Contemporary Issues in Adult Nursing: Preoperative Fasting
Contemporary Issues in Adult Nursing: Preoperative Fasting
Trends in healthcare are continually evolving and changing, these fluctuations can often have massive implications for nursing practice. How we practice as nurses is often dictated by new policy and guidelines which are brought about by the evolving healthcare system. For an issue to be contemporary it has to be occurring in the present and in the sense of nursing it would seem that many issues could be deemed as contemporary due to the ever fluctuating nature of our healthcare service. For the purpose of this assignment I am going to address the issue of pre-operative fasting and the tradition of fasting patients from midnight until surgery the following day. Evidence suggests that this practice is outdated and unnecessary but still the practice occurs on many surgical wards. I aim to explore the reasons why patients are still subjected to unnecessarily long fasting times and how we as nurses can change this outdated practice.
I have chosen to look at this area of contemporary nursing because as a student nurse I have had practice experience in both a surgical ward and in general theatre. I feel that having had experience in both of these settings I would be able to link theory to practice experience.
Fasting patients from midnight before day of surgery has long been a time honoured tradition. The main reason for the Nil by Mouth rule from midnight has been to ensure an empty stomach at time of anaesthesia. If the patient is not fasted, gastric contents could be inhaled by the patient while they are under anaesthetic. Because the contents of the stomach are acidic it is important that regurgitation and inhalation does not occur as this can lead to an inflammatory response within the lungs which can have dire effects for the patient (Tudor, 2006). Although an empty stomach is vital for safe sedation, the time which the patient is fasted for is also of relevance as is the type of foods the patient consumes before surgery. Woodhead & Wicker (2005) state that new fasting guidelines are more humane and evidence based. Guidelines in the UK have been produced by the Royal College of Anaesthetists and they state that at 6 hours before surgery, patients can consume solids and milk, have a light meal but are not allowed to eat meat or fried foods. At 2 hours before surgery, patients can have clear fluids which include black tea or coffee and fruit juices without pulp (Woodhead & Wicker, 2005).
Oshodi (2004), comments upon the effects of excessive fasting on the patient. He concludes that prolonged fasting is not only unpleasant for patients as they often complain of a dry mouth but post operative nausea can be reduced if patients are allowed to drink clear fluids up to 2 hours before surgery. Rowe (2000) emphasises the point further by stating that patients who undergo excessive preoperative fasting can experience hypoglycaemia, ketosis, hypovalaemia, confusion and headaches. It could be argued that by allowing patients to eat and especially drink up to the recommended fasting times the patient will not only be more comfortable in recovery but the costs of care could be reduced. For instance, the patient's time in recovery would be reduced, as would the patients need for anti-emetics and possibly pain relief.
The British based Royal College of Anaesthetists recommend the above fasting times however according to Saqr & Chambers (2006) it would seem that these recommendations are still not being followed in the UK. Change of practice has been slow in other countries too. Crenshaw & Winslow (2002) report on a study carried out by the American Society of Anaesthesiology which found that on average surgical patients fasted from solids and liquids for 12 and 14 hours and some patients were found to fast for 20 hours from fluids and 37 hours from solids.
From my own ...
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The British based Royal College of Anaesthetists recommend the above fasting times however according to Saqr & Chambers (2006) it would seem that these recommendations are still not being followed in the UK. Change of practice has been slow in other countries too. Crenshaw & Winslow (2002) report on a study carried out by the American Society of Anaesthesiology which found that on average surgical patients fasted from solids and liquids for 12 and 14 hours and some patients were found to fast for 20 hours from fluids and 37 hours from solids.
From my own practice experience of working in theatres, I found that the anaesthetic staff, nurse and anaesthetist, were concerned with when the last time the patient ate and drank. However, I felt that they were not concerned about how long the patient had fasted for as long as they met the minimum 2 hour liquids and 6 hour solids consumption requirement which would allow the surgery to commence. From practice on a surgical ward I found that depending on when the patient was to have surgery depended on when they were advised to have their last consumption of food or drink. In many cases I observed, patients who were to have surgery in the afternoon were given an early breakfast at around 5:30am and patients who were to have morning surgery were not to eat anything after midnight.
Guidelines aimed at the multidisciplinary team have been produced by the
RCN (2005) which give a comprehensive guide to recommended fasting times for adult and child surgical patients. Information from other organisations, journals and books all adhere to the recommended 2 hour fast for fluids and 6 hours for solids rule so it worth asking why in practice this is still not happening.
Oshodi (2004) suggests that one of the reasons that fasting guidelines are not being met is to do with the fact that literature surrounding this issue is aimed at doctors and anaesthetists, not at nursing staff. I would argue that this is not the case as information is readily available to those who seek it. The RCN published guidelines and from my own literature review I found that information can be found, written with nurses in mind.
The idea that nursing ritual plays a part in unnecessary fasting times is supported by Crenshaw &Winslow (2002). Barriers to changing practice as suggested by Hung (1992) could include the nurses' reluctance to change practice without clinical guidelines in place. The trust in which I carried out my own placements did not have any guidelines in place to advise on the appropriate fasting times for surgical patients. Similarly, the National Institute for Clinical Excellence (NICE) does not have guidelines regarding this issue either. It could be suggested that without guidelines in place nurses are reluctant to act on their own knowledge in fear of litigation or because they do not have the confidence or certainty that they are acting in the patients best interests. With this in mind it is unsurprising that nurses follow ritual and not fact when it comes to fasting patients.
In current practice and nursing education it is favourable to distance ones self from rituals and instead practice in a manner which is evidence based. The NMC code of professional conduct (2004) states that:
"You must keep your knowledge and skills up-to-date throughout your working life."
And:
"To practice competently, you must possess the knowledge, skills and abilities required for lawful, safe and effective practice without direct supervision."
Ford and Walsh (1994) comment that nursing as a profession has a reputation for being traditional and reactionary in practice. They believe that as nurses we do not change because the profession has for too long been the subordinate to the medical staff and more recently the general management. They go on further to state that for too long nurses have not acted upon their own knowledge base but rely on information and instruction from the healthcare professionals. It is believed that for nurses to change they must work more autonomously and believe in their own knowledge.
Rituals in practice are not confined to the subject addressed in this essay and changes to rituals are not always easy to overcome. Tonuma & Winbolt (2000) report on one unit's journey to overcome ritualistic practice and it was found that the barriers to change they faced included people's automatic resistance to change, systems in place which do not allow change and learnt behaviours from staff were difficult to alter.
The 'theory - practice gap' could be a suggestion as to why nursing rituals still persist. Rolfe (2002) suggests that what happens in clinical practice rarely matches what is said in textbooks and journals. He goes on further to say that if nursing theory can not account for what is happening in clinical practice with out a degree of certainty then it makes the entire body of nursing knowledge redundant.
From the literature review carried out several themes have emerged:
) Patient's do not benefit from excessive fasting preoperatively
2) Patients comfort before and after surgery could be increased if the Royal College of Anaesthetists guidelines were followed.
3) A sound knowledge base is available to nurses regarding safe fasting times for preoperative patients.
4) Rituals in nursing practice could be accountable for excessive preoperative fasting times.
5) Nurses are bound by the NMC to be responsible for providing knowledge based care to their patients.
With the five themes that have emerged in mind, I aim to look at how we as nurses can address these issues in developing practice and look for solutions to improve preoperative patient care.
As discussed previously, evidenced based information is available to nurses from a variety of sources. However, nurses must be able to work more autonomously and take a certain amount of responsibility to ensure that they are up to date with current practice within their field. By ensuring their own knowledge is up to date they are working within their own professions code of conduct which in turn protects the patients they are caring for. If nurses are confident in their own knowledge and abilities they would be able to exercise their own clinical judgement when advising patients of fasting times before surgery.
Ford & Walsh (1994) believe that as a profession nursing has in the past been seen to be subordinate to the medical profession. To improve future practice in this subject and other areas of nursing we as nurses should believe in our own practice and be confident in our own knowledge and abilities. This can be achieved by making sure we are up to date with current issues in practice. If we see nurses as equals to the medical staff, surgeons and anaesthetists we should be empowered to negotiate as contemporaries with regard to patient care. Patients spend more time being cared for by nurses than the anaesthetist or surgeon and it is within our role to be the patients advocate and look out for their best interests. Communicating effectively with the medical staff ensures patient advocacy, promotes interprofessional working and can encourage nurses to work autonomously.
Communication between nurse and medical staff has already been addressed but communication between nurse and patient should also be of importance. Within our role as a nurse we should be able to empower our patients to take responsibility for their own health. This could include letting the patient take responsibility for their own fasting regime. This idea is supported by O'Callaghan (2002) who further suggests that as patients are required to spend less time in hospital to recover after surgery, they should be made aware of the health benefits of accurate fasting times with regards to their recovery period.
One of the major themes to have come from the literature is that change in practice is slow. Suggestions to why change is not occurring include lack of definite policy surrounding preoperative fasting and nursing ritual. It is clear from the literature that patients are not receiving the best possible care if they are experiencing excessive fasting times before surgery and it is clear that a change in practice needs to occur. With this in mind, whose responsibility is it for a change in process to occur? Should the individual nurse look out for their patient's best interest and move away from the traditional practice of the ward or should they try and facilitate change across the entire ward, hospital and trust? It is interesting that the RCN published guidelines in 2005 about preoperative fasting, 5 years after the Royal College of Anaesthetists made their own recommendations. What is interesting is that none of this information is new; it is information which has been available for many years. I assume it was made to guide nurses and members of the MDT about fasting times and why it is important but it doesn't, throughout the entire document, make any suggestion on how to change practice. Saqr & Chambers (2006) suggest that prolonged fasting times are due to organisational issues rather than lack of knowledge and suggest that these guidelines would be of little impact. I believe that changing practice is multifaceted and it should be a responsibility of the individual nurse, the anaesthetist and ward manager to ensure safe and correct fasting times for patients. It has been established that the evidence is there to support change in practice and I would suggest that collaboration would be needed to facilitate this change. Through collaboration between the different members of the MDT, new hospital / trust policy could be made to ensure that correct fasting times are adhered to. The implications for a change in practice could include: increased patient satisfaction, comfort and awareness; if nurses are following guidelines they could feel more confident in their actions; the importance of the issues are raised along with education in the subject; and costs to the hospital could be reduced as patients would not require as many anti emetics; and time spent in recovery would also be reduced.
Clinical audits carried out in practice could also improve the care patients receive. They work well at a local level and can be carried out by staff nurses. If nursing staff were committed to change in practice they would also be committed to maintaining the highest standards of care they could possibly offer. One definition of clinical audit is:
"Clinical audit is a quality improvement process that seeks to improve the patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structures, processes and outcomes of care are selected are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual team, or service level and further monitoring is used to confirm improvement in healthcare delivery."
(Clinical Governance Support Team, 2005)
In conclusion there are a number of ways in which nurses can improve and implement future nursing practice. Keeping up to date with knowledge and skills, working within the NMC's code of conduct and not being afraid to facilitate change in practice are some of the key areas which could help improve future nursing practice.
References
) Clinical Governance Support Team, 2005 'A Practical Handbook for Clinical Audit'
2) Tudor G 2006, 'Fasting: how long is too long?' Australian Nursing Journal, 13, 7, pg 29 - 31
3) O'Callaghan N 2002, 'Preoperative Fasting' Nursing Standard, 16, 36, pg 33 -37
4) Rolfe G 2002, Closing the Theory Practice Gap: A new Paradigm for Nursing, Elsevier: Edinburgh
5) Tonuma M & Winbolt M 2000, 'From rituals to reason: Creating an environment that allows nurses to nurse' International Journal of Nursing Practice, 6, 4, pg 214 - 218
6) Ford P & Walsh M 1994, New Rituals for Old: Nursing Through the Looking Glass, Butterworth/Heinemann: Oxford
7) NMC Code of Professional Conduct 2004, NMC: London
8) Hung P 1992, 'Preoperative Fasting' Nursing Times, 88, 48, pg 57- 60
9) RCN 2005, Perioperative fasting in adults and children, RCN: London
0) Crenshaw J & Winslow E 2002, 'preoperative fasting: Old habits die hard' AJN, 102, 5, pg 36 - 44
1) Saqr L & Chambers W 2006, 'Preventing excessive preoperative fasting: national or local protocol?' Anaesthesia, 61 pg 1-3
2) Oshodi T 2004 'Clinical Skills: an evidence based approach to preoperative fasting' British journal of Nursing 13, 16, pg 958 - 962
3) Woodhead K & Wicker P 2005, A Textbook of Perioperative Care, Elsevier: London
Contemporary Issues in Adult Nursing
AA084
Preoperative Fasting
Donna Scott
GF: Melanie Fisher
