VOL: 103, ISSUE: 18, PAGE NO: 30-31
RGN, ONC, DMS, is trauma nurse co-ordinator at Carmarthenshire NHS trust
Abstract Lorch, A. (2007) Implementation of fasting guidelines through nursing leadership. www.nursingtimes.net
This study describes how leadership can work to produce organisational change through the implementation of fasting guidelines in an NHS trust. Prolonged periods of fasting were a common occurrence for trauma and orthopaedic patients in this trust, and much evidence was available highlighting this poor practice. The specialist nurse and their role as a change agent are examined, along with the use of Lewin’s force-field model of change and the factors that influence this process.
During the first six months in their new role as a specialist trauma nurse co-ordinator in trauma and orthopaedics, the author identified a variety of problems that affected the care of patients awaiting urgent surgery. In particular, there were concerns about the long periods of starvation of the very young and elderly on the three wards within the unit. A prospective snapshot study was undertaken of 50 patients within a three-month period during 2002. This looked at patients over the age of 60 with limb fractures. Results showed 16 patients were inappropriately starved with the average fasting period of 7-12 hours (Lorch, 2002).
One of the most common daily practices on a surgical ward involves the responsibility of the nurse in fasting patients before an anaesthetic for surgery. This routine practice came about after an incident when an obese patient vomited and died following anaesthetic with chloroform (Simpson, 1848). The justification for this practice is the serious and often fatal complication of aspiration of the stomach contents into the lungs, namely aspiration pneumonia or Mendelson’s syndrome (Mendelson, 1946). Following observation of animal studies, it became clear that the safe level of residual gastric volume or fluid remaining in the stomach was 25ml, with a pH value above 2.5 and food particles nogreater than 2mm (Roberts and Shirley, 1974). It was recognised that fluids and food have different emptying times from the stomach (Beaumont, 1883, cited by Green et al, 1996). A volume of 150ml of clear fluid disappears from the stomach within two hours (Maltby et al, 1993; Phillips, 1993). Depending on the type and quantity of the meal and the size of pieces when swallowed, food disappears from the stomach within six hours (Chapman, 1996; Maltby, 1993; Hung, 1992). Protein and carbohydrate are the quickest to leave the stomach, while fat and cellulose take the longest. Several studies highlighted that in the majority, there was a decrease in the volume of stomach contents and an increase in the pH following the ingestion of a volume of 150ml clear fluid, 2-3 hours before surgery (Maltby et al, 1988; Maltby et al, 1986).
The damaging effects of prolonged fasting can be divided into physiological and psychosocial factors (Hamilton-Smith, 1972):
- Electrolyte imbalance;
- Nausea and vomiting;
- Unpleasant experience;
- Irritability and resentment;
- Social isolation of missing meals.
These factors can occur more quickly in the young and elderly and be more hazardous. If dehydration is not detected early enough, the resulting imbalance of electrolytes will disrupt the equilibrium of the cardiovascular, nervous and renal systems (Iggulden, 1999). The early recognition of symptoms of tachycardia, hypotension, oliguria, confusion and decreased level of consciousness is essential (Goode et al, 1985). This will avoid the common occurrence of elderly patients being found unfit and ultimately having anaesthesia and surgery cancelled.
From this evidence, it is now a medical and legal requirement to starve patients in concurrence with the evidence for the preparation of anaesthesia (Hung, 1992). Shockingly, as early as 1883, surgeon Joseph Lister acknowledged the problem of unnecessary lengthy pre-operative fasting. Fluid deprivation for excessive periods is related to an increase in the volume of gastric fluid and lowering of pH. The stomach still secretes at least 50ml of fluid an hour during the fasting period (Hutchinson et al, 1988). Yet today, the same dilemma is taking place, where patient safety is compromised due to extensive fasting times (Jester and Williams, 1999; Green et al, 1996; Hung, 1992; Thomas, 1987).
Evidence has also demonstrated that some patients are at a higher risk than others: those with obesity, diabetes, pregnancy, peptic ulcer/gastric reflux, stress/pain, narcotics, difficult intubation, medication (bisphosphonates and steroids), alcohol and trauma (Phillips et al, 1993; Olsson et al, 1986).
The benefits of adhering to increased fluid intake pre-operatively include a marked reduction in the feeling of thirst at this time and therefore a decline in post-operative nausea and vomiting with a quicker likelihood of restarting a normal diet (Smith, 1972; Maltby et al, 1991). The administration of medication at prescribed times controls specific medical conditions such as hypertension and avoids cancellations because of this; the giving of analgesia when needed can prevent unnecessary discomfort (Pearse and Rajakulendran, 1999). The body is more able to cope during this experience, through a lower risk of surgical complications such as infection and blood loss, therefore ensuring a smoother road to recovery (Bird, 2000; Rowe, 2000).
Excessive periods of fasting may be caused by the lack of a fasting guideline or policy in an organisation, according to several nursing studies (Chapman, 1996; Hung, 1992; Thomas, 1987). National guidelines were introduced, emphasising the need for good practice based on evidence (Royal College of Nursing, 2005; American Society of Anaesthetists, 1999). This is the ‘two and six rule’ for adults and the ‘two, four and six rule’ for children recommendation in the UK, which says adults can ingest water up to two hours before anaesthesia and food and milk up to six hours before. For children the rule is water up to two hours, breast milk up to four hours and solids up to six hours before.
Studies on healthcare professionals’ knowledge and attitudes found that fasting times were lengthy due to staff being overcautious about lists changing. In reality, nursing staff exaggerated changes to scheduled lists, as in practice there were very few delays (Chapman, 1996). Water is a fundamental necessity for life and the withholding of fluid is exposing the patient to an act of inhumanity, a practice that is totally unacceptable (Cox, 2001).
Nurse as a change agent
The leader in her new role used skills developed through knowledge and experience to influence colleagues and patients to achieve specific objectives. To make this possible, a selection of various approaches and actions were necessary; these depended on the particular time and circumstances presented (Sullivan and Decker, 2001). In the past, concepts of leadership have concentrated on the characteristics of a person, the behaviour of the leader and the group and, later, the organisation’s environment (Clegg, 2000).
The style of leadership is influential during the process of change (Bennett, 2003). Limitations of the leader’s characteristics may result in difficulties with followers in the group (Jooste, 2004).
Within this particular environment of trauma and orthopaedics, responsibility involves collaboration with other key members: theatre staff, ward nurses, domestics, anaesthetists, orthopaedic surgeons and junior and senior medical staff. To enable a leadership style that is appropriate for these groups of professionals, the democratic approach was used. Having been an employee within the organisation for the past 14 years was thought to be a huge benefit. The majority of the staff in these departments had also completed many years of service, so were known to the author.
One of the characteristics of this style of leadership is guidance. This was considered an important factor, as some of the other key members would be involved in this process involving communication and decision-making.
There are advantages to being an insider. By being a familiar individual and identifying with the objectives, the politics, culture and language of the organisation, an individual has a better understanding of the norms (Sullivan and Decker, 2001). This does not necessarily mean the process is going to be straightforward. Restricted time and motivation did not allow the freedom to progress autonomously. To enable change to take place, there must be a clear strategy to allow the change process to begin. The change agent (the nurse) takes on the responsibility for changing the existing model of behaviour of the group within the organisation.
Adjusting to the role of a change agent requires many responsibilities which include: new knowledge, facilitation, nurturing and inspiration of staff, managing obstacles and ensuring a conducive environment (Gilley et al, 2001). Having foresight, being rational, mental alertness and good team-building skills are personal traits necessary for the distinctive demands of a change agent (Johnson and Scholes, 1999).
There are several different theories that describe the change process. Lewin’s force-field analysis was chosen, a change model developed by Kurt Lewin in 1951, illustrated by Sullivan and Decker (2001). Lewin, according to Burnes (2004) believed the necessary ingredients of planned change consisted of four elements:
- Field theory;
- Group dynamics;
- Action research; and
- Three-step model of change.
Before using Lewin’s three-step model, an understanding of the status quo is needed. Within this organisation, it was the tradition for routine patients on the same operation list to be fasted at the same time, irrespective of their position on the list. This procedure was performed for the convenience of ward and theatre management, rather than the well-being and interests of the patients. A lack of knowledge and expertise from nursing staff and poor patient understanding and compliance resulted in poor communication and no uniformity of practice.
This behaviour of individuals is a purpose of the ‘field’ or group, the first notion according to Burnes’ (2004) account of Lewin. He describes Lewin’s field theory as having a particular rate and pattern of behaviour, altering continuously to the forces and conditions affecting it.
The second notion of group dynamics is important in understanding how the participants of a group react when these forces or situations encroach upon the status quo. Burnes’ (2004) account of Lewin describes how change must be directed towards the group and not the individual.
Marquis and Huston (2003) state: ‘It is much easier to change a person’s behaviour than it is to change an entire group’s behaviour. It is also easier to change knowledge levels than attitudes.’
The data collated from the study was presented and evidence from the literature search was shared with the nurses, anaesthetic team and orthopaedic team during several meetings. The evidence was a surprise to the majority of staff.
The third notion of action research focuses on two issues. The first is that change necessitates action and the second focuses on choosing the most suitable answer, following an analysis of all the possible options. In this case, there seemed to be no other option. It was evident that change was necessary. This practice could no longer continue the way it was, with the discomfort of patients and continuing complaints and potential risks.
Goals are set for the process of change, which include training sessions for small groups of staff and individual instruction for those difficult to reach. Laminated fasting instructions for staff were strategically placed in the ward kitchens. The old ‘nil by mouth’ signs were removed from the ward storage cupboard and replaced with a box file with a copy of the guidelines and the new fasting signs.
There were initial concerns when the old familiar signs were first removed. These white signs with red print - some with chains and others with metal clips that did not fit the beds any more - had always been part of the ward fixtures. It was considered essential to keep a few of the original signs for patients who were fasted for other reasons. Examples included fasting in preparation for specific tests, or patients with swallowing difficulties or intestinal obstruction.
The basis of action research is to assist group members to understand the status quo and acquire a different perspective (Burnes, 2004). Lewin’s view is interpreted as the importance of changing behaviour, by allowing the group members to identify with the present situation and gaining knowledge from this notion of action research, more so than change itself.
The fourth idea is that the three-step model has to be used in conjunction with the other notions for change to be successful, according to Burnes’ account of Lewin. To enable change to take place, the change agent must progress through a three-step process of:
An assessment is made of the shift from the present situation or status quo to the proposed change. Lewin’s force-field model sees driving and restraining forces acting in conflicting directions within an organisation. An analysis of these behavioural forces is necessary to ensure there is a balance. To enable change to take place, the driving forces must outweigh the restraining forces. This approach is a reliable way for nurses to identify with human behaviour, especially with the notion of thawing and refreezing (Sullivan and Decker, 2001). The author could see this approach working in these circumstances.
The first stage of unfreezing involves being aware that a problem exists. The data collated from an audit of the pre-operative preparation of trauma patients indicated that patients were being starved for long periods of between seven and 12 hours before surgery. The study, which was prospective and involved 50 patients, was undertaken over a three-month period (Lorch, 2002). To help others realise that the current practice was in fact poor practice, it was essential to determine the forces that were supporting and resisting change.
The driving forces were:
- Evidence of best practice resulting in patient well-being;
- Knowledge and awareness by patient;
- Support of manager, team leader and consultant anaesthetist.
The restraining forces were:
- Resistance from theatre staff and a few orthopaedic consultants;
- Difficulty educating the night staff;
- The rapid turnover of domestic staff;
- Fear from SHOs and nursing staff of upsetting the orthopaedic surgeons’ routine;
- Lack of awareness by nursing staff of free space on morning elective orthopaedic list;
- Nil by mouth signs unclear.
The second stage of movement involves being aware of the forces occurring and looking at the best solutions available. The new arrangements for practice were implemented following individual group meetings with those who were involved in a practical way - the nursing staff and the domestics.
This proved to be more difficult than anticipated. Due to the high seasonal turnover of domestic staff, problems occurred with patients’ water jugs in the morning. They were either removed when fluids were permitted, or left in place when they should have been removed. It also became extremely difficult to communicate with the permanent night staff. This resulted in patients not being woken up for early breakfast, not being persuaded to have breakfast if they refused and not sat up and assisted with feeding if they were unable to feed themselves. Ultimately, when the trauma round took place, many patients had been fasted incorrectly, some with their breakfast uneaten on their bedside table. This became frustrating for the author as it was occurring on a regular basis and resulted in some of the consultants becoming very disgruntled.
This stage of the process became long and arduous, with much time spent trouble-shooting the problems. There was also a need to contend with the irritability of some of the consultants when confronted with these events. During the morning trauma round, one consultant argued the guidelines were not effective and should be discontinued; theatre staff insisted at the beginning that all patients should be starved and prepared at the same time, in case the list order was changed.
During this movement phase, time was spent working closely with the manager, team leader and consultant anaesthetist. From these discussions it was decided that there would be a choice of three fasting times that must be adhered to by all. The choice would be dependent on whether the patient was young or old, whether a procedure was major or minor and when the procedure was likely to be performed (morning or afternoon). It was also decided that two small cases of fit individuals could be fasted for morning surgery, in case there was a change to the list. This was not ideal.
The third and final stage of re-freezing is the new stability or equilibrium of the group, a change of organisational culture, norms and policies.The reinforcement of this new behaviour was by continual encouragement.
It became clear that new fasting signs were essential to replace the existing non-informative signs, following discussion with the anaesthetists. Tailor-made signs were designed, which excluded the words ‘nil by mouth’, instead using ‘oral intake instructions’. It was believed nurses and domestics did not read the rest of the sign as it was clear the patient was nil by mouth. A trial was undertaken to explore staff views on the signs and their implementation. Feedback via a questionnaire was good. Now it was hoped the trust would sanction the signs and hopefully incorporate their use for elective orthopaedic patients.
Change agent strategies
The rational-empirical strategy was used here, particularly when it was thought there would be minimal opposition to the change. This is because this strategy involves defending the change, with evidence from the research available. It was clear that some staff were unaware of why the ritual of prolonged starvation occurred.
Unfortunately, the power-coercive strategy must be used when individuals do not want to change because that is the way it has always been. There will always be some who do not want to change (Marquis and Huston, 2003). This is particularly relevant with some orthopaedic consultants. Traditionally and even now, there is still gender inequality between the professions of nurses and doctors, and nurses have been intimidated by power struggles. There were some disagreements, such as instances when a patient was cancelled as unfit during the morning orthopaedic elective list but a trauma patient had not been fasted instead; the space was offered to the surgeon doing the trauma list but the inability to fill the slot caused unnecessary disruption and the surgeon was frustrated about changes to the routine.
The use of Lewin’s planned approach to change is relevant in this situation. There are many models available, but few are suitable to nursing. This process of change continues indefinitely, with modifications, until the necessary results are achieved. The action research notion is useful for its realistic and bottom-up approach, where change is necessary for improved practice and not for the sake of change. There is still progress to make but much has been achieved during this time.
This change process through leadership has benefited patients by:
1.Improved knowledge and understanding by staff and patient
An explanation is given to staff and patients to aid compliance. Regular educational updates are given to new nursing and medical staff and all patients on admission.
2.Patient comfort and safety
This minimises the risk of fatal complications and there are fewer physical and psychosocial effects. Changing the signs to read ‘oral intake instructions’ instead of ‘nil by mouth’ means that nurses and domestics now do not avoid replenishing jugs of water to patients early each morning.
3.Uniformity of practice
The use of tailor-made, colour-coded laminated signs ensures standards are achieved. These are combined with the same colour-coded laminated cards, but with a larger version in the notes trolley, that state theatre morning/afternoon list. There is no excuse for fasting patients inappropriately as there are three times for doctors to choose from.
The use of the colour-coded signs positioned above the bed ensures the patient and staff know which list the patient is scheduled on and what time they have been fasted from. It avoids repeating the question ‘When did you last eat?’ to the patient. The guidelines and signs are kept in a box file for ease of access. The tailor-made, colour co-ordinated oral intake signs have returned from the printers following management approval. They now have trust ownership with a more professional appearance and magnetic fixing to avoid displacement. The guidelines are available on the trust intranet site for reference. This results in better communications with the theatre and anaesthetic staff, with the author acting as a link with the ward staff.
5.Avoiding missed medication
Clear instructions are given in the guidelines that all prescribed medication must be given the morning of surgery and during the fasting period, except oral hypoglycaemics. Any doubts must be checked with the anaesthetist. This avoids the omission of drugs, such as steroids and anti hypertensives, which may result in the cancellation of the patient’s surgery.
Evaluation of process
2002 - Audit on the documentation and pre-operative preparation of trauma patients;
2003 - Guidelines devised, disseminated and implemented with teaching programme;
2003-2004 - Troubleshooting problems;
2004 - Colour-coded signs/signs for notes trolley;
2005 - Revised guidelines to include orthopaedic elective patients and children; trial of the new signs and their implementation;
2006 - Authorisation by trust for printed signs with magnetic backing; plan to implement trust wide (two sites).
Attempts were made to implement the guidelines on the elective orthopaedic ward in the partner hospital, 24 miles away. This failed due to traditional practices of fasting all patients from the same time on an all-day list. Efforts were also made to address the issue through consultation in anaesthetic meetings with those involved with anaesthetising patients only. The author was advised not to get involved at this stage. The problem was not resolved and therefore identified and discussed at a clinical quality improvement meeting.
It was agreed to compare and align with the national RCN published guidelines that had just been published, and reissue the guidelines to the committee in an attempt to implement it trust wide for all surgical wards. Once this had been implemented with an educational programme, compliance across the trust on both sites would be monitored. Individualised fasting instructions tailored by the anaesthetist are not common practice as yet in this trust. Perhaps in the near future there will be more confidence to implement new ideas.
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