Management of Gastrointestinal Function in Patients After Laparoscopic Surgery for Benign Gynaecological Diseases: A Best Practice Implementation Project.

Li Ning assisted in conceiving and designing the study. Mengdan Zhou designed the study and wrote the main manuscript text, Shuixian Zhang performed the data collection and analysis, Aiping Fu provided help and support for the entire project from the policy and read and approved the submitted version.

The study was approved by the Ethical Committee of Hangzhou First People's Hospital and was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

This study was funded by the Zhejiang Medical Health Science and Technology Project (Grant No. 2023KY922).

In the baseline audit, we included 45 patients and 15 nurses who were informed about the study and consented to participate in the study group, with the same number of candidates involved in the follow‐up audit. Patients were included from the study for the following criteria: (i) age ≥ 18 years old, (ii) the type of disease was gynaecological benign disease, (iii) voluntarily participated in this study, signed informed consent, and could cooperate with the treatment; (iv) ASA (American Society of Anesthesiologists) grading standards ASA I or II, no history of chronic diseases known to affect gastrointestinal motility (e.g., diabetes mellitus, thyroid dysfunction) or other major systemic illnesses and a history of inflammatory bowel disease, a history of bowel surgery, current diarrhoea, symptoms or signs of gastrointestinal obstruction and abdominal pain with unknown cause. ASA classification is typically determined by the anesthesiologist after reviewing the patient's medical history, performing a physical examination, and assessing the patient's overall condition on the day before surgery or before entering the operating room on the day of surgery. Throughout the study period, the surgical team, anesthesiologists and ward nursing staff responsible for patient care remained unchanged. All patients in both groups underwent surgery using a standardised laparoscopic technical pathway; intraoperative CO 2 pneumoperitoneum pressure was set and maintained within the same range; a unified multimodal analgesia protocol was administered postoperatively; and identical basic nursing care protocols—including dietary management and catheter care—were implemented. This evidence implementation project applied Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) audit and feedback tools. This project can be divided into three parts, including audit‐feedback‐re‐audit. It took a total of 4 months, from 1 September 2023 to 31 December 2023. This project can be separated into three consecutive phases under the lead of the PACES and GRiP frameworks. Prepare for the baseline audit: Establish a multidisciplinary team for the project, integrate the best evidence and conduct a baseline review based on the evidence. Implement best practice: Reflects on the outcomes of the baseline audit and promotes strategies to address non‐compliance with any criteria found in the baseline audit, informed by the JBI GRiP framework. Conduct a follow‐up audit of postimplementation change strategies: Evaluate the results and outcomes of the strategies implemented and identify future practice issues to address in the following best practice implementation. Prepare for the baseline audit: Establish a multidisciplinary team for the project, integrate the best evidence and conduct a baseline review based on the evidence. Implement best practice: Reflects on the outcomes of the baseline audit and promotes strategies to address non‐compliance with any criteria found in the baseline audit, informed by the JBI GRiP framework. Conduct a follow‐up audit of postimplementation change strategies: Evaluate the results and outcomes of the strategies implemented and identify future practice issues to address in the following best practice implementation. This study was reviewed and approved by the hospital's ethics committee (KY‐20230418‐0073‐01). In the transformation of the applied research, all patients who participated in the study signed an informed consent form. The researchers strictly kept the patients' information confidential. During on‐the‐spot observation, the process of observation, the method of collecting data and the rights and interests of the observed are explained to the observed so that they have the power to decide whether to participate. The name of the study is not presented in the research process, such as the code used to represent argumentation experts at the expert meeting. Establishing an evidence‐based practice team, comprising one director of the nursing department, who is a chief nursing officer with a doctoral degree, serves as the project leader responsible for project quality control and progress advancement. The team also includes one gynaecologist, who is an associate chief physician with a doctoral degree and oversees clinical observations and project guidance. Additionally, one head nurse, who is an associate chief nurse with a bachelor's degree, is responsible for quality supervision and project guidance. Another team member is a specialised gynaecological nurse with a bachelor's degree in charge of project guidance. Two evidence‐based practice experts, both associate chief nurses with graduate degrees, are responsible for project guidance and quality monitoring. Finally, a graduate student nurse was assigned the role of handling clinical data collection and other related tasks. Our project began with a structured search of the literature on the management of postoperative gastrointestinal function in patients undergoing laparoscopic surgery for benign gynaecological diseases. The research involved structured retrieval, extraction and summarisation of evidence by the project team. Through iterative discussions and revisions among team members, a final set of 20 best‐evidence statements was developed, encompassing preoperative preparation, intraoperative measures and postoperative care. The detailed process is documented in a previous study (Zhou et al.  2023 ). Subsequently, an expert meeting was convened to validate the evidence based on the FAME (Feasibility, Appropriateness, Meaningfulness and Effectiveness) framework. The meeting invited experts from the medical, nursing, nursing management and evidence‐based practice domains with a high expert authority coefficient of 0.93, ensuring the reliability of the expert consensus. Based on expert opinions, 16 evidence statements were identified for clinical transformation. Following the experts' opinions and group discussions, 27 audit criteria were formulated, specifying audit methods and targets. The above evidence and recommendations were then utilised to develop an audit standard list within the JBI PACES software program. Table  1 presents the evidence‐based audit standards used in the project (both baseline and follow‐up audits), along with descriptions of the samples and methods employed to measure compliance with each audit standard, aligning with best practices. Audit criteria, sample and method employed to measure compliance with the best practice. Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients ‘Yes’ if he/she was able to abstain from dairy products and starchy solid foods 6 h before surgery ‘No’ if he/she was unable to do so Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients ‘Yes’ if he/she was able to abstain from fried, fatty and meaty foods for 8 h before surgery ‘No’ if he/she was unable to do so Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients ‘Yes’ if he/she was able to fast from clear liquids 2 h before surgery ‘No’ if he/she was unable to do so Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients ‘Yes’ if he/she drank one bottle of ShuNeng 4 h before surgery ‘No’ if he/she did not comply Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she completed walking 1500 m within 30 min on the night before surgery ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients ‘Yes’ if he/she chewed 1 piece of chewing gum 30–60 min before surgery for 30 min ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients ‘Yes’ if he/she spit out the gum before entering the operating room ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients ‘Yes’ if he/she had been supplemented 1 to 2 L of balanced salt solution during surgery ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from anesthesiologists ‘Yes’ if he/she had been used the lung recruitment method to promote the discharge of trapped CO 2 gas after the operation ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she drank 10–15/h of warm water if they have no nausea or vomiting after returning to the ward ‘No’ if he/she did not meet the requirements Baseline: 45patients Follow‐up: 45 patients ‘Yes’ if he/she had a doctor's order of take a liquid diet 6 h after surgery ‘No’ if he/she did not meet the requirements Baseline: 45patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she took a liquid diet 6 h after surgery ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she he or she adopts a supine position or a semi‐recumbent position with the head of the bed raised according to the patient's condition and actual situation after the patient returns to the ward ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she was guided bed activities by nurses after they returned to the ward ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she took the knee‐chest decubitus position 6 h after surgery and maintain it for 4 to 5 min ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she was able to get out of bed and move for 1 h on the first day after surgery ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she was able to get out of bed for 4 h a day from the second day after surgery to the time of discharge ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients ‘Yes’ if he/she was prescribed multimodal analgesia after surgery ‘No’ if he/she did not meet the requirements Baseline: 15 nurses Follow‐up: 15 nurses ‘Yes’ if he/she can correctly tell the location, time and frequency of acupoint massage ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she began receiving acupressure therapy 6 h after surgery, selecting Zusanli, Neiguan, Zhongshu and Sanyinjiao, three times a day, 1 to 2 min each time, until the anal exhaust ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she was able to chew gum once in the morning and afternoon on the first day after surgery, for 30 min each time, until anal exhaust ‘No’ if he/she did not meet the requirements Baseline: 15 nurses Follow‐up: 15 nurses Field observation Feedback from patients Nurse records ‘Yes’ if he/she had closely observed the patient's chewing gum and the changes in his condition when patrolling the ward, and record them ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients ‘Yes’ if he/she can accurately say that chewing gum should be avoided when coughing or lying down ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she had no accidents such as swallowing and aspiration during chewing gum ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she could drink a 150 mL cup of caffeinated coffee 6 h after surgery ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she could drink a 150 mL cup of caffeinated coffee 18 h after surgery ‘No’ if he/she did not meet the requirements Baseline: 45 patients Follow‐up: 45 patients Field observation Feedback from patients Nurse records ‘Yes’ if he/she could drink a 150 mL cup of caffeinated coffee 24 h after surgery ‘No’ if he/she did not meet the requirements The baseline audit was conducted from 1 September to 31 September 2023. Following discussions on audit standards and data collection methods during an expert meeting, the project team members conducted a baseline audit using the JBI PACES. All data were collected by nurses through questionnaire surveys, nursing records and feedback from the patients and their families. After the auditing process was completed, compliance rates for all criteria were documented and the project team discussed the audit results. Our project team evaluated the results of compliance with best practice after the baseline audit was completed in September 2023 to identify current gaps in our practice with the GRiP module (Joanna  2011 ). This phase was completed between October and November 2023. We can see that there are gaps between evidence and practice in Phase 1. The project team held three discussion sessions with departments of medicine, nursing and anaesthesia to reach the final consensus for change strategies. In the sessions, we hope to garner support for the project, listen to specific experiences and identify any potential barriers to implementing the best practice. Finally, we identified barriers to implementation for each criterion and developed strategies to overcome these barriers based on the available resources. The staff received feedback via unit meetings and education sessions at regular intervals throughout the implementation phase to facilitate compliance. The same evidence‐based audit criteria were used as in the baseline audit in the follow‐up audit. The postimplementation audit was carried out from 1 December to 31 December 2023, with the same number of patients during the baseline audit period, and data collection was performed by the same two teams as in the baseline audit. According to the literature (Zhuang et al.  2014 ), subjective, objective and laboratory indicators can be used to evaluate postoperative gastrointestinal function. The subjective indicators included the incidence of postoperative abdominal distension, nausea and vomiting. Objective indicators included the time to the first postoperative anal exhaust, time to the first postoperative defecation and bowel sound recovery time. Laboratory indicators include gastrointestinal hormones such as motilin and gastrin. Due to limitations in research time and funding, the research team decided, after discussion, to use a combination of subjective and objective indicators for evaluation. The selected subjective indicator was the degree of abdominal distension at 24 h postoperatively, while the chosen objective indicators were the time to first postoperative anal exhaust and the time to first postoperative defecation. With reference to the Guidelines for Clinical Research of New Traditional Chinese Medicine, the symptom grading scale for ‘fullness syndrome’ was used to classify abdominal distension into four levels. No abdominal distension: The patient reported no noticeable sensation of bloating. – Mild abdominal distension: The patient complained of slight bloating, with a subjective feeling of gas movement in the abdomen and mildly increased abdominal wall tension, but it did not affect normal rest or sleep – Moderate abdominal distension: The abdomen appears distended, and the patient reports incision‐related bloating pain that is tolerable. Abdominal wall tension was significantly increased, interfering with normal rest and sleep. – Severe abdominal distension: The abdomen is visibly distended, with intense incision‐related bloating pain that is difficult to endure. Abdominal wall tension markedly increases, rendering the patient unable to rest or sleep. Mild abdominal distension: The patient complained of slight bloating, with a subjective feeling of gas movement in the abdomen and mildly increased abdominal wall tension, but it did not affect normal rest or sleep Moderate abdominal distension: The abdomen appears distended, and the patient reports incision‐related bloating pain that is tolerable. Abdominal wall tension was significantly increased, interfering with normal rest and sleep. Severe abdominal distension: The abdomen is visibly distended, with intense incision‐related bloating pain that is difficult to endure. Abdominal wall tension markedly increases, rendering the patient unable to rest or sleep. The grading criteria were carefully explained to the patients, and their degree of abdominal distension at 24 h postoperatively was assessed and recorded. The time to the first postoperative anal exhaust (unit: h) was defined as the time interval between the patient's first postoperative flatus and the completion of surgery (patients and their family members were thoroughly instructed to monitor and report the timing of the first postoperative flatus). The time to the first postoperative defecation (unit: h) was defined as the time interval between the patient's first postoperative bowel movement and the completion of surgery (patients and their family members were thoroughly instructed to monitor and report the timing of the first postoperative defecation). Survey Tools Survey Tools The study utilised a self‐designed ‘Postoperative Data Collection Form for Laparoscopic Patients with Benign Gynecological Diseases’ (Appendix  I : Table  A1 ) and a customised checklist based on review criteria (Appendix  II : Table  A2 ). The main content of the ‘Postoperative Data Collection Form for Laparoscopic Patients with Benign Gynaecological Diseases’ includes the patient's general information (such as name, sex, age, height, weight, operation time, operation name, intraoperative haemorrhage, etc.) and outcome indicators (including the time of first postoperative anal exhaust, defecation time, etc.). The questionnaire for nurses to test their knowledge of promoting the recovery of gastrointestinal function demonstrated good psychometric properties, with a Content Validity Index of 0.96 and an overall Cronbach's alpha coefficient of 0.80. 2 Survey Methods Survey Methods Data collection was completed by two members of the evidence‐based team, both of whom underwent professional training and passed assessments before the review. During the review, the reviewers conducted participatory observations of patients/nurses in accordance with pre‐established review criteria and specific review methods to assess their compliance with the indicators. If the review criterion was met, a checkmark was placed in the corresponding column. The collected data were derived from patient medical records, bedside observations, inquiries, etc., and the investigation period spanned from admission to discharge. Among the review criteria, three items (C7–C9) were evaluated in the operating room. Therefore, the evidence‐based team specifically requested the assistance of operating room nurses for these reviews. Before the review, the reviewers received training including detailed explanations of the review methods to ensure their full understanding. Once eligible patients were identified, the reviewers were notified in advance and the empty review forms were brought into the operating room. The reviewers marked the forms based on actual observations and returned them along with the patients upon their transfer to the ward post‐surgery. 3 Data Analysis Data Analysis The data were aggregated to calculate compliance rates for each criterion, comparing current practices against best‐evidence benchmarks to identify gaps. Gaps between current practices and best evidence were analysed to identify areas for improvement. The main outcomes to measure the treatment results were as follows: the degree of abdominal distension 24 h after operation, the time of first flatus and the time of first defecation after operation. Statistical analysis was performed using SPSS 26.0 for Mac (Armonk, NY, USA). Statistical methods were selected based on the type and distribution characteristics of the data. Continuous variables with a normal distribution were described as the mean ± standard deviation and compared using the independent samples t ‐test. Continuous variables without a normal distribution were described as the median (interquartile range) and compared using the Wilcoxon rank‐sum test. For categorical variables, the Fisher's exact test was used for unordered variables, and the Wilcoxon rank‐sum test was used for ordinal variables.

Non‐diabetic patients without gastrointestinal dysfunction (such as gastric emptying disorder, gastrointestinal obstruction, gastroesophageal reflux or history of gastrointestinal surgery) should not eat dairy products and starchy solid foods 6 h before surgery. Non‐diabetic patients without gastrointestinal dysfunction (such as gastric emptying disorder, gastrointestinal obstruction, gastroesophageal reflux or history of gastrointestinal surgery) should not eat fried, fatty and meaty foods 8 h before surgery. Non‐diabetic patients without gastrointestinal dysfunction (such as gastric emptying disorder, gastrointestinal obstruction, gastroesophageal reflux or history of gastrointestinal surgery) should not eat clear liquids 2 h before surgery. Non‐diabetic patients without gastrointestinal dysfunction (such as gastric emptying disorder, gastrointestinal obstruction, gastroesophageal reflux or history of gastrointestinal surgery, etc.) should drink one bottle of ShuNeng (one kind of 12.5% carbohydrate drinks with a total volume of 355 mL) 4 h before surgery. The patient should walk 1500 m in 30 min under the supervision of a nurse the night before surgery. Patients should chew 1 piece of gum 30–60 min before surgery and chewed it for 30 min. Patient should spit out gum before entering the operating room. During the operation, the anaesthesiologist should add 1–2 L of balanced salt solution to the patient. After the surgery, the anaesthesiologist should use lung recruitment to promote the discharge of trapped CO 2 gas. After patients wake up from anaesthesia and return to the ward, they can drink 10–15 mL of warm water every hour until they resume eating if they have no nausea or vomiting. The doctor prescribed a liquid diet for 6 h after surgery. Patient can take a liquid diet 6 h after surgery. After patients return to the ward after surgery, they should take a supine or semi‐recumbent position with the head of the bed elevated according to the patient's condition and actual situation. After patient returns to the ward after surgery, the nurse should guide him bed activities. Patients who are conscious of stable vital signs and physical permission should take the knee‐chest decubitus position 6 h after the operation and maintain it for 4–5 min, and then alternate between the left and right decubitus positions. Patients should get out of bed and move around for 1 h on the first postoperative day. The patient should get out of bed for 4 h a day from the second day after surgery to the time of discharge. Doctor should prescribe postoperative multimodal analgesia. Nurses should have relevant knowledge and skills in acupoint massage to promote gastrointestinal function recovery. The nurse should select the patient's Zusanli, Neiguan, Zhongshu and Sanyinjiao acupoints for massage 6 h after the operation. Each acupoint is massaged thrice a day until the anus is exhausted. Patients who have no contraindications to chewing gum or who are unable to eat early should chew gum once in the morning and once in the afternoon starting from the first day after surgery, for 30 min each time, until the anus is exhausted. While chewing gum, the nurse should closely observe the patient's chewing gum and changes in his condition when patrolling the ward and recording them Patient did not chew gum while coughing or lying down. No accidents such as swallowing or aspiration occurred in patient while chewing gum. Patients who are able to accept coffee drinking after surgery should drink a 150 mL cup of caffeinated coffee 6 h after surgery and finish it within 20 min. Patients who are able to accept coffee drinking after surgery should drink a 150 mL cup of caffeinated coffee 12 h after surgery and finish it within 20 min. Patients who are able to accept coffee drinking after surgery should drink a 150 mL cup of caffeinated coffee 18 h after surgery and finish it within 20 min. Non‐diabetic patients without gastrointestinal dysfunction (such as gastric emptying disorder, gastrointestinal obstruction, gastroesophageal reflux or history of gastrointestinal surgery) should not eat dairy products and starchy solid foods 6 h before surgery. Non‐diabetic patients without gastrointestinal dysfunction (such as gastric emptying disorder, gastrointestinal obstruction, gastroesophageal reflux or history of gastrointestinal surgery) should not eat fried, fatty and meaty foods 8 h before surgery. Non‐diabetic patients without gastrointestinal dysfunction (such as gastric emptying disorder, gastrointestinal obstruction, gastroesophageal reflux or history of gastrointestinal surgery) should not eat clear liquids 2 h before surgery. Non‐diabetic patients without gastrointestinal dysfunction (such as gastric emptying disorder, gastrointestinal obstruction, gastroesophageal reflux or history of gastrointestinal surgery, etc.) should drink one bottle of ShuNeng (one kind of 12.5% carbohydrate drinks with a total volume of 355 mL) 4 h before surgery. The patient should walk 1500 m in 30 min under the supervision of a nurse the night before surgery. Patients should chew 1 piece of gum 30–60 min before surgery and chewed it for 30 min. Patient should spit out gum before entering the operating room. During the operation, the anaesthesiologist should add 1–2 L of balanced salt solution to the patient. After the surgery, the anaesthesiologist should use lung recruitment to promote the discharge of trapped CO 2 gas. After patients wake up from anaesthesia and return to the ward, they can drink 10–15 mL of warm water every hour until they resume eating if they have no nausea or vomiting. The doctor prescribed a liquid diet for 6 h after surgery. Patient can take a liquid diet 6 h after surgery. After patients return to the ward after surgery, they should take a supine or semi‐recumbent position with the head of the bed elevated according to the patient's condition and actual situation. After patient returns to the ward after surgery, the nurse should guide him bed activities. Patients who are conscious of stable vital signs and physical permission should take the knee‐chest decubitus position 6 h after the operation and maintain it for 4–5 min, and then alternate between the left and right decubitus positions. Patients should get out of bed and move around for 1 h on the first postoperative day. The patient should get out of bed for 4 h a day from the second day after surgery to the time of discharge. Doctor should prescribe postoperative multimodal analgesia. Nurses should have relevant knowledge and skills in acupoint massage to promote gastrointestinal function recovery. The nurse should select the patient's Zusanli, Neiguan, Zhongshu and Sanyinjiao acupoints for massage 6 h after the operation. Each acupoint is massaged thrice a day until the anus is exhausted. Patients who have no contraindications to chewing gum or who are unable to eat early should chew gum once in the morning and once in the afternoon starting from the first day after surgery, for 30 min each time, until the anus is exhausted. While chewing gum, the nurse should closely observe the patient's chewing gum and changes in his condition when patrolling the ward and recording them Patient did not chew gum while coughing or lying down. No accidents such as swallowing or aspiration occurred in patient while chewing gum. Patients who are able to accept coffee drinking after surgery should drink a 150 mL cup of caffeinated coffee 6 h after surgery and finish it within 20 min. Patients who are able to accept coffee drinking after surgery should drink a 150 mL cup of caffeinated coffee 12 h after surgery and finish it within 20 min. Patients who are able to accept coffee drinking after surgery should drink a 150 mL cup of caffeinated coffee 18 h after surgery and finish it within 20 min. The results of the baseline audit are presented in bar graphs in Figure  1 . According to the baseline cycle in Figure  1 , among the 27 review indicators, there were 16 indicators with a clinical compliance rate < 50%. Among them, the implementation rate of indicators 5, 6, 7, 10, 15, 19–27 was 0, the implementation rate of indicator 16 was 35.5% and the implementation rate of indicator 17 was 19.4%. It can be seen that in terms of postoperative gastrointestinal function management, compared with the best evidence, the clinical practice status of the pilot ward is not good, and measures need to be taken to improve it. Compliance (%) with best practice for audit criteria in follow‐up audit compared with baseline audit for management of gastrointestinal function in patients after laparoscopic surgery for benign gynaecological diseases. Compliance (%) = (Number of audit criteria met)/(Total number of cases audited during the same period) × 100%. During phase 2, we identified three barriers to compliance with best practices and produced strategies to address these barriers, as summarised in Table  2 . Getting research into the practice matrix. Nurses lack the knowledge to promote postoperative gastrointestinal function recovery and are unable to guide patients on how to promote gastrointestinal function activities. During the baseline audit, questionnaires were distributed to nurses to test their knowledge of promoting the recovery of gastrointestinal function (Appendix  III ). The project team designed training courses on how to promote the recovery of laparoscopic surgery in patients with gastrointestinal function of benign gynaecological diseases(Appendix  IV : Table  A3 ), including the best practice of gastrointestinal function management in patients with benign gynaecological diseases, management of gastrointestinal function management in patients with benign gynaecological diseases and the training of related knowledge and technology of acupoint massage (Appendix  V , Figure  A1 in Appendix  VI ). The project leader and TCM experts were invited to give lectures to ward nurses, who were tested again with a knowledge questionnaire. For the newly introduced acupoint massage technology, nurses were given a theoretical and operational assessment to ensure that everyone obtained it. Project team members developed the education plan, and the head nurse efficiently organised the training courses. All nurses were trained in the system of promoting gastrointestinal function recovery and completed theoretical testing. In the questionnaire test, the average score (98.32 ± 3.01) for the recovery of gynaecological benign laparoscopic disease, which was statistically significant compared with the average score (60.67 ± 10.56) ( t  = −12.771, p  < 0.01) before. All the nurses have mastered the acupressure skills and have passed the theoretical and operational assessment. The department lacks information on the standardised process and health education materials for the relevant measures to promote the recovery of postoperative gastrointestinal function. According to the content of the best evidence and the characteristics of the testing ward, the project team developed a standardised process of relevant measures to promote the recovery of postoperative gastrointestinal function (Appendix  VII : Figure  A2 ). This process starts from the patient's admission to the patient's discharge and runs through the entire preoperative, intraoperative and postoperative hospitalisation process, which perfectly fits the best evidence. The project team also produced some educational material (Figure  A3 in Appendix  VIII , Appendix  IX ), including the performance and harm of postoperative gastrointestinal dysfunction, measures to promote postoperative gastrointestinal dysfunction in the perioperative period, which embodied the nursing plan from preoperative to postoperative, so that patients and their caregivers can be clear at a glance. Resources included a standardised process of relevant measures to promote the recovery of postoperative gastrointestinal function and relevant health education materials. Nurses were able to perform a standardised gastrointestinal function management of patients according to a standardised process. The compliance rate of audit criterion 5, 6, 7, 10, 15, 19–27 has increased. Criterion 6, 7, 19, 22, 23, 24 reached 100%, and criterion 5, 10, 15, 16, 17, 20, 21, 25, 26 and 27 were 93.56%, 90.89%, 6.67%, 87.89%, 70.56%, 86.40%, 88.89%, 60.67%, 70.89% and 78.60%, respectively. Health education materials are placed in the preparation room to receive new patients and the health education column in the ward corridor to meet the needs of patients and their caregivers to read at any time, which improves their degree of participation and the awareness rate of the relevant knowledge. Nurses have a large workload and pay little attention to promoting postoperative gastrointestinal function recovery. The preliminary investigation found that a large number of operations and fast patient turnover are major features of the ward, and the record of nursing documents cost nurses time to care for patients to a certain extent. How to make nursing measures and health education implemented in practice rather than in form, after discussion, the project team designed the record sheet of nursing measures to promote the recovery of gastrointestinal function in laparoscopic patients with benign gynaecological diseases (Appendix  X : Table  A4 ). It mainly includes the implementation of nursing measures in each period (the night before operation, the day after operation, 1 to 3 days after operation, 4 days after operation and 5 days after operation). On the day of the patient's confirmed operation, the responsible nurse will put the sheet at the end of the bed, and the responsible nurse checks the project according to the actual implementation of nursing measures in different periods, and head nurses should supervise them well. Resources included a record sheet of nursing measures to promote the recovery of gastrointestinal function in laparoscopic patients with benign gynaecological diseases. The new nursing measures record sheet covers the contents that nurses need to educate, evaluate and the nursing measures they provide to patients. Nurses only needed to draw ‘√’ to check the content. On one hand, it saves time; on the other hand, it also improves the degree of nurses' attention to the implementation of the best evidence, which can promote the project. In the follow‐up audit cycle, there were improvements in compliance for each audit criterion implementation rates of indicators 1, 2, 3, 4, 8, 9, 11, 12, 13, 14 and 18 were still above 80%, among which the implementation rate of indicators 1, 2, 3, 11, 12, 13, 14 and 18 was 100%. The implementation rates of indicators 5, 6, 7, 10, 15 and 19–27 had all improved, the implementation rates of indicators 6, 7, 19, 22, 23 and 24 reached 100%, the implementation rates of indicators 5, 10, 15, 16, 17, 20, 21, 25, 26, 27 were 93.56%, 90.89%, 6.67%, 87.89%, 70.56%, 86.40%, 88.89%, 60.67%, 70.89%, 78.60%, respectively, average score of nurses' knowledge on promoting the recovery of gastrointestinal function after laparoscopy was (98.32 ± 3.01), which was statistically significant compared with the mean score (60.67 ± 10.56) ( t  = −12.771, p  < 0.01). The average score of personnel with nurse title (98.01 ± 3.32), average score of personnel with nurse titles or above (99.00 ± 2.03) and the average score of nurses was not significantly different from the average score of personnel with nurse titles or above ( t  = 0.577, p  > 0.05). The results of the knowledge test paper showed that the 15 nurses had mastered the performance and influencing factors of postoperative gastrointestinal disorders, how to evaluate the indicators of postoperative gastrointestinal disorders and other problems, and greatly improved the mastery of the measures to promote the recovery of postoperative gastrointestinal function. Compared with the test results before the training, the effect of the training was remarkable, and the results of the nurses with different professional titles were greatly improved, indicating that the training was very effective. Ninety patients with benign gynaecological diseases after laparoscopic surgery were included in this study: 45 in the control group and 45 in the experimental group. Age, weight and intraoperative blood loss were not normally distributed, whereas height, operation time and pre/postoperative kalium values were normally distributed. The general data of the two groups are compared in Table  3 . There were no significant differences in age, height, weight, operation time, intraoperative blood loss, ASA grade, preoperative serum potassium level or postoperative serum potassium value between the two groups. Comparison of general data of patients between baseline audit group and follow‐up audit group. Note: There were also significant differences in recovery parameters between the baseline audit group and the follow‐up audit group; for example, the time of the first postoperative anal discharge ( z  = −4.810, p  < 0.001), the time of the first postoperative defecation ( z  = −2.934, p  < 0.01) and the degree of abdominal distension ( z  = −2.567, p  = 0.010 < 0.05). The results are reported in Tables  4 , 5 , 6 . Time to first anal discharge between baseline audit group and follow‐up audit group (unit: h). First defecation time between baseline audit group and follow‐up audit group (unit: h). The degree of abdominal distension of the patient between baseline audit group and follow‐up audit group (example number).

The best evidence for the management of gastrointestinal function in patients with benign gynaecological diseases after laparoscopic surgery is scientific. High‐quality evidence is at the core of evidence‐based practice. This study strictly followed the steps of evidence‐based nursing, through literature search, screening, quality evaluation, evidence extraction and integration, and summarised the best evidence summary of postoperative gastrointestinal function management in patients with benign gynaecological diseases after laparoscopic surgery. The summary of the evidence covers the entire process before, during and after surgery. The postoperative nursing component includes six aspects: early eating, posture and activity, multimodal analgesia, TCM prevention and control measures, chewing gum and drinking coffee. In addition, an expert meeting was held to invite experts to discuss and determine the recommended level of each piece of evidence based on the FAME attribute of the evidence. The entire process of evidence generation is scientific and rigorous, which provides some guidance for clinical nursing staff to promote the management of gastrointestinal function in patients with benign gynaecological diseases after laparoscopic surgery. The best evidence has a high feasibility for clinical applications. Evidence‐based practice can guide medical staff in conducting practical decision‐making scientifically. The core elements of evidence‐based practice include the best evidence, professional judgement, patients' needs and preferences and the place of application of evidence. To make the best evidence better for clinical transformation, the evidence‐based group repeatedly discussed and revised it according to the opinions of experts in clinical, nursing, management, evidence‐based and other fields, and combined it with the actual situation of the pilot ward. Finally, 27 audit criteria and specific review methods were developed to determine the introduction of clinical evidence. Several pieces of evidence were removed because they were not suitable for conversion application in the current ward, including reasons of the current inability to obtain a drug, a technology or a device. The best evidence for this is effective in clinical transformation. The baseline review found that in past nursing work, nursing staff paid little attention to the recovery of gastrointestinal function after surgery until the occurrence of serious complications such as intestinal obstruction. The introduction of the best evidence improved the nursing staff's understanding of the importance of recovery of gastrointestinal function after surgery. Through systematic training in theory and operation, the nursing staff's knowledge of postoperative gastrointestinal function recovery has also been greatly improved. Before the training, the average score of the nursing staff's knowledge test was (60.67 ± 10.56) points, and the average score increased to (98.32 ± 3.01) points. It shows the effectiveness of the training. In the stage of clinical reform, the research group introduced measures such as late walking before surgery, early eating after surgery, chewing gum, drinking coffee and acupoint massage based on the best evidence. Preoperative walking activates the body's metabolism and neuro‐endocrine system, providing physiological preparation for the recovery of postoperative intestinal peristalsis (Özdemir et al.  2019 ); chewing gum utilises the ‘sham feeding’ principle, stimulating the vagus nerve and promoting the release of gastrointestinal hormones (Chae et al.  2024 ); early postoperative oral intake accelerates the recovery of intestinal motility through direct stimulation of the gastrointestinal tract by food (Nelson et al.  2023 ); caffeine and related active components in coffee enhance colonic contractions and facilitate the transit of intestinal content (Cornwall et al.  2020 ); acupoint massage (e.g., Zusanli, Neiguan) regulates autonomic nervous system balance and gastrointestinal hormone secretion via the somatovisceral reflex (Ruan et al.  2021 ). Based on organisational training and process optimization, clinical practice was gradually introduced and accepted by nursing staff and patients. The review after the application of evidence showed that the implementation rate of the measures with an implementation rate of 0 before the application of the best evidence was significantly improved after the application of evidence, which also verified the effectiveness of the clinical changes. However, for some audit criteria, such as ‘taking knee‐chest position 6 h after surgery, can accelerate the time of anal exhaust and defecation’, the review implementation rate after the application of evidence was 6.67%. This may be related to the postoperative infusion restriction and pain effects. Therefore, after clarifying the problem, researchers should fully analyse the obstacles and promoting factors, formulate targeted strategies, enter the next round of evidence transformation cycle and scientifically and effectively promote the further transformation of evidence to clinical practice. This study showed that after the implementation of the best evidence, the first postoperative anal exhaust time was shorter than before ( t  = 2.709, p  < 0.05), the first postoperative defecation time was shortened ( t  = 2.733, p  < 0.05) and the degree of abdominal distension was reduced ( z  = −2.567, p  < 0.05). The differences were statistically significant. This shows that the application of the best evidence promotes the recovery of postoperative gastrointestinal function and accelerates the postoperative recovery of patients. This also verifies the effectiveness of the reform measures, such as systematically strengthening the training of nurses and creating publicity materials. These measures have increased the attention of nurses and patients to the recovery of postoperative gastrointestinal function, mastered the measures to promote the recovery of postoperative gastrointestinal function and promoted the change of evidence. The implementation of this evidence conversion project has expanded the relevant processes and standards of the department. For example, a process was formulated to promote the recovery of gastrointestinal function after laparoscopic surgery for benign gynaecological diseases, a record of nursing measures was added to promote the recovery of gastrointestinal function after laparoscopic surgery for benign gynaecological diseases and publicity materials for health education were produced. For the newly introduced acupoint massage technology, experts were invited to carry out theoretical and operational training and assessment, and a flowchart of the acupoint massage was developed. In future studies, we will continue to observe and record the effects of evidence application, continuously promote the nursing process of postoperative gastrointestinal function recovery, analyse and solve existing and potential problems and continuously improve the quality of nursing.

Informed consent was obtained from all the participants.

This study has several limitations that warrant consideration. First, the evidence implementation phase was constrained by a relatively short duration and limited sample size, which may have restricted the full optimization of evidence application. While certain barriers have been identified and addressed, persistent challenges, such as the low adherence rate to postoperative knee‐chest positioning, require further investigation. Future research should extend the implementation period, increase the sample size and conduct longitudinal evaluations of evidence uptake. Continuous monitoring is essential to identify emerging barriers, refine implementation strategies and ensure timely evidence updates, thereby facilitating more effective translation into clinical practice and reducing the evidence‐practice gap. Second, the scope of evidence implementation was confined to a single institution in China, which may limit generalizability. To enhance the robustness and applicability of findings, future studies should broaden the implementation settings and incorporate diverse clinical environments to promote standardised and systematic postoperative gastrointestinal function management across multiple healthcare facilities. Third, while the assessment of gastrointestinal recovery incorporates both subjective and objective measures, the absence of laboratory‐based biomarkers represents a notable limitation. Subsequent investigations should integrate laboratory indicators (e.g., inflammatory markers and motility‐related biomarkers) as objective endpoints to further validate clinical outcomes and strengthen the evidence base. Further auditing will be necessary to continue improving clinical outcomes and nursing quality and to ensure the sustainability of the project.

There are many benign gynaecological diseases, including benign ovarian tumours, uterine fibroids, endometriosis and adenomyosis. The incidence of benign gynaecological diseases is higher than that of malignant tumour. Uterine fibroids (UFs) are the most common benign gynaecological tumours in premenopausal women worldwide. It is estimated that the lifetime prevalence in premenopausal women ranges from 40% to 89% (Marsh et al.  2024 ). Endometriosis affects from 10% to 15% of women of reproductive age and 35% to 50% of women with pelvic pain and/or infertility (Smolarz et al.  2021 ). Ovarian cysts also have a high occurrence of between 14% and 18% in postmenopausal women and approximately 7% in asymptomatic women of childbearing age (Tsiampa et al.  2021 ). Therefore, the population of patients with benign gynaecological diseases is large. Surgery is a rapid and effective method for treating benign gynaecological diseases. In the 1940s, laparoscopic examination technology pioneered by Dr. Palmal in Germany began to be applied to gynaecological clinical practice. It has been considered one of the most valuable advances in gynaecology over the past 20 years (Ellis  2019 ). Compared with open surgery, the advantages of laparoscopic technology are reflected in less bleeding, small incision and quick recovery; therefore, it has been favoured by an increasing number of female patients, and with the rapid development of medical technology, laparoscopic technology plays an important role in the field of gynaecology today. Laparoscopic gynaecological surgery includes almost all surgical procedures, including those involving the ovaries, fallopian tubes and uterus. Owing to the advantages of minimally invasive surgical treatment, an increasing number of patients have actively selected laparoscopic surgery (Glaser et al.  2018 ). However, owing to residual carbon dioxide gas in the abdominal cavity after surgery, the effect of anaesthetic drugs, and the limited mobility of patients after surgery, gynaecological laparoscopic patients often have gastrointestinal dysfunction with abdominal distension, abdominal pain, nausea, vomiting and delayed defecation as the main manifestations. This not only affects patient comfort but also reduces patient satisfaction, which is not conducive to postoperative rehabilitation. It may even lead to serious complications such as acute gastric dilatation, intestinal paralysis, intestinal adhesion, intestinal obstruction, increased hospitalisation costs and prolonged hospital stay. By consulting relevant literature, it was found that many guidelines and expert consensus issued by medical institutions and societies have mentioned measures to promote the recovery of gastrointestinal function after gynaecological laparoscopic surgery. Foreign guidelines, such as the American Association of Gynecologic Laparoscopy (AAGL) (Stone et al.  2021 ), pointed out that oral carbohydrate drinks within 2–3 h before surgery can accelerate the recovery of gastrointestinal function. The guidelines issued by the International Enhanced Recovery After Surgery Association (Nelson et al.  2019 ) also point out that simple measures, such as drinking coffee and chewing gum, are beneficial to the recovery of postoperative gastrointestinal function. The domestic expert consensus (Bo et al.  2019 ; Enhanced Recovery After Surgery (ERAS) Cooperation Group of Obstetrics and Gynecology Branch of Chinese Medical Association  2019 ) pointed out that multimodal analgesia, early feeding and off‐bed activities can promote the recovery of postoperative intestinal function. Many scholars have studied how to promote the recovery of gastrointestinal function in patients with benign gynaecological diseases after laparoscopic surgery. These measures include early postoperative eating (Nelson et al.  2023 ; Silva et al.  2022 ), chewing gum (Chae et al.  2024 ; Turkay et al.  2020 ), drinking coffee (Cornwall et al.  2020 ), acupoint massage (Tsiampa et al.  2021 ), acupoint application (Gui et al.  2020 ), electroacupuncture therapy (Zhu et al.  2022 ) and so on. However, the literature types of these studies include guidelines, expert consensus, systematic reviews, meta‐analyses and original studies. The quality of these studies is uneven, and much evidence cannot be directly promoted in clinical practice. However, the problem of gastrointestinal dysfunction after gynaecological laparoscopic surgery has not been investigated, and its incidence remains high. It is reported that the incidence of postoperative abdominal distension in gynaecological laparoscopic patients is 81%–92% (Ding et al.  2019 ). The incidence of postoperative vomiting is 30% (Zhang et al.  2025 ). It has been reported in the literature that the incidence of postoperative temporary intestinal paralysis is approximately 10% (Stannard and Jang  2020 ), and the incidence of postoperative intestinal obstruction is between 12.9% and 32.4% (Gungorduk et al.  2020 ). Postoperative intestinal obstruction leads to an annual increase of USD 750 million in hospital expenditure (Asgeirsson et al.  2010 ), which poses a huge burden on the healthcare system. In many hospitals in China, healthcare system personnel have not yet provided patients with scientific and standardised management of gastrointestinal function, and some interventions may not follow best practice. Healthcare professionals need to be aware that postoperative gastrointestinal dysfunction is a serious problem that needs to be managed effectively; therefore, the project aims to scientifically integrate the evidence in the literature and ‘debug’ it according to the clinical situation, so as to transform it into clinically feasible measures to standardise the management of gastrointestinal function after laparoscopic surgery for benign gynaecological diseases and promote postoperative recovery. The current project was carried out in a hospital in Hangzhou, which is a comprehensive tertiary hospital with a history of 100 years. Gynaecology is a key discipline jointly built by provinces and cities and a special disease diagnosis and treatment center in northern Zhejiang. It has 60 beds, an annual outpatient volume of approximately 200,000, and approximately 3000 hospitalised patients. More than 85% of the surgeries were completed laparoscopically. Laparoscopic hysterectomy, myomectomy, ovarian cystectomy, adnexectomy, endometriosis, conservative or radical adenomyosis surgery, laparoscopic repair of pelvic floor dysfunction and other operations have been performed. In terms of the allocation of nursing staff, there were 18 on‐the‐job nurses in the department, 7 nurses directly participating in the nursing work on the day shift and 3 nurses on the night shift. The department irregularly accepts nursing interns and refresher nurses for learning, which can play a supporting role in the promotion of the program. The aim of this evidence implementation project was to improve local clinical practice in the management of gastrointestinal function after laparoscopic surgery in patients with benign gynaecological diseases in hospitals in Hangzhou, China. Specific objectives of the project were as follows: To increase patient compliance with gastrointestinal function management, we evaluated and monitored the entire process. To enrich nurses' knowledge and raise their awareness of the importance of managing gastrointestinal function in patients after laparoscopic surgery for benign gynaecological diseases. To enhance nurses' ability to manage gastrointestinal function in patients with benign gynaecological diseases after laparoscopic surgery. Establish a standard protocol for the management of gastrointestinal function by implementing evidence‐based practice criteria. To reduce the incidence of postoperative gastrointestinal dysfunction. To increase patient compliance with gastrointestinal function management, we evaluated and monitored the entire process. To enrich nurses' knowledge and raise their awareness of the importance of managing gastrointestinal function in patients after laparoscopic surgery for benign gynaecological diseases. To enhance nurses' ability to manage gastrointestinal function in patients with benign gynaecological diseases after laparoscopic surgery. Establish a standard protocol for the management of gastrointestinal function by implementing evidence‐based practice criteria. To reduce the incidence of postoperative gastrointestinal dysfunction.

The authors declare no conflicts of interest.