NURS 225 Week 5 Evidence-Based Practice Project Part 2 Example

Gum Chewing After Abdominal Surgery: Iowa Model Decision, Pilot Plan and Five Additional Annotated Sources

The Question and What We Found

Our PICO asks whether adults after elective abdominal surgery who chew sugar-free gum three times daily from the day of surgery recover bowel function sooner and go home earlier than those receiving usual care. In Part 1, five systematic and umbrella reviews published in 2024 and 2025 found that gum shortened time to first flatus by several hours and time to first stool by many more, across colorectal, general, gynecologic and cesarean surgery, while noting wide variation among trials.

Is the Evidence Sufficient?

The Iowa Model directs the team to decide whether there is sufficient evidence before designing a change (Iowa Model Collaborative, 2017). Our answer is yes, for three reasons. First, the evidence is consistent: every review we found points in the same direction. Second, it is drawn from many randomized trials across several surgical populations, the strongest design for testing an intervention, as Boswell and Cannon (2017) explain. Third, the intervention is low in risk and cost, so the balance of benefit and harm favors trying it. We also note two cautions. Effect sizes vary widely, and in one gynecologic meta-analysis gum shortened time to flatus but not time to first stool or length of stay (Tuscharoenporn et al., 2024). Our pilot therefore treats length of stay as a secondary outcome and does not promise it.

Pilot Design

The pilot will run for twelve weeks on one surgical unit. Eligible patients are adults after elective abdominal surgery without contraindications such as a jaw problem, dentures that make chewing difficult or a surgeon's order against it. Nurses will offer sugar-free gum for 15 minutes three times daily beginning when the patient is awake and alert after surgery, and will document each session. Following the example of shared governance projects, the unit practice council will lead the pilot, with the surgeons' agreement obtained in advance (Atwood et al., 2026).

Evaluation and Next Step

At twelve weeks, the group will compare pilot outcomes with baseline and review fidelity. If fidelity is above 80% and time to flatus or stool has improved, the council will recommend adoption across surgical units. If fidelity is low, the team will address barriers before judging effectiveness, since a protocol that is not delivered cannot be expected to work (Jerez González et al., 2026). A pilot is the place to learn whether good evidence survives contact with a real unit.

Annotated Bibliography

Atwood, B., Romito, K., Garcia, J., Bernaola, M., & Kessinger, S. (2026). The impact of shared governance: Implementing preoperative warming to improve postanesthesia outcomes among gynecological patients. Journal of PeriAnesthesia Nursing. Advance online publication. https://doi.org/10.1016/j.jopan.2026.08.009

Atwood et al. (2026) report a council-led practice change on a perianesthesia unit, structured by the Iowa Model, that made a fixed period of forced-air warming before surgery routine for women having planned gynecologic operations. Compared with a historical group of 19 patients, the 30 patients in the post-implementation group had an average stay in the recovery unit about 12 minutes shorter, though temperature, pain medication doses, shivering and comfort did not differ meaningfully. The small samples and historical comparison limit causal claims, a common feature of practice projects. Its value for our group is as a model: it shows a shared governance council using the Iowa Model in a perioperative setting, defining outcomes and comparing before and after data. We will borrow its structure for our pilot, including leadership by the unit council and a before-and-after comparison, while using a concurrent rather than historical measure of fidelity.

Bourazani, M., Maglari, C., Anagnostopoulos, A., & Fyrfiris, N. (2026). Implementation of enhanced recovery after surgery pathways in gynecologic oncology: Multidisciplinary coordination, nursing roles, and practical challenges. Cureus, 18(8), e115198. https://doi.org/10.7759/cureus.115198

This narrative review by Bourazani et al. (2026) examines how enhanced recovery pathways are put into practice in gynecologic oncology. It concludes that formally adopting a pathway does not ensure that its components are delivered, that higher adherence is linked to better outcomes and that nurses hold a central role through education, symptom assessment, mobilization, nutrition and recovery monitoring. As a narrative review, it does not pool data or use a systematic search, so it supports reasoning rather than effect estimates. For our project, it explains why gum chewing should be presented as one element of a recovery pathway, delivered and documented by nurses, rather than a stand-alone order that may be forgotten. We will use it to justify nurse ownership of the protocol and the need to define who offers gum, when and how it is recorded, and to plan the patient education handout that will accompany the pilot.

Jerez González, J. A., Hidalgo-Blanco, M. Á., Puig Llobet, M., Adamuz, J., Juvé-Udina, M. E., Polushkina-Merchanskaya, O., Miguel-Huguet, B., Mariscal Cabeza, M., & Moreno Arroyo, C. (2026). ERAS implementation fidelity, care complexity, and postoperative outcomes in oncological colorectal surgery: A real-world observational study. Healthcare, 14(11), 1519. https://doi.org/10.3390/healthcare14111519

Jerez González et al. (2026) reviewed 90 adults having elective colorectal cancer surgery at two university hospitals and measured how closely enhanced recovery protocols were followed. Overall adherence was 64%, lower after surgery than before it, and higher adherence was associated with a shorter median stay of 4 versus 5 days and better compliance with expected length of stay. Patient care complexity was high but was not associated with adherence. The retrospective design and small sample limit conclusions, and association does not prove that adherence caused shorter stays. Still, the finding that postoperative elements are the most often missed applies directly to gum chewing, which is a postoperative nursing action. We will use this study to justify measuring fidelity during our pilot and to set our target of documenting at least 80% of eligible gum sessions before judging effectiveness.

Saltzman, B., Fayram, L., Houston, M., & Laures, E. (2026). Reducing pressure injuries due to noninvasive ventilation masks in the pediatric intensive care unit: An interprofessional approach. Critical Care Nurse, 46(3), 57-64. https://doi.org/10.4037/ccn2026322

Saltzman et al. (2026) report an evidence-based practice project in a pediatric intensive care unit, where 66% of stage 2 or greater device-related pressure injuries in 2021 were facial injuries from noninvasive ventilation masks. Using the revised Iowa Model and interprofessional collaboration, the team built a unit-specific prevention bundle and collected process data on staff knowledge, attitudes and behaviors as well as outcome data; mask-related injuries fell from 6 in 2021 to 0 in 2022 after implementation. Because there was no comparison unit, other changes during the same period may explain part of the drop, and the patients were children rather than surgical adults. Its relevance is methodological: it shows how measuring staff knowledge and behavior alongside patient outcomes explains why a change works. We will add a short staff survey before and after education in our pilot, following this model, to learn whether nurses understand and accept the gum protocol.

Tuscharoenporn, T., Uruwankul, K., & Charoenkwan, K. (2024). Effects of postoperative gum chewing on recovery of gastrointestinal function following laparoscopic gynecologic surgery: Systematic review and meta-analysis of prospective studies. Journal of Clinical Medicine, 13(10), 2851. https://doi.org/10.3390/jcm13102851

Tuscharoenporn et al. (2024) combined nine prospective trials, just over a thousand women in all, recovering from keyhole gynecologic operations. Chewing brought bowel sounds back roughly two and a half hours earlier and gas about four hours earlier, yet the first stool, ileus rates, getting out of bed and days in hospital were statistically unchanged. Only a third of the included trials earned a low risk-of-bias rating, and the authors tempered their conclusions accordingly. The review is narrower than those in Part 1 and limited to minimally invasive surgery, where ileus is already shorter. For our group, it is an important counterweight: it shows that benefits may be smaller after laparoscopic procedures and may not shorten hospital stays. We will use it to set realistic expectations, to analyze laparoscopic and open procedures separately in the pilot and to keep length of stay a secondary outcome.

Looking Ahead

Part 3 will present the funding needed for gum, education time and data collection, identify the stakeholders who must approve the change and plan how to share results with the surgical services and the hospital's nursing research council.