance the depth and interpretive value of the study findings.
• Scope of surgical cancellations: The protocol does not specify whether cancellations occurring after patient admission to the operating theatre will be considered, or if the focus is limited to preoperative preparation. However, many cancellations occur intraoperatively or immediately before anesthesia induction, as shown in several large-scale studies. Including this dimension in the survey would enhance the research's comprehensiveness and contribute to a more nuanced understanding of the underlying causes. The authors are encouraged to explore this aspect further in both data collection and subsequent discussion of results.