NR 439 Week 1 Sources of Nursing Knowledge Post Example

Week 1 Discussion: Sources of Nursing Knowledge

NPO After Midnight: A Routine I Followed Without Asking Why

On the surgical floor where I worked nights for three years, every patient scheduled for a morning procedure got the same order set and the same sign on the door: NPO after midnight. At 2330 I would walk the hall with a pitcher cart, offer the last cup of water, and then take the pitchers away. A 78-year-old woman booked as the third case of the day, which in practice meant early afternoon, would go from 2400 until roughly 1400 with nothing to drink. I enforced that without once asking where the rule came from.

Using the categories from this week's reading, the basis for that practice was tradition first and authority second. Tradition, because the midnight cutoff was simply how the unit ran; nobody on staff could tell me when it started. Authority, because the order set was signed by the surgical service and the charge nurse checked that pitchers were gone at shift change. What it did not rest on was research. Polit and Beck (2021) describe tradition as knowledge accepted because it has always been accepted, and authority as knowledge accepted because of who holds it, and both describe my pitcher cart better than evidence does.

I want to separate one thing carefully, because it is the part I would have argued with a year ago. I believed the rule was clinical judgment, since experienced nurses defended it and aspiration during anesthesia is a real and serious harm. But judgment would have asked whether the length of the fast matched the risk. A single cutoff applied to a 0730 case and a 1400 case is not judgment; it is habit borrowed from judgment. When I finally read the practice guideline from the American Society of Anesthesiologists (2017), it recommended a minimum fast of two hours for clear liquids and six hours for a light meal in healthy patients having elective procedures. The midnight rule was stricter than the evidence by many hours, and for my afternoon patients it produced thirst, headache and, for at least one frail patient, orthostatic dizziness the first time she stood after surgery.

The question the practice raises is testable. In adults having elective surgery, does allowing clear liquids up to two hours before the scheduled procedure, compared with NPO after midnight, change the rate of aspiration events and the patient's reported thirst and hunger before induction? That can be answered by comparing outcomes before and after a policy change, or better by a trial, and the guideline suggests it largely has been. Melnyk and Fineout-Overholt (2023) note that the gap between available evidence and daily practice is often measured in years, and this seems to be a clean example of that gap sitting on my old unit.

Here is what I would like classmates to push on. If the evidence has allowed clear liquids closer to surgery for years, why do so many units still use a midnight cutoff? My guess is that it protects the operating room schedule, since a case that moves earlier is never delayed by a patient who drank at 0600. If that is the real reason, is it still a nursing tradition, or is it a scheduling policy that nurses enforce? Has anyone worked on a unit that changed this, and what had to happen before it did?

References

American Society of Anesthesiologists. (2017). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. Anesthesiology, 126(3), 376-393. https://doi.org/10.1097/ALN.0000000000001452

Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-based practice in nursing and healthcare: A guide to best practice (5th ed.). Wolters Kluwer.

Polit, D. F., & Beck, C. T. (2021). Nursing research: Generating and assessing evidence for nursing practice (11th ed.). Wolters Kluwer.