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Ritualistic care can make patients feel less valued than their dogs

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A few weeks ago a discussion on Twitter began with a plea from a frustrated anaesthetist.

“Stop telling people that it is nil by mouth from midnight […] six hours for food and two hours for clear fluids (a shorter time for clear fluids at some places). Stop excessively starving and dehydrating patients” (Natalie Silvey: @silv24).

The need to review pre-operative starving times has been discussed for decades. In 1972 a nursing research study – Nil by Mouth? – questioned the practice of starving patients from midnight and looked at complex reasons for the practice. These included issues around unpredictability in theatre schedules, lack of communications between teams and the role of ritual and routine.

There have been reams written about pre-op starving since the 1970s, and it is worrying that the ritual of starving from midnight continues to be followed in some areas despite the weight of evidence against it.

And ritualistic care is also seen in other areas of nursing.

This was highlighted to me a few weeks ago when I was looking at the evidence base for intramuscular injection (IM). I was surprised that a commonly used manual on nursing procedures recommended that gloves and disposable apron be worn for the procedure.

“Clear, evidence-based guidance on when gloves should be worn has been available for years”

Somewhat puzzled by this suggestion, I took to Twitter and several experts pointed to the evidence that gloves are not routinely required.

Clear, evidence-based guidance on when gloves should be worn has been available for years, yet infection prevention nurses suggest that guidelines are frequently not followed in practice and gloves are overused.

The reasons for overuse of gloves are complex but the practice may actually increase risks of infection – and wearing gloves unnecessarily can have a negative effect on patients. This was vividly illustrated in a blog on the Nursing Times website by the late Tony Nicklinson, who was paralysed after a stroke and campaigned for the right to assisted dying.

He described how “carers would pet my dog but they wouldn’t touch me without gloves”. This is stark reminder of why thoughtless ritualistic care has to be challenged.

When I was first introduced to the idea of evidence-based practice in the 1980s, I believed it would put an end to the routines and ritual described above, but I over the years I have noticed that as established rituals disappear, new ones are invented – glove use is an example. These rituals quickly become ingrained in routine clinical practice and are difficult to challenge.

The Nil by Mouth? research paper opens with a wonderful quote from 13th-century philosopher Roger Bacon, who noted that force of habit was “one of the four grounds for ignorance and one of the four great obstacles to learning”.

“Nursing claims to be an evidence-based profession, but sometimes it fails to live up to this claim”

Nursing claims to be an evidence-based profession, but sometimes it fails to live up to this claim. It is vital that we continually seek out the latest evidence and use it to question and challenge our own practice and that of our colleagues to ensure patients receive safe and effective care. Adherence to ritual and routine – we have always done it that way – is not an excuse for poor care.

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Readers' comments (1)

  • I find it interesting that the person who complains about excessively starving patients pre op is the one with the power to change it. So I'd throw back to the aneasthetist and ask how many times they had written in the medical chart when to start witholding food and water pre op. I guess it's easier to tweet about nurses than to be proactive in changing existing cultures.

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