Facilitators and Barriers to Implementing Pediatric Preoperative Fasting Guidelines Among Chinese Healthcare Practitioners

Facilitators and Barriers to Implementing Pediatric Preoperative Fasting Guidelines Among Chinese Healthcare Practitioners | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Facilitators and Barriers to Implementing Pediatric Preoperative Fasting Guidelines Among Chinese Healthcare Practitioners Ting Liu, Fanglin Zou, Lei Guo, Bin Zhang, Zhaofang Zhang, Kankan Zhang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8291324/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Preoperative fasting is critical for reducing intraoperative aspiration risk; however, pediatric fasting durations frequently exceed guideline recommendations such as the 6-4-2 fasting regimen (minimum fasting times of 6 h for solid food and infant formula, 4 h for breast milk, and 2 h for clear fluids). A significant evidence gap exists regarding barriers to and facilitators of adherence to these guidelines among pediatric healthcare practitioners in China. This study aimed to identify key barriers and facilitators influencing the implementation of pediatric preoperative fasting guidelines from the perspectives of anesthesiologists, nurses, and surgeons. Methods A qualitative descriptive design was employed. Using purposive sampling, 22 practitioners (8 surgeons, 8 anesthesiologists, and 6 nurses) were recruited from six tertiary grade A hospitals in mainland China. Semi-structured interviews were conducted between January and March 2025. Data were analyzed thematically, guided by the integrated the Capability, Opportunity, Motivation and Behaviour model(COM-B)and the Theoretical Domains Framework (TDF). Results Three components from the COM-B model and seven domains from the TDF were identified as barriers to pediatric preoperative fasting guideline adoption. The most prominent barriers mapped to the Opportunity component: lack of policy support, unpredictable surgical scheduling, insufficient training resources, communication challenges and a conservative culture. Interprofessional role conflicts between anesthesiologists and surgeons were also prominent. Additional Capability barriers included practitioners lack of knowledge and insufficient collaborative practices. Motivation barriers encompassed child anxiety and non-cooperation during fasting periods, lack of leadership engagement, and practitioner indifference. Conversely, facilitators aligned with four TDF domains under Capability and Motivation included healthcare professionals' strong communication and assessment skills, and the development of action plans. Additionally, all three professional groups demonstrated a profound sense of moral responsibility, strong professional beliefs, and clear role identity. Conclusions Effectively addressing the implementation challenges of pediatric preoperative fasting guidelines in China’s healthcare context requires systematically integrating existing facilitators while tackling barriers. Multifaceted intervention strategies are recommended, including establishing an anesthesiologist-led multidisciplinary collaboration framework, optimizing clinician-caregiver communication tools and processes, allocating necessary technological and human resources, strengthening hospital-wide policy support, and clarifying professional authority and responsibilities to resolve interprofessional conflicts. Clinical trial number: Not applicable Barriers Child Facilitators Preoperative fasting Qualitative research Figures Figure 1 Introduction Preoperative fasting management plays a vital role in pediatric perioperative safety by reducing anesthetic risks and promoting postoperative recovery. Since the American Society of Anesthesiologists (ASA) issued evidence-based recommendations in 1999 to shorten fasting durations, the "6-4-2 regimen" has gained increasing adoption worldwide [1]. These guidelines were formally incorporated into China's pediatric preoperative fasting protocols by the Chinese Society of Anesthesiology in 2021 [2]. Despite these clear recommendations, their translation into clinical practice remains inconsistent, with significant variations observed across regions [3, 4]. Studies in China indicate that pediatric patients undergoing elective surgery consistently experience prolonged fasting, averaging 13.2 hours for solid foods and 10.4 hours for clear fluids [5]. This trend is consistent with international reports; UK studies document mean fasting times of 11.7 hours for solids and 6.9 hours for clear fluids [6], while children in the United States and Italy fast approximately 10.2 [7] and 9.9 hours [8] for clear fluids—substantially exceeding guideline recommendations. A significant gap exists between guidelines and clinical practice, partly due to healthcare practitioners’ insufficient understanding of the core recommendations. A multinational survey by Merchant et al. involving anesthesiologists from Canada, Australia, New Zealand, and Europe revealed that 50.4% did not support clear fluid intake 2–3 hours before surgery, primarily citing "lack of systemic support for safe implementation" and "operating room schedule variability" as barriers [9]. Similarly, only 70.3% of pediatric nurses in Australia correctly answered all core knowledge items on preoperative fasting [10]. In India, Rawlani et al. found that 43.6% of hospital staff still mistakenly consider "fasting from midnight" as the optimal strategy to prevent pulmonary aspiration [11]. Although several implementation initiatives have been piloted globally to improve guideline adherence, most explorations of barriers remain superficial [3]. For example, Nye et al. identified local cultural factors as a key barrier to guideline adoption in a single-center quality improvement project in the United States [12]. Multiple questionnaire-based studies attributed prolonged fasting to factors such as children refusing fluids or being asleep [13, 14]. In France, Thomasseau et al. highlighted that insufficient provider education and limited parental health literacy contribute to excessive fasting durations [15]. However, existing research exhibits two major limitations. First, findings are predominantly based on cross-sectional quantitative surveys, which are inadequate for uncovering the complex behavioral mechanisms underlying non-adherence. Second, studies generally lack a theoretical framework, preventing systematic identification of multidimensional barriers and facilitators. This theoretical gap has resulted in fragmented and poorly targeted implementation strategies. Given that theory-based behavioral interventions are more effective than non-theory-informed approaches [16], and considering the proven efficacy of such methodologies across diverse healthcare contexts [17, 18], a more systematic approach is warranted. This study employs an integrated approach combining the COM-B model and the TDF to systematically examine the barriers and facilitators experienced by Chinese practitioners in implementing pediatric preoperative fasting guidelines. The TDF offers a comprehensive structure that synthesizes 14 domains derived from 33 behavior-change theories, enabling detailed analysis of cognitive, affective, social, and environmental influences on practice implementation within healthcare systems [19]. These domains are consolidated within the COM-B model's three interconnected components: Capability (psychological and physical capacity), Opportunity (external factors enabling behavior), and Motivation (conscious and unconscious processes directing behavior), which interact synergistically to form a dynamic system essential for behavioral change [19]. By mapping practitioners' behaviors to the COM-B components and further classifying them into TDF domains, this integrated framework provides a holistic perspective for understanding multifactorial influences on guideline adherence in China. Compared to models focusing solely on knowledge or attitudes, this approach's innovative strength lies in its integration of individual capabilities, external opportunities, and internal motivations. This study aims to explore the facilitators and barriers to implementing pediatric preoperative fasting guidelines among Chinese healthcare practitioners. Specifically, it seeks to address two research questions: (1) What are the key barriers and facilitators identified from a multi-disciplinary perspective (anesthesiologists, surgeons, and nurses) within the Chinese healthcare context? (2) How do culturally specific barriers identified in the Chinese setting influence the implementation of pediatric preoperative fasting guidelines? Methods 1.1. Study Design This study utilized a qualitative descriptive design, conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (see Supplementary File 1). The research design, developed by the first author (T.L.), was informed by the COM-B model and TDF. All team members received standardized training in interview techniques, coding procedures, and thematic analysis. 1.2. Participants and setting Using purposive sampling, we recruited twenty-two practitioners from six tertiary hospitals in China, comprising eight surgeons, eight anesthesiologists, and six nurses. All participating institutions maintained independent pediatric surgery departments and were geographically distributed, representing the high-caliber medical resources and specialized expertise characteristic of Chinese tertiary hospitals. Based on established methodological research indicating that 16-24 interviews typically achieve meaning saturation[20], data saturation was attained after including nineteen participants (7 surgeons [S1-S7], 7 anesthesiologists [A1-A7], and 5 nurses [N1-N5]). Three additional interviews were conducted to confirm saturation—one from each professional group—and since no new themes emerged, these data were excluded from final analysis. 1.3. Data collection Data collection occurred between January and March 2025. Participants were recruited through the WeChat platform. They could choose between online or face-to-face interview formats according to their preference. All interviews were conducted privately with only the researcher and participant present, with a mean duration of 33 minutes (range: 20-58 minutes). The interview guide was developed using the COM-B model [21] and TDF [19]. To enhance methodological rigor, the research team conducted pilot interviews with three participants and refined question wording and sequence iteratively based on feedback. Data from these pilot interviews were encrypted and anonymized prior to inclusion in the final analysis, and had already been consented by reconfirmation of participants. The revised interview guide (see Table 1) demonstrated strong theoretical consistency and operational feasibility. Table 1. Interview Outline Based on the COM-B model and TDF. COM-B Question Prompt Capability Psychological Do you understand the specific guidelines for anesthesia before pediatric surgery? If yes → Where did you hear about/learn this guideline? (Do you think fasting is important for pediatric anesthesia? What key steps should be followed during implementation? To what extent do you think this guideline is being followed? How familiar are you with the evidence behind this guideline? Do you know any other evidence? If not → What do you think is the reason you are not aware of this guideline? If you are considering changing your approach， how would you improve adherence to the guideline? What changes would your hospital or department need to make to support the implementation of the guideline? physical What skills do you think healthcare professionals need to effectively implement this guideline? What skills do you think healthcare professionals need to effectively implement this guideline? In your opinion, which skills were not fully utilized during implementation? What specific challenges have you encountered while following the guideline? How did you address and solve these issues? Has your hospital or department provided relevant training or supported you in seeking external learning to improve knowledge and skills in this area? Opportunity Social How do the actions or opinions of colleagues, leaders, patients, or families impact you when applying the pediatric anesthesia guidelines? What might these actions or opinions be? Physical Does your hospital or department have the resources to support the implementation of the guidelines? If not, what areas do you think need improvement? Motivation Reflective What benefits do you think following the guidelines brings to individuals, the hospital, and patients? What do you think the consequences are of not following the guidelines? How would these consequences affect your and your colleagues' attitudes and behavior Automatic What responsibilities do you think healthcare professionals have in implementing this guideline? What role do you typically take when implementing the guidelines? If you strictly follow the guidelines, do you feel your professional autonomy is limited? In what areas? All interviews were conducted in Mandarin by the second author (F.L.Z., female), a registered nurse and Master of Nursing candidate with comprehensive training in qualitative methodology and clinical interviewing. With participant consent, interviews were audio-recorded using iFLYTEK devices. Mindful of potential interviewer effects, F.L.Z. maintained strict value neutrality and avoided leading questions throughout data collection. The corresponding author completed verbatim transcription and independent cross-verification within 24 hours after each interview to ensure accuracy. 1.4. Data Analysis Data analysis employed the Framework Method for thematic analysis [22], which integrated an inductive phase allowing themes to emerge directly from the data with a subsequent deductive phase guided by the COM-B model and TDF. This methodology enabled a comprehensive examination of key determinants influencing behavioral change processes by first capturing participants' raw insights and then interpreting these findings through established theoretical lenses. Following transcription and verification, the interview data were imported into NVivo 20 for systematic coding and analysis. Two coders (F.L.Z. and K.K.Z.) independently reviewed transcripts through an iterative process involving familiarization, initial coding, and thematic framework development. To ensure confirmability and maintain neutrality toward participants' narratives, both coders adopted a neutral stance throughout data examination. To enhance analytical rigor and minimize bias, the coders first independently performed inductive coding on five identical transcripts. During this initial phase, they identified relevant excerpts related to barriers and facilitators, assigning distinct code labels without predetermined frameworks to allow organic theme emergence. The coders subsequently convened to compare independently generated codes, resolve discrepancies, and collaboratively develop a preliminary thematic framework through iterative refinement until consensus was achieved. Inductive coding adhered to three established criteria—frequency of belief occurrence, conflicts between beliefs, and intensity of behavioral influence—ensuring thematic representativeness and analytical depth [23]. Inter-coder reliability was assessed using Cohen's kappa [24], with discrepancies resolved through structured group discussions. Meaning saturation was determined to have been achieved with data from 7 surgeons, 7 anesthesiologists, and 5 nurses [25], operationalized as the point where "complete comprehension of the issue's essence with no emergence of new dimensions or insights" was attained [20]. 1.5. Ethical Considerations This study received ethical approval from the Institutional Review Board of Jinan Children’s Hospital (Approval No. SDFE-IRB/P-2025004) and was conducted in accordance with the principles of the Declaration of Helsinki. Prior to participation, all participants were fully informed of the study’s purpose, procedures, estimated duration, voluntary nature, and their right to withdraw at any time without prejudice. They were also assured of the confidentiality and anonymity of their data, and were notified regarding access to aggregated study findings upon completion. Written informed consent was obtained from all participants. No financial incentives were provided for participation. Results​ The final analysis included 19 healthcare practitioners from three specialties: anesthesiology, surgery, and nursing. Participants were recruited from six tertiary hospitals, categorized as general hospitals (58%) and specialized pediatric institutions (42%). Detailed demographic and professional characteristics are presented in Table 2. A systematic examination of the data using the COM-B model and TDF identified key determinants of guideline adherence. The distribution of facilitating factors and barriers within the COM-B and TDF is shown in Figure 1. The following section presents the findings of the directed content analysis, including the coded constructs, their corresponding segments, and supporting quotes. Table 2. Participant Demographics and Professional Characteristics. Characteristic Participants, No. (%) Total participants 19 Age group, years 20-29 2 (10%) 30-39 10 (53%) 40-49 6 (32%) 49-59 1 (5%) Gender Female 12（63%) Male 7（37% ) Professional role Anesthesiologist 7（37%） Surgeon 7（37%） Nurse 5（26%） Hospital type General hospital 11（58%） Children's hospital 8（42%） Years of Clinical Experience <5 3（16%） 5-9 5（26%） 10-15 7（37%） 16-20 4（21%） Note: Data are presented as number (percentage) of participants. 2.1. Domain1: Capability-Skills 2.1.1. Facilitators: Communication skills Effective communication skills were identified as a key facilitator for guideline implementation. Most anesthesiologists and surgeons reported providing comprehensive medical advice to caregivers to ensure prompt resolution of concerns and accurate execution of fasting protocols. "In fact, most parents effectively follow medical advice when properly informed. We also strive to make these instructions as simple, clear, and time-efficient as possible to enhance comprehension and compliance." (S7) 2.1.2. Facilitators: Assessment skills Several anesthesiologists highlighted the role of assessment skills, suggesting that preoperative gastric ultrasound could enhance guideline application by ensuring timely risk assessment. "In instances of unintended preoperative ingestion, we conduct an ultrasound assessment of gastric emptying before proceeding with surgery." (A3) 2.2. Domain2: Capability-Knowledge 2.1.1． Barriers：Practitioners lack knowledge A deficiency in training and education regarding the guidelines was highlighted by most nurses. Some anesthesiologists noted that surgeons' knowledge of preoperative fasting was not updated in a timely manner, and the teaching materials they relied on lagged behind contemporary standards. The need to promptly revise textbooks, integrate the latest guidelines into clinical practice, and raise awareness was emphasized. "We scratch the surface of the content of the guideline, without detailed knowledge." (N4) "This situation arises because they (surgeons) are updated more slowly than we are; sometimes their understanding remains rooted in outdated guidelines and rules." (A7) "It's primarily because the guidelines are established by anesthesiologists. They (surgeons) may not pay sufficient attention, and it is also possible that their traditional surgical textbooks still recommend 4 hours, which have not been updated." (A4) Furthermore, some nurses contend that the training on the guidelines should be administered by anesthesiologists; however, they currently lack the requisite knowledge. "Anesthesiologists are the best individuals to lead training... so we nurses think it's time for anesthesiologists' knowledge to be updated and improved." (N3) 2.3. Domain3: Capability- Behavioural Regulation 2.3.1. Barriers: lack of collaboration Some participants observed a current deficiency in collaboration among practitioners. They underscored that tripartite collaboration and timely adjustments to fasting protocols could enhance the implementation of the guidelines. "Regarding the implementation of the guideline, there has been no formal dialogue among the three parties—surgeons, anesthesiologists, and nurses—to establish a consensus on this matter." (N3) "Anesthesiologists, doctors, and nurses must ensure highly coordinated and effective communication. For instance, through tripartite collaboration, patients can be informed in advance about when they may resume fluid intake. This approach may represent the most effective path forward." (S4) 2.3.2. Facilitators: Plan of action Participants expressed strong support for the introduction of Artificial Intelligence（AI）large models that could enhance the prediction of surgical processes, noting that appropriate technical support may facilitate the implementation of guidelines. "In fact, there are times when we could proactively communicate and prepare in advance. In the future, could we develop an intelligent AI prediction software? For instance, if the first surgery is delayed, how long might the second surgery take? What is the required anesthesia time? For the third and fourth surgeries, could the software automatically analyze these variables? Additionally, there could be a screen or an app to alert nurses, guiding pediatric patients on when to drink water. This system should also integrate with the hospital wards." (A4) 2.4. Domain4：Opportunity-Environmental Context and Resources 2.4.1. Barriers：Lack of policy support Participants across all three occupations emphasized the urgent need for stronger policy support, citing inadequate backing from administrative departments. They stressed that the Medical Affairs Department and Nursing Department must actively endorse and prioritize guideline implementation at the hospital level. "Hospital-level implementation is necessary when the administration mandates compliance, supported by implementation directives from both the Medical Affairs Department and Nursing Department." (A1) 2.4.2. Barriers：Unpredictable surgical scheduling The majority of participants indicated that, given current conditions in China—where human and environmental resources are constrained—numerous operational scheduling challenges arise and operation times become unpredictable. These factors have significantly impacted the implementation of fasting guidelines, particularly for emergency surgical procedures. "Surgical uncertainty exists because while some procedures adhere to the estimated timeline, emergency cases may unexpectedly arise, necessitating deviations from the scheduled time... This is the biggest obstacle." (N1) "The temporary changes complicate timely updates for families. For instance, when an emergency occurs during an ongoing surgery and requires additional time for intervention, the subsequent pediatric surgery patient may be subjected to an excessively prolonged fasting period." (A5) 2.4.3. Barriers：Lack of training resources Several participants across three professions reported a lack of training resources on fasting guidelines, which prevented practitioners from updating their knowledge promptly. "I have not attended many academic conferences focused on pediatrics; thus, my knowledge is likely more aligned with traditional practices." (A6) 2.4.4. Barriers：Conservative culture Participants reported that some practitioners exhibited heightened risk aversion and expressed significant concern about potential hazards associated with clinical procedures. This conservative stance hindered adoption of the latest fasting guidelines, and their reluctance to deviate from established protocols impeded effective implementation of the new recommendations. "Everyone is so hyper-focused on safety—prioritizing absolute safety over the guidelines’ recommendations—that they fail to fully consider the child's comfort or even their basic needs." (S4) "If a procedure has been performed in a certain manner for years without any apparent issues, it is often assumed to be correct. Even when a superior method emerges, its adoption is perceived as risky. Some individuals resist that risk and prefer to adhere to familiar practices." (S7) 2.5. Domain5: Opportunity-Social Influences 2.5.1. Barriers：Interprofessional role conflict Participants from various occupations expressed concern about inconsistent preoperative fasting standards for children among anesthesiologists and surgeons. This variability in decision-making undermines the uniform application of established guidelines. "If I insist on implementing the guideline, but the anesthesiologist does not endorse it and declines to accept the surgery, this will inevitably impact..." (S4) “The issue lies in the fact that, although we （ anesthesiologists ） adheres to guidelines, the preoperative fasting orders are determined by the surgeons .” (A1) The primary responsibility of nurses is to ensure that children adhere to these guidelines. It is perplexing that even among medical professionals within the same specialty, there may be differing recommendations for nurses. “There can be some variation between anesthesiologists. For instance, I might recommend that a patient can consume water up to two hours prior to surgery. One anesthesiologist may find this acceptable, while another may disagree.” (N3) 2.5.2. Barriers：Communication challenges Caregivers of pediatric patients with lower educational attainment often struggle to comprehend preoperative fasting requirements, despite repeated explanations from practitioners. This challenge undermines the effectiveness of preoperative education initiatives. "Sometimes the grandparents are the primary caregivers, and they may not hear the instructions clearly." (N2) "The current issue arises when caregivers fail to grasp the timing requirements; repeated explanations may prove ineffective." (A2) Moreover, because the primary caregivers of young children in China are often grandparents, their compliance tends to be low, and they are more likely to violate guidelines due to indulgence. Consequently, the implementation of these guidelines in clinical practice proves challenging and fails to meet the expected standards. "When grandparents are the primary caregivers, their ability to follow through might not be as good; it's a bit frustrating sometimes." (A5) "Furthermore, for afternoon surgical procedures, caregivers may compromise fasting protocols by covertly providing food in the morning." (S5) Additionally, some nurses have noted that the pronunciation of "fasting" in Mandarin is identical to that of "eating," which can lead to misunderstandings regarding fasting instructions. "I am concerned that, even after providing explanations, caregivers may not implement the instructions correctly. For example, a parent might confuse ' jìn shí ' (fasting) with ' jìn shí ' (eating)." (N4) 2.6. Domain6: Motivation-Emotion 2.6.1． Barriers：Anxiety and non-cooperation Most participants indicated that children's emotional reactions, such as protest and anxiety during fasting, translate into stress for caregivers. This stress can create a chain reaction that affects practitioners, ultimately hindering the implementation of the guidelines. "Whereas others protest angrily after two hours: 'Why must I starve? I can't bear it!' Such tantrums increase parental anxiety, which then pressures medical staff." (S7) 2.7. Domain7: Motivation-Social/Professional Role & Identity 2.7.1. Barriers：Leadership A few participants noted that leadership dynamics within professional roles impeded the implementation of guidelines during the initial phases of change. "Although clinical staff are aware of the new guideline, they remain unimplemented... as their application is prohibited by the head of Anesthesiology." (S3) 2.7.2. Facilitators: Professional identity A strong sense of professional identity rooted in the core values of "everything for the child" was evident across all surveyed institutions. Participants indicated that this intrinsic sense of mission motivated them to adhere to the guidelines. "Adherence to the guideline to ensure the safety of pediatric patients is, I believe, an integral part of our professional duty." (N1) "As a doctor, I view safe preoperative fasting guidance as a fundamental aspect of my responsibility to heal and ensure patient safety, which is of paramount importance." (S2) 2.7.3. Facilitators: Driving force Most participants indicated that the influential role of anesthesiologists, grounded in their professional authority and knowledge leadership, significantly impacted the implementation of the guidelines by healthcare practitioners. This role effectively coordinates the consistency of clinical practice and promotes the ongoing adherence to the guidelines by clarifying responsibilities and providing professional leadership. "Who is responsible for drafting these guidelines? ... Because we anesthesiologists are particularly focused on fasting and are quite familiar with the latest research advancements in this area. In fact, these fasting guidelines were primarily written by us, the anesthesiologists." (A1) "Anesthesiologists serve as the driving force behind preoperative fasting guidelines, and their guidance is essential. " (S2) "In the preparatory stage of the establishment of the department, under the guidance of anesthesia, we ultimately formed a unified clinical regulation through consultation." (N5) 2.7.4. Facilitators: Champions Nurses, as champions of guideline implementation, prioritize, oversee, and actively promote the ongoing application of these guidelines. "Take our department, for example. Our head nurse is very strict in enforcing the guidelines, and we nurses have also begun to focus on them." (N3) "I believe the nursing team manages most of the processes. Often, after we issue the surgical order, the nurse informs the patient about the fasting schedule. That's typically how it proceeds." (S6) 2.8. Domain8: Motivation-Beliefs about Capabilities 2.8.1. Facilitators: Moral responsibility Most participants regarded the implementation of guidelines as part of their professional responsibility. However, some individuals perceived child safety as a profound personal moral obligation, which facilitated adherence to the guidelines. "I've been through something like this - a child choking from aspiration - and I would be under enormous psychological stress. Even if no serious consequences actually occur, I still feel guilty." (N2) 2.8.2. Facilitators: Beliefs Practitioners’ confidence in the guidelines is essential to earn patients’ trust and encourage strict adherence by families. "I believe that the guidelines are correct, and if I can communicate with you confidently and effectively, then implementing the fasting guidelines becomes a firm decision." (S7) 2.9. Domain9: Motivation-Beliefs about Consequences 2.9.1. Barriers: Indifference Some participants exhibit a disregard for the established guidelines. They believe it is permissible to adhere to either the preoperative fasting guidelins or traditional practices, perceiving the connection between them as insignificant. Consequently, they are inclined to maintain their old habits and display apathy toward the adoption of the guidelines, which ultimately hinders the progress of their implementation. "Reducing the fasting period as recommended by current guidelines would undoubtedly enhance patient comfort; however, it is important to note that few individuals have genuinely considered the experiences of the children involved." (S4) "Surgeons and nurses typically instruct patients to refrain from clear fluids for 4 hours, a guideline we generally do not alter due to our belief in its modest impact. Occasionally, we suggest that patients may avoid clear fluids for only 2 hours prior to surgery. " (A4) "From a practical perspective, maintaining a uniform extended fasting period streamlines operations for medical staff to some extent. However, when managing a large number of children, this practice also reduces the likelihood of errors involving parents. If the fasting periods of children within the same ward differ, they may approach the nurses' station with inquiries, thereby significantly increasing the workload for our nursing and medical teams." (S7) Discusion The implementation of pediatric preoperative fasting guidelines represents a critical evidence-based practice for ensuring perioperative safety. However, integrating these guidelines into clinical workflows presents substantial challenges, particularly within China's healthcare context where limited resources and a tradition-oriented culture complicate implementation. Guideline adoption involves multiple dimensions：multidisciplinary collaboration, clinician-caregiver communication, resource allocation, defensive medicine, and interprofessional conflicts. These factors collectively create a unique complexity in the implementation process. Our findings revealed substantial variation in the clinical implementation of pediatric preoperative fasting guidelines across hospitals in China. While variations in fasting protocols among different tertiary hospitals were consistent with the multicenter quantitative study by Zhang et al. [26], we further identified inconsistencies even within the same institution，across surgical teams and individual anesthesiologists. This suggests that guideline implementation has not yet reached standardization, likely because preoperative fasting involves balancing patient safety, comfort, and surgical efficiency，priorities that vary across specialties [27]，coupled with ineffective inter-departmental communication mechanisms and a lack of unified consensus-building processes. Within the Capability component, a key barrier was the absence of effective collaboration among surgeons, nurses, and anesthesiologists. The core conflict manifested as interprofessional role conflict: when anesthesiologists and surgeons held divergent interpretations of guideline appropriateness, the lack of an authoritative coordinator to facilitate dialogue and resolve differences often led to surgery suspension due to safety concerns, thereby impeding guideline implementation. In the Opportunity component, most practitioners reported that unpredictable surgical start times and duration，particularly during sequential operations，posed a major barrier to fasting guideline adherence, a finding consistent with both international and domestic studies [28, 29]. Under China's current healthcare conditions, characterized by high patient volumes and heavy surgical loads, operating rooms consistently function at overcapacity with tightly packed schedules. This high-pressure environment has fundamentally shifted clinical decision-making toward efficiency-first approaches, where pediatric patients' comfort is often secondary. This prioritization reflects not practitioner indifference but an adaptive strategy—a form of pragmatic "survival wisdom"—within systemic constraints. Looking forward, artificial intelligence offers promising solutions. Large language models (LLMs) could be utilized to develop surgical-duration prediction tools [30], which would integrate multidimensional data，including patient history, procedure type, and surgeon habits，significantly enhancing prediction accuracy and optimizing scheduling efficiency to reduce unplanned delays. For closed-loop management, these predictions could be integrated into real-time visual electronic boards and mobile nursing platforms connecting wards and operating rooms, enabling precise fasting monitoring and early warnings. Furthermore, a nurse empowerment mechanism could be established: when surgeries are delayed, nurses would follow standardized protocols to guide children to consume clear fluids two hours before estimated anesthesia induction. For patients with surgery rescheduled to an earlier time, anesthesiologists could use bedside ultrasound to assess gastric content [31], thereby avoiding unnecessary prolonged fasting while maintaining safety standards. A notable barrier identified was the pronounced conservative tendency among both surgeons and anesthesiologists. This phenomenon likely stems from defensive risk management strategies adopted by administrative and institutional systems within China's healthcare environment, coupled with insufficient institutional mechanisms to support Evidence - Based Practice（EBP）implementation among practitioners. These conditions have led to clinical decision-making being dominated by risk-minimization logic, resulting in defensive medical practices [32]. Furthermore, within this context, Chinese practitioners are influenced by a "conservative culture" [33], which fosters unconscious, habitual resistance to updates and changes. This mindset often manifests through reasoning such as "since previous practices caused no problems, why change now?" It should be emphasized that this phenomenon is not unique to China. Similar patterns are observed in North America, Europe, and the Middle East, where practitioners tend to maintain existing practices to avoid potential medical disputes and legal liabilities[34–36]. Contributing factors may include doctor-patient relationships, institutional systems, and social environments [32]. We recommend implementing multidimensional strategies integrating institutional, technological, and cultural approaches [37], including enhanced policy support at the administrative level [38] to provide practitioners with more adequate resources and safeguards. Nurses identified significant challenges in preoperative fasting education when grandparents served as primary caregivers, revealing two primary communication barriers. First, cognitive differences emerged as a key factor: influenced by cultural values where "food represents love" and personal experiences growing up during periods of scarcity, grandparents often developed compensatory psychological attitudes toward fasting. This cultural perspective became a significant barrier to guideline adherence. Additionally, elderly caregivers frequently struggled to understand medical terminology such as "clear fluids" and "solid foods," often confusing different food categories' corresponding fasting windows (e.g., mistaking soups for clear fluids), necessitating repeated and patient explanations. Under this pressure, practitioners sometimes resorted to a "one-size-fits-all" midnight fasting policy to improve efficiency [11].Second, homophone-related communication barriers in Mandarin posed challenges: the identical pronunciation of "禁食" (fasting) and "进食" (eating) - both pronounced "jìn shí" - created potential misunderstandings during verbal instructions, leading to potential misinterpretations and incorrect implementations. To address these challenges, we recommend implementing culturally adapted, multimodal education strategies. These include illustrated fasting guideline brochures using actual food photographs instead of verbal instructions alone, and utilizing digital tools for education. The teach-back method [39] should be employed by having primary caregivers repeat key information, with grandparents subsequently conveying this information to parents, thereby creating a dual verification system for information accuracy. All three practitioner groups (surgeons, anesthesiologists, and nurses) reported insufficient training in evidence-based practice guidelines and inadequate training resources. In China, few anesthesiologists receive standardized residency training, resulting in significant disparities in pediatric anesthesia knowledge and decision-making capabilities across different institutions [26]. Within this context, some anesthesiologists and surgeons demonstrated limited recognition of the clinical value of fasting guidelines, failing to complete the conceptual transition from "experience-based safety" to "evidence-based safety." This phenomenon represents a compound barrier spanning three domains: outdated knowledge (Capability), lack of training resources (Opportunity), and insufficient conceptual emphasis (Motivation). Nevertheless, this study identified key motivational facilitators. Anesthesiologists demonstrated strong professional moral responsibility, beliefs, and role identity, indicating their potential as core drivers for guideline implementation. All three practitioner groups reached a high consensus on an ideal division of responsibilities: anesthesiologist-led regimen development and approval, nurse-driven education and compliance monitoring, and surgeon cooperation in adjusting clinical decisions. To leverage these facilitators, we recommend establishing an anesthesia-led standardized knowledge dissemination system. This includes developing hospital-wide unified fasting lists specifying permitted/prohibited clear fluids and solid foods under anesthesia department leadership. Additionally, interprofessional training mechanisms should be created through regular workshops, lectures, and seminars to systematically update guideline-related knowledge. 4. Strengths and limitations To date, few descriptive qualitative studies have investigated barriers to implementing pediatric preoperative fasting guidelines in China. As the first study to integrate the COM-B model and TDF, this research systematically examined implementation challenges within real-world clinical settings by incorporating multiple stakeholder perspectives—including anesthesiologists, nurses, and surgeons—thereby providing localized evidence for guideline implementation in Asian contexts. The study reveals the current state of guideline implementation within China's complex healthcare system, with particular significance in identifying previously unrecognized latent barriers such as culturally influenced beliefs, homophone-induced communication challenges in Mandarin, conservative clinical culture combined with defensive medical practices, and interprofessional tensions arising from role perception differences between surgeons and anesthesiologists. These findings highlight how non-technical factors, including cultural beliefs, linguistic expressions, and organizational dynamics, critically constrain guideline implementation. The study establishes a solid foundation for designing more feasible and targeted behavioral intervention strategies. This study has limitations. First, all participants were recruited from tertiary grade A hospitals, excluding practitioners from primary healthcare institutions (e.g., primary and secondary hospitals, community health service centers), which may limit the applicability of findings to primary care settings. Second, although some clinicians indirectly referenced caregiver behaviors and perceptions, the study did not include direct interviews with primary caregivers (e.g., parents or grandparents) of pediatric patients. Consequently, barriers and facilitators related to caregiver cognition, decision-making logic, and interactions with clinical teams lack first-hand accounts from these key stakeholders. Although data saturation was achieved through purposive sampling and constant comparative analysis, these structural sampling limitations may reduce the representativeness and applicability of findings across other hospital levels. Future research should build upon this study by incorporating primary care practitioners and caregiver groups to validate and extend the identified behavioral determinants. Integrating the TDF with Behavior Change Techniques（BCTs）could facilitate the development of targeted intervention strategies, whose feasibility and effectiveness should be evaluated through mixed-methods or pragmatic trials across multi-level healthcare institutions. Conclusıons This qualitative study, employing the COM-B model and the TDF, identified key barriers and facilitators influencing practitioners' implementation of pediatric preoperative fasting guidelines, providing critical insights for improving clinical practice. Our findings indicate that strategically leveraging existing facilitators—such as strong professional moral responsibility, clinical skills, and professional role identity—while addressing critical challenges including interdisciplinary collaboration, clinician-caregiver communication, resource allocation, policy support, and interprofessional role conflicts is essential for successful guideline implementation. As pediatric care needs grow increasingly complex, systematically identifying and addressing these barriers holds global significance for preoperative fasting management. These findings support targeted interventions, such as establishing anesthesiologist-led multidisciplinary collaboration mechanisms, optimizing communication tools and processes, allocating necessary technological resources, strengthening institutional policy support, and clarifying professional roles to resolve conflicts. This study addresses important evidence gaps regarding guideline implementation among healthcare providers and offers timely, actionable recommendations for clinicians managing pediatric surgical patients. Abbreviations ASA American Society of Anesthesiologists BCTs Behaviour Change Techniques COM-B Capability, Opportunity, Motivation-Behaviour COREQ Consolidated Criteria for Reporting Qualitative Research EBP Evidence-Based Practice LLMs Large Language Models TDF Theoretical Domains Framework Declarations Ethics approval and consent to participate This study received ethical approval from the Institutional Review Board of Jinan Children’s Hospital (Approval No. SDFE-IRB/P-2025004) and was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication Written informed consent was obtained from all participants. Competing interests The authors declare that they have no competing interests. Author Contribution TL: Conceptualization, Methodology, Writing – Original Draft, Supervision; FZ: Investigation, Data Curation, Formal Analysis; LG: Supervision, Project Administration, Validation; BZ: Writing – Review & Editing, Validation; ZZ: Investigation, Resources; KZ: Methodology, Formal Analysis; BL: Validation, Data Curation; GL: Conceptualization, Methodology, Writing – Review & Editing, Supervision. All authors have read and approved the final manuscript. Acknowledgement The authors would like to thank all participants for their valuable contributions to this study. Data Availability The datasets used and analysed during the current study are available from the corresponding author on reasonable request. References Roberts K, Brindle M, McLuckie D (2020) Enhanced recovery after surgery in paediatrics: a review of the literature. BJA Educ 20:235–241. https://doi.org/10.1016/j.bjae.2020.03.004 Society of Surgery C, Society of Anesthesiology C (2021) Clinical Practice Guidelines for E༲AS in China (2021) (Ⅰ). Med J Peking Union Med Coll Hosp 12:624–631. https://doi.org/10.12290/xhyxzz.20210001 Dulay E, Griffin B, Brannigan J, McBride C, Hudson A, Ullman A (2024) Interventions to optimise preoperative fasting in paediatrics: a scoping review. Br J Anaesth 133:1201–1211. https://doi.org/10.1016/j.bja.2024.08.010 Xu D, Chen J, Cai Y (2024) Past and Present of Implementation Science (PartI)—Origin and Development. Med J Peking Union Med Coll Hosp 15:442–449. https://doi.org/10.12290/xhyxzz.2024-0023 Zhang B, Pan S, Guo H, Fang H, Hu W, Liu G (2025) Investigation on the actual fasting time of children before surgery in China. J Clin Anesthesiology 41:169–175. https://doi.org/10.12089/jca.2025.02.012 Al-Robeye AM, Barnard AN, Bew S (2019) Thirsty work: Exploring children’s experiences of preoperative fasting. Paediatr Anaesth 30:43–49. https://doi.org/10.1111/pan.13759 Carroll AR, McCoy AB, Modes K, Krehnbrink M, Starnes LS, Frost PA et al (2022) Decreasing pre-procedural fasting times in hospitalized children. J Hosp Med 17:96–103. https://doi.org/10.1002/jhm.12782 Webb AR, Kalam I, Lui N, Loughnan RM, Leong S (2024) A pre and post interventional audit of an ‘apple juice on arrival’ protocol to reduce excessive clear fluid fasting times in paediatric patients. Anaesth Intensive Care 52:328–334. https://doi.org/10.1177/0310057x241263112 Merchant RN, Chima N, Ljungqvist O, Kok JNJ (2020) Preoperative Fasting Practices Across Three Anesthesia Societies: Survey of Practitioners. JMIR Perioper Med 3:e15905. https://doi.org/10.2196/15905 Wong ANY, Ragg PG, Chong SW, Morton H, Oliver L (2022) Multicenter Survey on Staff Understanding of Preoperative Fasting Guidelines. J Perianesth Nurs 37:369–373. https://doi.org/10.1016/j.jopan.2021.05.004 Department of Paediatric Anaesthesia N-SCH, Rawlani SS, Dave NM, Karnik PP (2022) The Preoperative Fasting Conundrum: An Audit of Practice in a Tertiary Care Children’s Hospital. Turk J Anaesthesiol Reanim 50:207–211. https://doi.org/10.5152/tjar.2022.21132 Nye A, Conner E, Wang E, Chadwick W, Marquez J, Caruso TJ (2019) A Pilot Quality Improvement Project to Reduce Preoperative Fasting Duration in Pediatric Inpatients. Pediatr Qual Saf 4:e246. https://doi.org/10.1097/pq9.0000000000000246 Isserman R, Elliott E, Subramanyam R, Kraus B, Sutherland T, Madu C et al (2019) Quality improvement project to reduce pediatric clear liquid fasting times prior to anesthesia. Paediatr Anaesth 29:698–704. https://doi.org/10.1111/pan.13661 Ricci Z, Colosimo D, Saccarelli L, Pizzo M, Schirru E, Giacalone S et al (2024) Preoperative clear fluids fasting times in children: retrospective analysis of actual times and complications after the implementation of 1-h clear fasting. J Anesth Analg Crit Care 4:1–7. https://doi.org/10.1186/s44158-024-00149-3 Thomasseau A, Rebollar Y, Dupuis M, Marschal N, Mcheik J, Debaene B et al (2021) Observance of preoperative clear fluid fasting in pediatric anesthesia: oral and written information versus text message information. A before-and‐after study. Paediatr Anaesth 31:557–562. https://doi.org/10.1111/pan.14145 Buchanan H, Newton JT, Baker SR, Asimakopoulou K (2021) Adopting the COM-B model and TDF framework in oral and dental research: A narrative review. Community Dent Oral Epidemiol 49:385–393. https://doi.org/10.1111/cdoe.12677 Hoang AN, Eades C, Harris FM, Cheyne H (2024) Barriers and enablers toward healthy eating and weight gain among pregnant women in Vietnam: A qualitative study with analysis informed by the theoretical domains framework and COM-B model. Appetite 203:107710–107710. https://doi.org/10.1016/j.appet.2024.107710 Mecoli MD, Sahu K, McSoley JW, Aronson LA, Narayanasamy S (2024) The use of point of care gastric ultrasound and anesthesia management in pediatric patients with preoperative fasting non-adherence scheduled for elective surgical procedures: a retrospective study. BMC Anesthesiol 24:1–6. https://doi.org/10.1186/s12871-024-02628-0 Cane J, O’Connor D, Michie S (2012) Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci 7:1–17. https://doi.org/10.1186/1748-5908-7-37 Hennink MM, Kaiser BN, Marconi VC (2016) Code Saturation Versus Meaning Saturation. Qual Health Res 27:591–608. https://doi.org/10.1177/1049732316665344 Michie S, van Stralen MM, West R (2011) The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci 6:42–42. https://doi.org/10.1186/1748-5908-6-42 Gale NK, Heath G, Cameron E, Rashid S, Redwood S (2013) Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 13:1–8. https://doi.org/10.1186/1471-2288-13-117 Patey AM, Islam R, Francis JJ, Bryson GL, Grimshaw JM (2012) Anesthesiologists’ and surgeons’ perceptions about routine pre-operative testing in low-risk patients: application of the Theoretical Domains Framework (TDF) to identify factors that influence physicians’ decisions to order pre-operative tests. Implement Sci 7:52–52. https://doi.org/10.1186/1748-5908-7-52 Mchugh ML (2012) Interrater reliability the:kappa statistic. Biochemia Med 22:276–282 Hennink M, Kaiser BN (2021) Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Soc Sci Med 292:114523–114523. https://doi.org/10.1016/j.socscimed.2021.114523 Zhang B, Pan S, Zheng J, Li B, Miao Y, Liu G (2025) Optimizing pediatric preoperative fasting management: a survey of practices and real durations in Chinese hospitals. BMC Anesthesiol 25:1–10. https://doi.org/10.1186/s12871-025-03064-4 Paul PA, Joselyn AS, Pande PV, Gowri M (2022) A cross sectional, observational study to evaluate the surgeons’ knowledge and perspective on preoperative fasting guidelines in a tertiary care teaching hospital in Southern India. J Anaesthesiol Clin Pharmacol 38:434–439. https://doi.org/10.4103/joacp.joacp_413_20 Yimer AH, Haddis L, Abrar M, Seid AM (2022) Adherence to pre-operative fasting guidelines and associated factors among pediatric surgical patients in selected public referral hospitals, Addis Ababa, Ethiopia: Cross sectional study. Ann Med Surg (Lond) 78. https://doi.org/10.1016/j.amsu.2022.103813 Tingting Y, Sufang L, Yanan X, Pei N (2023) Clinical translation status and research progress of preoperative fasting and drinking prohibition guidelines for children undergoing elective surgery. Chin J Mod Nurs 29:1676–1680. https://doi.org/10.3760/cma.j.cn115682-20220614-02865 Ramamurthi A, Neupane B, Deshpande P, Hanson R, Vegesna S, Cray D et al (2025) Applying Large Language Models for Surgical Case Length Prediction. JAMA Surg. https://doi.org/10.1001/jamasurg.2025.2154 Baettig SJ, Filipovic MG, Hebeisen M, Meierhans R, Ganter MT (2023) Pre-operative gastric ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study. Anaesthesia 78:1327–1337. https://doi.org/10.1111/anae.16117 Chinese Hospital (2024) Management 44:6–10 Academic E (2015) ;:54–58 Kakemam E, Arab-Zozani M, Raeissi P, Albelbeisi AH (2022) The occurrence, types, reasons, and mitigation strategies of defensive medicine among physicians: a scoping review. BMC Health Serv Res 22. https://doi.org/10.1186/s12913-022-08194-w Baungaard N, Skovvang PL, Assing Hvidt E, Gerbild H, Kirstine Andersen M, Lykkegaard J (2022) How defensive medicine is defined in European medical literature: a systematic review. BMJ Open 12:e057169. https://doi.org/10.1136/bmjopen-2021-057169 Sami R, Salehi K, Sadegh R, Solgi H, Atashi V (2022) Barriers to rational antibiotic prescription in Iran: a descriptive qualitative study. Antimicrob Resist Infect Control 11. https://doi.org/10.1186/s13756-022-01151-6 Chinese Hospital (2025) Management 45:1–5 Zhang N, Zhang Q, Li C, Huang Y, Hu J, Wang J et al (2025) Barriers and facilitators of implementation sustainability of evidence-based practice for peristomal irritant contact dermatitis: A descriptive qualitative study. Int J Nurs Sci 285–292. https://doi.org/10.1016/j.ijnss.2025.04.002 Wong CI, Desrochers MD, Conway M, Stuver SO, Mahan RM, Billett AL (2023) Improving Home Caregiver Independence With Central Line Care for Pediatric Cancer Patients. Pediatrics 151. https://doi.org/10.1542/peds.2022-056617 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8291324","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":559664707,"identity":"f0605303-5e9f-4ba3-a182-7f952640c49b","order_by":0,"name":"Ting Liu","email":"","orcid":"","institution":"Children's Hospital Affiliated to Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Ting","middleName":"","lastName":"Liu","suffix":""},{"id":559664708,"identity":"36d00af1-f4ac-4a1f-8d82-6fe102fa8725","order_by":1,"name":"Fanglin Zou","email":"","orcid":"","institution":"Children's Hospital Affiliated to Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Fanglin","middleName":"","lastName":"Zou","suffix":""},{"id":559664709,"identity":"cd08d9da-7d71-4ee1-9757-b33043afa5bc","order_by":2,"name":"Lei Guo","email":"","orcid":"","institution":"Children's Hospital Affiliated to Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Guo","suffix":""},{"id":559664710,"identity":"1b1e1908-d778-4130-9539-c201b5f8f8f0","order_by":3,"name":"Bin Zhang","email":"","orcid":"","institution":"Children's Hospital Affiliated to Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Zhang","suffix":""},{"id":559664711,"identity":"4c8cff56-da3f-4c08-a947-bb2376a8907f","order_by":4,"name":"Zhaofang Zhang","email":"","orcid":"","institution":"Children's Hospital Affiliated to Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Zhaofang","middleName":"","lastName":"Zhang","suffix":""},{"id":559664712,"identity":"6b6cbcde-2694-4050-a288-94588fd2a565","order_by":5,"name":"Kankan Zhang","email":"","orcid":"","institution":"Children's Hospital Affiliated to Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Kankan","middleName":"","lastName":"Zhang","suffix":""},{"id":559664713,"identity":"a6382caf-e8df-4352-a109-ed134ce02b37","order_by":6,"name":"Baoyan Liu","email":"","orcid":"","institution":"Children's Hospital Affiliated to Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Baoyan","middleName":"","lastName":"Liu","suffix":""},{"id":559664714,"identity":"a6ee88e6-45f2-4420-b004-fd05891baabc","order_by":7,"name":"Guohua Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYDACdjBpwWDA3sDATJwWZgbGBgYGCQYDngMka5FIIFIL32Hm44952yTstks+f/i4sI1Bnl/sAH4tkofZEpuBWpJ3zs4xNp7ZxmA4c3YCfi0Gh3kMwVoMbuewSfO2MSQY3Caohf8jRMvN48+I1cLDCNJiZ3CDwYw4LUC/GM6cc04iweAM0C885yQI+4XvePODD2/KbOwNjh9/+JinzEaeX5qAFoYDDAxMvGwMiQ0QrgQB5VAtjD/+MNgToXQUjIJRMApGKgAA1kdA51DYHQ0AAAAASUVORK5CYII=","orcid":"","institution":"Children's Hospital Affiliated to Shandong University","correspondingAuthor":true,"prefix":"","firstName":"Guohua","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-12-06 01:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8291324/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8291324/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98433439,"identity":"cbcaad73-55b7-4a97-9b75-c992e4e5a3ff","added_by":"auto","created_at":"2025-12-17 16:50:46","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":293602,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-8291324/v1/1320574aca681924d6792680.docx"},{"id":98433962,"identity":"0dfc0d6d-7ae3-4275-a4fe-692275e7d993","added_by":"auto","created_at":"2025-12-17 16:51:17","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10422,"visible":true,"origin":"","legend":"","description":"","filename":"1c564f11e85c420daae4510fa44e93f7.json","url":"https://assets-eu.researchsquare.com/files/rs-8291324/v1/cc1381a23bf2e6a114944ee7.json"},{"id":98433840,"identity":"edae517a-068c-4f41-9d4f-617232130b82","added_by":"auto","created_at":"2025-12-17 16:51:09","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":145640,"visible":true,"origin":"","legend":"","description":"","filename":"1c564f11e85c420daae4510fa44e93f71enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8291324/v1/b93ed709c8a9aecd9284d263.xml"},{"id":98433455,"identity":"33262277-c9c0-499d-97d1-f72a8d52f226","added_by":"auto","created_at":"2025-12-17 16:50:47","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":83302,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8291324/v1/3314775cb337a205294a8cef.png"},{"id":98218668,"identity":"726f3ff3-3287-44af-aa21-4d4c1b939a0a","added_by":"auto","created_at":"2025-12-15 11:03:32","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":128983,"visible":true,"origin":"","legend":"","description":"","filename":"1c564f11e85c420daae4510fa44e93f71structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8291324/v1/03695050231c5130d0da5bf7.xml"},{"id":98433511,"identity":"efaef4ab-e413-4a5e-88e3-eb48f166cf59","added_by":"auto","created_at":"2025-12-17 16:50:51","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":164323,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8291324/v1/40eb3aa781f6f40c35ca11b9.html"},{"id":98431963,"identity":"2afd4375-25f4-4359-bbf1-bd3a0193be2c","added_by":"auto","created_at":"2025-12-17 16:48:42","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":380016,"visible":true,"origin":"","legend":"\u003cp\u003eCOM-B/TDF Analysis of Pediatric Preoperative Fasting Guidelines\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8291324/v1/26fc48020779d54b0f19bf7f.jpeg"},{"id":103232334,"identity":"95916936-bf87-4d2e-9e21-44bdb715cdbe","added_by":"auto","created_at":"2026-02-23 12:27:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":942942,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8291324/v1/3dde4adb-6c04-4ac6-b43b-4c5d1c4ff25d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Facilitators and Barriers to Implementing Pediatric Preoperative Fasting Guidelines Among Chinese Healthcare Practitioners","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePreoperative fasting management plays a vital role in pediatric perioperative safety by reducing anesthetic risks and promoting postoperative recovery. Since the American Society of Anesthesiologists (ASA) issued evidence-based recommendations in 1999 to shorten fasting durations, the \u0026quot;6-4-2 regimen\u0026quot; has gained increasing adoption worldwide [1]. These guidelines were formally incorporated into China\u0026apos;s pediatric preoperative fasting protocols by the Chinese Society of Anesthesiology in 2021 [2]. Despite these clear recommendations, their translation into clinical practice remains inconsistent, with significant variations observed across regions [3, 4]. Studies in China indicate that pediatric patients undergoing elective surgery consistently experience prolonged fasting, averaging 13.2 hours for solid foods and 10.4 hours for clear fluids [5]. This trend is consistent with international reports; UK studies document mean fasting times of 11.7 hours for solids and 6.9 hours for clear fluids [6], while children in the United States and Italy fast approximately 10.2 [7] and 9.9 hours [8] for clear fluids\u0026mdash;substantially exceeding guideline recommendations.\u003c/p\u003e\n\u003cp\u003eA significant gap exists between guidelines and clinical practice, partly due to healthcare\u0026nbsp;practitioners\u0026rsquo; insufficient understanding of the core recommendations. A multinational survey by Merchant et al. involving anesthesiologists from Canada, Australia, New Zealand, and Europe revealed that 50.4% did not support clear fluid intake 2\u0026ndash;3 hours before surgery, primarily citing \u0026quot;lack of systemic support for safe implementation\u0026quot; and \u0026quot;operating room schedule variability\u0026quot; as barriers\u0026nbsp;[9]. Similarly, only 70.3% of pediatric nurses in Australia correctly answered all core knowledge items on preoperative fasting\u0026nbsp;[10]. In India, Rawlani et al. found that 43.6% of hospital staff still mistakenly consider \u0026quot;fasting from midnight\u0026quot; as the optimal strategy to prevent pulmonary aspiration\u0026nbsp;[11]. Although several implementation initiatives have been piloted globally to improve guideline adherence, most explorations of barriers remain superficial\u0026nbsp;[3]. For example, Nye et al. identified local cultural factors as a key barrier to guideline adoption in a single-center quality improvement project in the United States\u0026nbsp;[12]. Multiple questionnaire-based studies attributed prolonged fasting to factors such as children refusing fluids or being asleep\u0026nbsp;[13, 14]. In France, Thomasseau et al. highlighted that insufficient provider education and limited parental health literacy contribute to excessive fasting durations\u0026nbsp;[15]. However, existing research exhibits two major limitations. First, findings are predominantly based on cross-sectional quantitative surveys, which are inadequate for uncovering the complex behavioral mechanisms underlying non-adherence. Second, studies generally lack a theoretical framework, preventing systematic identification of multidimensional barriers and facilitators. This theoretical gap has resulted in fragmented and poorly targeted implementation strategies. Given that theory-based behavioral interventions are more effective than non-theory-informed approaches\u0026nbsp;[16], and considering the proven efficacy of such methodologies across diverse healthcare contexts\u0026nbsp;[17, 18], a more systematic approach is warranted.\u003c/p\u003e\n\u003cp\u003eThis study employs an integrated approach combining the COM-B model and the TDF to systematically examine the barriers and facilitators experienced by Chinese practitioners in implementing pediatric preoperative fasting guidelines. The TDF offers a comprehensive structure that synthesizes 14 domains derived from 33 behavior-change theories, enabling detailed analysis of cognitive, affective, social, and environmental influences on practice implementation within healthcare systems [19]. These domains are consolidated within the COM-B model\u0026apos;s three interconnected components: Capability (psychological and physical capacity), Opportunity (external factors enabling behavior), and Motivation (conscious and unconscious processes directing behavior), which interact synergistically to form a dynamic system essential for behavioral change [19]. By mapping practitioners\u0026apos; behaviors to the COM-B components and further classifying them into TDF domains, this integrated framework provides a holistic perspective for understanding multifactorial influences on guideline adherence in China. Compared to models focusing solely on knowledge or attitudes, this approach\u0026apos;s innovative strength lies in its integration of individual capabilities, external opportunities, and internal motivations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study aims to explore the facilitators and barriers to implementing pediatric preoperative fasting guidelines among Chinese healthcare practitioners. Specifically, it seeks to address two research questions: (1) What are the key barriers and facilitators identified from a multi-disciplinary perspective (anesthesiologists, surgeons, and nurses) within the Chinese healthcare context? (2) How do culturally specific barriers identified in the Chinese setting influence the implementation of pediatric preoperative fasting guidelines?\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003e1.1.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eStudy Design\u003c/p\u003e\n\u003cp\u003eThis study utilized a qualitative descriptive design, conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (see Supplementary File 1). The research design, developed by the first author (T.L.), was informed by the COM-B model and TDF. All team members received standardized training in interview techniques, coding procedures, and thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.2.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eParticipants and setting\u003c/p\u003e\n\u003cp\u003eUsing purposive sampling, we recruited twenty-two practitioners from six tertiary hospitals in China, comprising eight surgeons, eight anesthesiologists, and six nurses. All participating institutions maintained independent pediatric surgery departments and were geographically distributed, representing the high-caliber medical resources and specialized expertise characteristic of Chinese tertiary hospitals. Based on established methodological research indicating that 16-24 interviews typically achieve meaning saturation[20], data saturation was attained after including nineteen participants (7 surgeons [S1-S7], 7 anesthesiologists [A1-A7], and 5 nurses [N1-N5]). Three additional interviews were conducted to confirm saturation\u0026mdash;one from each professional group\u0026mdash;and since no new themes emerged, these data were excluded from final analysis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.3.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eData collection\u003c/p\u003e\n\u003cp\u003eData collection occurred between January and March 2025. Participants were recruited through the WeChat platform. They could choose between online or face-to-face interview formats according to their preference. All interviews were conducted privately with only the researcher and participant present, with a mean duration of 33 minutes (range: 20-58 minutes). The interview guide was developed using the COM-B model\u0026nbsp;[21]\u0026nbsp;and TDF\u0026nbsp;[19]. To enhance methodological rigor, the research team conducted pilot interviews with three participants and refined question wording and sequence iteratively based on feedback. Data from these pilot interviews were encrypted and anonymized prior to inclusion in the final analysis, and had already been consented by reconfirmation of participants. The revised interview guide (see Table 1) demonstrated strong theoretical consistency and operational feasibility.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eInterview Outline Based on the COM-B model and TDF.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" class=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eCOM-B\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eQuestion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 352px;\"\u003e\n \u003cp\u003ePrompt\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eCapability\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePsychological\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eDo you understand the specific guidelines for anesthesia before pediatric surgery?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 352px;\"\u003e\n \u003cp\u003eIf yes \u0026rarr; Where did you hear about/learn this guideline? (Do you think fasting is important for pediatric anesthesia? What key steps should be followed during implementation? To what extent do you think this guideline is being followed? How familiar are you with the evidence behind this guideline? Do you know any other evidence?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eIf not \u0026rarr; What do you think is the reason you are not aware of this guideline?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 352px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eIf you are considering changing your approach，\u0026nbsp;how would you improve adherence to the guideline?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 352px;\"\u003e\n \u003cp\u003eWhat changes would your hospital or department need to make to support the implementation of the guideline?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ephysical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eWhat skills do you think healthcare professionals need to effectively implement this guideline?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 352px;\"\u003e\n \u003cp\u003eWhat skills do you think healthcare professionals need to effectively implement this guideline? In your opinion, which skills were not fully utilized during implementation? What specific challenges have you encountered while following the guideline? How did you address and solve these issues? Has your hospital or department provided relevant training or supported you in seeking external learning to improve knowledge and skills in this area?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eOpportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eSocial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eHow do the actions or opinions of colleagues, leaders, patients, or families impact you when applying the pediatric anesthesia guidelines?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 352px;\"\u003e\n \u003cp\u003eWhat might these actions or opinions be?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePhysical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eDoes your hospital or department have the resources to support the implementation of the guidelines? If not, what areas do you think need improvement?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 352px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eMotivation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eReflective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eWhat benefits do you think following the guidelines brings to individuals, the hospital, and patients?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 352px;\"\u003e\n \u003cp\u003eWhat do you think the consequences are of not following the guidelines? How would these consequences affect your and your colleagues\u0026apos; attitudes and behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eAutomatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 323px;\"\u003e\n \u003cp\u003eWhat responsibilities do you think healthcare professionals have in implementing this guideline?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 352px;\"\u003e\n \u003cp\u003eWhat role do you typically take when implementing the guidelines? If you strictly follow the guidelines, do you feel your professional autonomy is limited? In what areas?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAll interviews were conducted in Mandarin by the second author (F.L.Z., female), a registered nurse and Master of Nursing candidate with comprehensive training in qualitative methodology and clinical interviewing. With participant consent, interviews were audio-recorded using iFLYTEK devices. Mindful of potential interviewer effects, F.L.Z. maintained strict value neutrality and avoided leading questions throughout data collection.\u003cs\u003e\u0026nbsp;\u003c/s\u003eThe corresponding author completed verbatim transcription and independent cross-verification within 24 hours after each interview to ensure accuracy.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.4.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eData Analysis\u003c/p\u003e\n\u003cp\u003eData analysis employed the Framework Method for thematic analysis\u0026nbsp;[22], which integrated an inductive phase allowing themes to emerge directly from the data with a subsequent deductive phase guided by the COM-B model and TDF. This methodology enabled a comprehensive examination of key determinants influencing behavioral change processes by first capturing participants\u0026apos; raw insights and then interpreting these findings through established theoretical lenses. Following transcription and verification, the interview data were imported into NVivo 20 for systematic coding and analysis. Two coders (F.L.Z. and K.K.Z.) independently reviewed transcripts through an iterative process involving familiarization, initial coding, and thematic framework development. To ensure confirmability and maintain neutrality toward participants\u0026apos; narratives, both coders adopted a neutral stance throughout data examination.\u003c/p\u003e\n\u003cp\u003eTo enhance analytical rigor and minimize bias, the coders first independently performed inductive coding on five identical transcripts. During this initial phase, they identified relevant excerpts related to barriers and facilitators, assigning distinct code labels without predetermined frameworks to allow organic theme emergence. The coders subsequently convened to compare independently generated codes, resolve discrepancies, and collaboratively develop a preliminary thematic framework through iterative refinement until consensus was achieved.\u003c/p\u003e\n\u003cp\u003eInductive coding adhered to three established criteria\u0026mdash;frequency of belief occurrence, conflicts between beliefs, and intensity of behavioral influence\u0026mdash;ensuring thematic representativeness and analytical depth\u0026nbsp;[23]. Inter-coder reliability was assessed using Cohen\u0026apos;s kappa\u0026nbsp;[24], with discrepancies resolved through structured group discussions. Meaning saturation was determined to have been achieved with data from 7 surgeons, 7 anesthesiologists, and 5 nurses\u0026nbsp;[25], operationalized as the point where \u0026quot;complete comprehension of the issue\u0026apos;s essence with no emergence of new dimensions or insights\u0026quot; was attained\u0026nbsp;[20].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.5.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eEthical Considerations\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the Institutional Review Board of Jinan Children\u0026rsquo;s Hospital (Approval No. SDFE-IRB/P-2025004) and was conducted in accordance with the principles of the Declaration of Helsinki. Prior to participation, all participants were fully informed of the study\u0026rsquo;s purpose, procedures, estimated duration, voluntary nature, and their right to withdraw at any time without prejudice. They were also assured of the confidentiality and anonymity of their data, and were notified regarding access to aggregated study findings upon completion. Written informed consent was obtained from all participants. No financial incentives were provided for participation.\u003c/p\u003e"},{"header":"Results​","content":"\u003cp\u003eThe final analysis included 19 healthcare practitioners from three specialties: anesthesiology, surgery, and nursing. Participants were recruited from six tertiary hospitals, categorized as general hospitals (58%) and specialized pediatric institutions (42%). Detailed demographic and professional characteristics are presented in Table 2. A systematic examination of the data using the COM-B model and TDF identified key determinants of guideline adherence. The distribution of facilitating factors and barriers within the COM-B and TDF is shown in Figure 1. The following section presents the findings of the directed content analysis, including the coded constructs, their corresponding segments, and supporting quotes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eParticipant Demographics and Professional Characteristics.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eParticipants, No. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eTotal participants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eAge group, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e20-29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e2 (10%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e30-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e10 (53%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e40-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e6 (32%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e49-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1 (5%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 355px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e12（63%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e7（37% ) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eProfessional role\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eAnesthesiologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e7（37%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eSurgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e7（37%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e5（26%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eHospital type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eGeneral hospital\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e11（58%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eChildren\u0026apos;s hospital \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e8（42%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 228px;\"\u003e\n \u003cp\u003eYears of Clinical Experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 228px;\"\u003e\n \u003cp\u003e\u0026lt;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e3（16%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 228px;\"\u003e\n \u003cp\u003e5-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e5（26%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 228px;\"\u003e\n \u003cp\u003e10-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e7（37%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 228px;\"\u003e\n \u003cp\u003e16-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e4（21%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 355px;\"\u003e\n \u003cp\u003eNote: Data are presented as number (percentage) of participants.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.1.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eDomain1: Capability-Skills\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.1.1.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eFacilitators: Communication skills\u003c/p\u003e\n\u003cp\u003eEffective communication skills were identified as a key facilitator for guideline implementation. Most\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eanesthesiologists and surgeons\u0026nbsp;reported providing comprehensive medical advice to caregivers to ensure prompt resolution of concerns and accurate execution of fasting protocols.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;In fact, most parents effectively follow medical advice when properly informed. We also strive to make these instructions as simple, clear, and time-efficient as possible to enhance comprehension and compliance.\u0026quot; (S7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.1.2.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eFacilitators: Assessment skills\u003c/p\u003e\n\u003cp\u003eSeveral anesthesiologists highlighted the role of assessment skills, suggesting that preoperative gastric ultrasound could enhance guideline application by ensuring timely risk assessment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;In instances of unintended preoperative ingestion, we conduct an ultrasound assessment of gastric emptying before proceeding with surgery.\u0026quot; (A3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.2.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eDomain2: Capability-Knowledge\u003c/p\u003e\n\u003cp\u003e2.1.1．\u0026nbsp;Barriers：Practitioners lack knowledge\u003c/p\u003e\n\u003cp\u003eA deficiency in training and education regarding the guidelines was highlighted by most nurses. Some anesthesiologists noted that surgeons\u0026apos; knowledge of preoperative fasting was not updated in a timely manner, and the teaching materials they relied on lagged behind contemporary standards. The need to promptly revise textbooks, integrate the latest guidelines into clinical practice, and raise awareness was emphasized.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We scratch the surface of the content of the guideline, without detailed knowledge.\u0026quot; (N4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;This situation arises because they (surgeons) are updated more slowly than we are; sometimes their understanding remains rooted in outdated guidelines and rules.\u0026quot; (A7)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;It\u0026apos;s primarily because the guidelines are established by anesthesiologists. They (surgeons) may not pay sufficient attention, and it is also possible that their traditional surgical textbooks still recommend 4 hours, which have not been updated.\u0026quot; (A4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurthermore, some\u0026nbsp;nurses\u0026nbsp;contend that the training on the guidelines should be administered by anesthesiologists; however, they currently lack the requisite knowledge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Anesthesiologists are the best individuals to lead training... so we nurses think it\u0026apos;s time for anesthesiologists\u0026apos; knowledge to be updated and improved.\u0026quot; (N3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.3.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eDomain3: Capability- Behavioural Regulation\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.3.1.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eBarriers: lack of collaboration\u003c/p\u003e\n\u003cp\u003eSome participants observed a current deficiency in collaboration among practitioners. They underscored that tripartite collaboration and timely adjustments to fasting protocols could enhance the implementation of the guidelines.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Regarding the implementation of the guideline, there has been no formal dialogue among the three parties\u0026mdash;surgeons, anesthesiologists, and nurses\u0026mdash;to establish a consensus on this matter.\u0026quot; (N3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Anesthesiologists, doctors, and nurses must ensure highly coordinated and effective communication. For instance, through tripartite collaboration, patients can be informed in advance about when they may resume fluid intake. This approach may represent the most effective path forward.\u0026quot; (S4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.3.2.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eFacilitators: Plan of action\u003c/p\u003e\n\u003cp\u003eParticipants expressed strong support for the introduction of Artificial Intelligence（AI）large models that could enhance the prediction of surgical processes, noting that appropriate technical support may facilitate the implementation of guidelines.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;In fact, there are times when we could proactively communicate and prepare in advance. In the future, could we develop an intelligent AI prediction software? For instance, if the first surgery is delayed, how long might the second surgery take? What is the required anesthesia time? For the third and fourth surgeries, could the software automatically analyze these variables? Additionally, there could be a screen or an app to alert nurses, guiding pediatric patients on when to drink water. This system should also integrate with the hospital wards.\u0026quot; (A4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.4.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eDomain4：Opportunity-Environmental Context and Resources\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.4.1.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eBarriers：Lack of policy support\u003c/p\u003e\n\u003cp\u003eParticipants across all three occupations emphasized the urgent need for stronger policy support, citing inadequate backing from administrative departments. They stressed that the Medical Affairs Department and Nursing Department must actively endorse and prioritize guideline implementation at the hospital level.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Hospital-level implementation is necessary when the administration mandates compliance, supported by implementation directives from both the Medical Affairs Department and Nursing Department.\u0026quot; (A1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.4.2.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eBarriers：Unpredictable\u0026nbsp;surgical scheduling\u003c/p\u003e\n\u003cp\u003eThe majority of participants indicated that, given current conditions in China\u0026mdash;where human and environmental resources are constrained\u0026mdash;numerous operational scheduling challenges arise and operation times become unpredictable. These factors have significantly impacted the implementation of fasting guidelines, particularly for emergency surgical procedures.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Surgical uncertainty exists because while some procedures adhere to the estimated timeline, emergency cases may unexpectedly arise, necessitating deviations from the scheduled time... This is the biggest obstacle.\u0026quot; (N1)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The temporary changes complicate timely updates for families. For instance, when an emergency occurs during an ongoing surgery and requires additional time for intervention, the subsequent pediatric surgery patient may be subjected to an excessively prolonged fasting period.\u0026quot; (A5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.4.3.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eBarriers：Lack of training resources\u003c/p\u003e\n\u003cp\u003eSeveral participants across three professions reported a lack of training resources on fasting guidelines, which prevented practitioners from updating their knowledge promptly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I have not attended many academic conferences focused on pediatrics; thus, my knowledge is likely more aligned with traditional practices.\u0026quot; (A6)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.4.4.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eBarriers：Conservative culture\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants reported that some practitioners exhibited heightened risk aversion and expressed significant concern about potential hazards associated with clinical procedures. This conservative stance hindered adoption of the latest fasting guidelines, and their reluctance to deviate from established protocols impeded effective implementation of the new recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Everyone is so hyper-focused on safety\u0026mdash;prioritizing absolute safety over the guidelines\u0026rsquo; recommendations\u0026mdash;that they fail to fully consider the child\u0026apos;s comfort or even their basic needs.\u0026quot; (S4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If a procedure has been performed in a certain manner for years without any apparent issues, it is often assumed to be correct. Even when a superior method emerges, its adoption is perceived as risky. Some individuals resist that risk and prefer to adhere to familiar practices.\u0026quot; (S7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.5.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eDomain5: Opportunity-Social Influences\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.5.1.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eBarriers：Interprofessional role conflict\u003c/p\u003e\n\u003cp\u003eParticipants from various occupations expressed concern about inconsistent preoperative fasting standards for children among anesthesiologists and surgeons. This variability in decision-making undermines the uniform application of established guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If I insist on implementing the guideline, but the anesthesiologist does not endorse it and declines to accept the surgery, this will inevitably impact...\u0026quot; (S4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The issue lies in the fact that, although we\u003c/em\u003e\u003cem\u003e（\u003c/em\u003e\u003cem\u003eanesthesiologists\u003c/em\u003e\u003cem\u003e）\u003c/em\u003e\u003cem\u003e\u0026nbsp;adheres to guidelines, the preoperative fasting orders are determined by the\u003c/em\u003e \u003cem\u003esurgeons\u003c/em\u003e\u003cem\u003e.\u0026rdquo; (A1)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe primary responsibility of nurses is to ensure that children adhere to these guidelines. It is perplexing that even among medical professionals within the same specialty, there may be differing recommendations for nurses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There can be some variation between anesthesiologists. For instance, I might recommend that a patient can consume water up to two hours prior to surgery. One anesthesiologist may find this acceptable, while another may disagree.\u0026rdquo; (N3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.5.2.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eBarriers：Communication challenges\u003c/p\u003e\n\u003cp\u003eCaregivers of pediatric patients with lower educational attainment often struggle to comprehend preoperative fasting requirements, despite repeated explanations from practitioners. This challenge undermines the effectiveness of preoperative education initiatives.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Sometimes the grandparents are the primary caregivers, and they may not hear the instructions clearly.\u0026quot; (N2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The current issue arises when caregivers fail to grasp the timing requirements; repeated explanations may prove ineffective.\u0026quot; (A2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMoreover, because the primary caregivers of young children in China are often grandparents, their compliance tends to be low, and they are more likely to violate guidelines due to indulgence. Consequently, the implementation of these guidelines in clinical practice proves challenging and fails to meet the expected standards.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;When grandparents are the primary caregivers, their ability to follow through might not be as good; it\u0026apos;s a bit frustrating sometimes.\u0026quot; (A5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Furthermore, for afternoon surgical procedures, caregivers may compromise fasting protocols by covertly providing food in the morning.\u0026quot; (S5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, some nurses have noted that the pronunciation of \u0026quot;fasting\u0026quot; in Mandarin is identical to that of \u0026quot;eating,\u0026quot; which can lead to misunderstandings regarding fasting instructions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I am concerned that, even after providing explanations, caregivers may not implement the instructions correctly. For example, a parent might confuse \u0026apos;\u003c/em\u003ej\u0026igrave;n sh\u0026iacute;\u003cem\u003e\u0026apos; (fasting) with \u0026apos;\u003c/em\u003ej\u0026igrave;n sh\u0026iacute;\u003cem\u003e\u0026apos; (eating).\u0026quot; (N4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.6.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eDomain6: Motivation-Emotion\u003c/p\u003e\n\u003cp\u003e2.6.1．\u0026nbsp;Barriers：Anxiety and non-cooperation\u003c/p\u003e\n\u003cp\u003eMost participants indicated that children\u0026apos;s emotional reactions, such as protest and anxiety during fasting, translate into stress for caregivers. This stress can create a chain reaction that affects practitioners, ultimately hindering the implementation of the guidelines.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Whereas others protest angrily after two hours: \u0026apos;Why must I starve? I can\u0026apos;t bear it!\u0026apos; Such tantrums increase parental anxiety, which then pressures medical staff.\u0026quot; (S7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.7.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eDomain7: Motivation-Social/Professional Role \u0026amp; Identity\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.7.1.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eBarriers：Leadership\u003c/p\u003e\n\u003cp\u003eA\u0026nbsp;few participants noted that leadership dynamics within professional roles impeded the implementation of guidelines during the initial phases of change.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Although clinical staff are aware of the new guideline, they remain unimplemented... as their application is prohibited by the head of Anesthesiology.\u0026quot; (S3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.7.2.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eFacilitators: Professional identity\u003c/p\u003e\n\u003cp\u003eA strong sense of professional identity rooted in the core values of \u0026quot;everything for the child\u0026quot; was evident across all surveyed institutions. Participants indicated that this intrinsic sense of mission motivated them to adhere to the guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Adherence to the guideline to ensure the safety of pediatric patients is, I believe, an integral part of our professional duty.\u0026quot; (N1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;As a doctor, I view safe preoperative fasting guidance as a fundamental aspect of my responsibility to heal and ensure patient safety, which is of paramount importance.\u0026quot; (S2)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.7.3.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eFacilitators: Driving force\u003c/p\u003e\n\u003cp\u003eMost participants indicated that the influential role of\u0026nbsp;anesthesiologists, grounded in their professional authority and knowledge leadership, significantly impacted the implementation of the guidelines by healthcare practitioners. This role effectively coordinates the consistency of clinical practice and promotes the ongoing adherence to the guidelines by clarifying responsibilities and providing professional leadership.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Who is responsible for drafting these guidelines? ... Because we anesthesiologists are particularly focused on fasting and are quite familiar with the latest research advancements in this area. In fact, these fasting guidelines were primarily written by us, the anesthesiologists.\u0026quot; (A1)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Anesthesiologists serve as the driving force behind preoperative fasting guidelines, and their guidance is essential. \u0026quot; (S2)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;In the preparatory stage of the establishment of the department, under the guidance of anesthesia, we ultimately formed a unified clinical regulation through consultation.\u0026quot; (N5)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.7.4.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eFacilitators: Champions\u003c/p\u003e\n\u003cp\u003eNurses, as champions of guideline implementation, prioritize, oversee, and actively promote the ongoing application of these guidelines.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Take our department, for example. Our head nurse is very strict in enforcing the guidelines, and we nurses have also begun to focus on them.\u0026quot; (N3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I believe the nursing team manages most of the processes. Often, after we issue the surgical order, the nurse informs the patient about the fasting schedule. That\u0026apos;s typically how it proceeds.\u0026quot; (S6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.8.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eDomain8: Motivation-Beliefs about Capabilities\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.8.1.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eFacilitators: Moral responsibility\u003c/p\u003e\n\u003cp\u003eMost participants regarded the implementation of guidelines as part of their professional responsibility. However, some individuals perceived child safety as a profound personal moral obligation, which facilitated adherence to the guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I\u0026apos;ve been through something like this - a child choking from aspiration - and I would be under enormous psychological stress. Even if no serious consequences actually occur, I still feel guilty.\u0026quot; (N2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.8.2.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eFacilitators: Beliefs\u003c/p\u003e\n\u003cp\u003ePractitioners\u0026rsquo; confidence in the guidelines is essential to earn patients\u0026rsquo; trust and encourage strict adherence by families.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I believe that the guidelines are correct, and if I can communicate with you confidently and effectively, then implementing the fasting guidelines becomes a firm decision.\u0026quot; (S7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.9.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003eDomain9: Motivation-Beliefs about Consequences\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.9.1.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/em\u003eBarriers: Indifference\u003c/p\u003e\n\u003cp\u003eSome participants exhibit a disregard for the established guidelines. They believe it is permissible to adhere to either the preoperative fasting guidelins or traditional practices, perceiving the connection between them as insignificant. Consequently, they are inclined to maintain their old habits and display apathy toward the adoption of the guidelines, which ultimately hinders the progress of their implementation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Reducing the fasting period as recommended\u003c/em\u003e \u003cem\u003eby current guidelines would undoubtedly enhance patient comfort; however, it is important to note that few individuals have genuinely considered the experiences of the children involved.\u0026quot; (S4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Surgeons and nurses typically instruct patients to refrain from clear fluids for 4 hours, a guideline we generally do not alter due to our belief in its modest impact. Occasionally, we suggest that patients may avoid clear fluids for only 2 hours prior to surgery. \u0026quot; (A4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;From a practical perspective, maintaining a uniform extended fasting period streamlines operations for medical staff to some extent. However, when managing a large number of children, this practice also reduces the likelihood of errors involving parents. If the fasting periods of children within the same ward differ, they may approach the nurses\u0026apos; station with inquiries, thereby significantly increasing the workload for our nursing and medical teams.\u0026quot; (S7)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discusion","content":"\u003cp\u003eThe implementation of pediatric preoperative fasting guidelines represents a critical evidence-based practice for ensuring perioperative safety. However, integrating these guidelines into clinical workflows presents substantial challenges, particularly within China\u0026apos;s healthcare context where limited resources and a tradition-oriented culture complicate implementation. Guideline adoption involves multiple dimensions：multidisciplinary collaboration, clinician-caregiver communication, resource allocation, defensive medicine, and interprofessional conflicts. These factors collectively create a unique complexity in the implementation process.\u003c/p\u003e\n\u003cp\u003eOur findings revealed substantial variation in the clinical implementation of pediatric preoperative fasting guidelines across hospitals in China. While variations in fasting protocols among different tertiary hospitals were consistent with the multicenter quantitative study by Zhang et al.\u0026nbsp;[26], we further identified inconsistencies even within the same institution，across surgical teams and individual anesthesiologists. This suggests that guideline implementation has not yet reached standardization, likely because preoperative fasting involves balancing patient safety, comfort, and surgical efficiency，priorities that vary across specialties\u0026nbsp;[27]，coupled with ineffective inter-departmental communication mechanisms and a lack of unified consensus-building processes. Within the Capability component, a key barrier was the absence of effective collaboration among surgeons, nurses, and anesthesiologists. The core conflict manifested as interprofessional role conflict: when anesthesiologists and surgeons held divergent interpretations of guideline appropriateness, the lack of an authoritative coordinator to facilitate dialogue and resolve differences often led to surgery suspension due to safety concerns, thereby impeding guideline implementation. In the Opportunity component, most practitioners reported that unpredictable surgical start times and duration，particularly during sequential operations，posed a major barrier to fasting guideline adherence, a finding consistent with both international and domestic studies\u0026nbsp;[28, 29].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUnder China\u0026apos;s current healthcare conditions, characterized by high patient volumes and heavy surgical loads, operating rooms consistently function at overcapacity with tightly packed schedules. This high-pressure environment has fundamentally shifted clinical decision-making toward efficiency-first approaches, where pediatric patients\u0026apos; comfort is often secondary. This prioritization reflects not practitioner indifference but an adaptive strategy\u0026mdash;a form of pragmatic \u0026quot;survival wisdom\u0026quot;\u0026mdash;within systemic constraints. Looking forward, artificial intelligence offers promising solutions. Large language models (LLMs) could be utilized to develop surgical-duration prediction tools\u0026nbsp;[30], which would integrate multidimensional data，including patient history, procedure type, and surgeon habits，significantly enhancing prediction accuracy and optimizing scheduling efficiency to reduce unplanned delays. For closed-loop management, these predictions could be integrated into real-time visual electronic boards and mobile nursing platforms connecting wards and operating rooms, enabling precise fasting monitoring and early warnings. Furthermore, a nurse empowerment mechanism could be established: when surgeries are delayed, nurses would follow standardized protocols to guide children to consume clear fluids two hours before estimated anesthesia induction. For patients with surgery rescheduled to an earlier time, anesthesiologists could use bedside ultrasound to assess gastric content\u0026nbsp;[31], thereby avoiding unnecessary prolonged fasting while maintaining safety standards.\u003c/p\u003e\n\u003cp\u003eA notable barrier identified was the pronounced conservative tendency among both surgeons and anesthesiologists. This phenomenon likely stems from defensive risk management strategies adopted by administrative and institutional systems within China\u0026apos;s healthcare environment, coupled with insufficient institutional mechanisms to support Evidence - Based Practice（EBP）implementation among practitioners. These conditions have led to clinical decision-making being dominated by risk-minimization logic, resulting in defensive medical practices\u0026nbsp;[32]. Furthermore, within this context, Chinese practitioners are influenced by a \u0026quot;conservative culture\u0026quot;\u0026nbsp;[33], which fosters unconscious, habitual resistance to updates and changes. This mindset often manifests through reasoning such as \u0026quot;since previous practices caused no problems, why change now?\u0026quot; It should be emphasized that this phenomenon is not unique to China. Similar patterns are observed in North America, Europe, and the Middle East, where practitioners tend to maintain existing practices to avoid potential medical disputes and legal liabilities[34\u0026ndash;36]. Contributing factors may include doctor-patient relationships, institutional systems, and social environments\u0026nbsp;[32]. We recommend implementing multidimensional strategies integrating institutional, technological, and cultural approaches\u0026nbsp;[37], including enhanced policy support at the administrative level\u0026nbsp;[38]\u0026nbsp;to provide practitioners with more adequate resources and safeguards.\u003c/p\u003e\n\u003cp\u003eNurses identified significant challenges in preoperative fasting education when grandparents served as primary caregivers, revealing two primary communication barriers. First, cognitive differences emerged as a key factor: influenced by cultural values where \u0026quot;food represents love\u0026quot; and personal experiences growing up during periods of scarcity, grandparents often developed compensatory psychological attitudes toward fasting. This cultural perspective became a significant barrier to guideline adherence. Additionally, elderly caregivers frequently struggled to understand medical terminology such as \u0026quot;clear fluids\u0026quot; and \u0026quot;solid foods,\u0026quot; often confusing different food categories\u0026apos; corresponding fasting windows (e.g., mistaking soups for clear fluids), necessitating repeated and patient explanations. Under this pressure, practitioners sometimes resorted to a \u0026quot;one-size-fits-all\u0026quot; midnight fasting policy to improve efficiency\u0026nbsp;[11].Second, homophone-related communication barriers in Mandarin posed challenges: the identical pronunciation of \u0026quot;禁食\u0026quot; (fasting) and \u0026quot;进食\u0026quot; (eating) - both pronounced \u0026quot;j\u0026igrave;n sh\u0026iacute;\u0026quot; - created potential misunderstandings during verbal instructions, leading to potential misinterpretations and incorrect implementations. To address these challenges, we recommend implementing culturally adapted, multimodal education strategies. These include illustrated fasting guideline brochures using actual food photographs instead of verbal instructions alone, and utilizing digital tools for education. The teach-back method\u0026nbsp;[39]\u0026nbsp;should be employed by having primary caregivers repeat key information, with grandparents subsequently conveying this information to parents, thereby creating a dual verification system for information accuracy.\u003c/p\u003e\n\u003cp\u003eAll three practitioner groups (surgeons, anesthesiologists, and nurses) reported insufficient training in evidence-based practice guidelines and inadequate training resources. In China, few anesthesiologists receive standardized residency training, resulting in significant disparities in pediatric anesthesia knowledge and decision-making capabilities across different institutions\u0026nbsp;[26]. Within this context, some anesthesiologists and surgeons demonstrated limited recognition of the clinical value of fasting guidelines, failing to complete the conceptual transition from \u0026quot;experience-based safety\u0026quot; to \u0026quot;evidence-based safety.\u0026quot; This phenomenon represents a compound barrier spanning three domains: outdated knowledge (Capability), lack of training resources (Opportunity), and insufficient conceptual emphasis (Motivation).\u003c/p\u003e\n\u003cp\u003eNevertheless, this study identified key motivational facilitators. Anesthesiologists demonstrated strong professional moral responsibility, beliefs, and role identity, indicating their potential as core drivers for guideline implementation. All three practitioner groups reached a high consensus on an ideal division of responsibilities: anesthesiologist-led\u0026nbsp;regimen development and approval, nurse-driven education and compliance monitoring, and surgeon cooperation in adjusting clinical decisions. To leverage these facilitators, we recommend establishing an anesthesia-led standardized knowledge dissemination system. This includes developing hospital-wide unified fasting lists specifying permitted/prohibited clear fluids and solid foods under anesthesia department leadership. Additionally, interprofessional training mechanisms should be created through regular workshops, lectures, and seminars to systematically update guideline-related knowledge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Strengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo date, few descriptive qualitative studies have investigated barriers to implementing pediatric preoperative fasting guidelines in China. As the first study to integrate the COM-B model and TDF, this research systematically examined implementation challenges within real-world clinical settings by incorporating multiple stakeholder perspectives\u0026mdash;including anesthesiologists, nurses, and surgeons\u0026mdash;thereby providing localized evidence for guideline implementation in Asian contexts. The study reveals the current state of guideline implementation within China\u0026apos;s complex healthcare system, with particular significance in identifying previously unrecognized latent barriers such as culturally influenced beliefs, homophone-induced communication challenges in Mandarin, conservative clinical culture combined with defensive medical practices, and interprofessional tensions arising from role perception differences between surgeons and anesthesiologists. These findings highlight how non-technical factors, including cultural beliefs, linguistic expressions, and organizational dynamics, critically constrain guideline implementation. The study establishes a solid foundation for designing more feasible and targeted behavioral intervention strategies.\u003c/p\u003e\n\u003cp\u003eThis study has limitations. First, all participants were recruited from tertiary grade A hospitals, excluding practitioners from primary healthcare institutions (e.g., primary and secondary hospitals, community health service centers), which may limit the applicability of findings to primary care settings. Second, although some clinicians indirectly referenced caregiver behaviors and perceptions, the study did not include direct interviews with primary caregivers (e.g., parents or grandparents) of pediatric patients. Consequently, barriers and facilitators related to caregiver cognition, decision-making logic, and interactions with clinical teams lack first-hand accounts from these key stakeholders. Although data saturation was achieved through purposive sampling and constant comparative analysis, these structural sampling limitations may reduce the representativeness and applicability of findings across other hospital levels. Future research should build upon this study by incorporating primary care practitioners and caregiver groups to validate and extend the identified behavioral determinants. Integrating the TDF with Behavior Change Techniques（BCTs）could facilitate the development of targeted intervention strategies, whose feasibility and effectiveness should be evaluated through mixed-methods or pragmatic trials across multi-level healthcare institutions.\u003c/p\u003e"},{"header":"Conclusıons","content":"\u003cp\u003eThis qualitative study, employing the COM-B model and the TDF, identified key barriers and facilitators influencing practitioners\u0026apos; implementation of pediatric preoperative fasting guidelines, providing critical insights for improving clinical practice. Our findings indicate that strategically leveraging existing facilitators\u0026mdash;such as \u0026nbsp;strong professional moral responsibility, clinical skills, and professional role identity\u0026mdash;while addressing critical challenges including interdisciplinary collaboration, clinician-caregiver communication, resource allocation, policy support, and interprofessional role conflicts is essential for successful guideline implementation. As pediatric care needs grow increasingly complex, systematically identifying and addressing these barriers holds global significance for preoperative fasting management. These findings support targeted interventions, such as establishing anesthesiologist-led multidisciplinary collaboration mechanisms, optimizing communication tools and processes, allocating necessary technological resources, strengthening institutional policy support, and clarifying professional roles to resolve conflicts. This study addresses important evidence gaps regarding guideline implementation among healthcare providers and offers timely, actionable recommendations for clinicians managing pediatric surgical patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBCTs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBehaviour Change Techniques\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOM-B\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCapability, Opportunity, Motivation-Behaviour\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOREQ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConsolidated Criteria for Reporting Qualitative Research\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEBP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEvidence-Based Practice\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLLMs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLarge Language Models\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTDF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTheoretical Domains Framework\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eThis study received ethical approval from the Institutional Review Board of Jinan Children\u0026rsquo;s Hospital (Approval No. SDFE-IRB/P-2025004) and was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eWritten informed consent was obtained from all participants.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTL: Conceptualization, Methodology, Writing \u0026ndash; Original Draft, Supervision; FZ: Investigation, Data Curation, Formal Analysis; LG: Supervision, Project Administration, Validation; BZ: Writing \u0026ndash; Review \u0026amp; Editing, Validation; ZZ: Investigation, Resources; KZ: Methodology, Formal Analysis; BL: Validation, Data Curation; GL: Conceptualization, Methodology, Writing \u0026ndash; Review \u0026amp; Editing, Supervision. All authors have read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank all participants for their valuable contributions to this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRoberts K, Brindle M, McLuckie D (2020) Enhanced recovery after surgery in paediatrics: a review of the literature. BJA Educ 20:235\u0026ndash;241. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bjae.2020.03.004\u003c/span\u003e\u003cspan address=\"10.1016/j.bjae.2020.03.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSociety of Surgery C, Society of Anesthesiology C (2021) Clinical Practice Guidelines for E༲AS in China (2021) (Ⅰ). Med J Peking Union Med Coll Hosp 12:624\u0026ndash;631. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.12290/xhyxzz.20210001\u003c/span\u003e\u003cspan address=\"10.12290/xhyxzz.20210001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDulay E, Griffin B, Brannigan J, McBride C, Hudson A, Ullman A (2024) Interventions to optimise preoperative fasting in paediatrics: a scoping review. Br J Anaesth 133:1201\u0026ndash;1211. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bja.2024.08.010\u003c/span\u003e\u003cspan address=\"10.1016/j.bja.2024.08.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXu D, Chen J, Cai Y (2024) Past and Present of Implementation Science (PartI)\u0026mdash;Origin and Development. Med J Peking Union Med Coll Hosp 15:442\u0026ndash;449. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.12290/xhyxzz.2024-0023\u003c/span\u003e\u003cspan address=\"10.12290/xhyxzz.2024-0023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang B, Pan S, Guo H, Fang H, Hu W, Liu G (2025) Investigation on the actual fasting time of children before surgery in China. J Clin Anesthesiology 41:169\u0026ndash;175. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.12089/jca.2025.02.012\u003c/span\u003e\u003cspan address=\"10.12089/jca.2025.02.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Robeye AM, Barnard AN, Bew S (2019) Thirsty work: Exploring children\u0026rsquo;s experiences of preoperative fasting. Paediatr Anaesth 30:43\u0026ndash;49. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/pan.13759\u003c/span\u003e\u003cspan address=\"10.1111/pan.13759\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarroll AR, McCoy AB, Modes K, Krehnbrink M, Starnes LS, Frost PA et al (2022) Decreasing pre-procedural fasting times in hospitalized children. J Hosp Med 17:96\u0026ndash;103. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/jhm.12782\u003c/span\u003e\u003cspan address=\"10.1002/jhm.12782\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWebb AR, Kalam I, Lui N, Loughnan RM, Leong S (2024) A pre and post interventional audit of an \u0026lsquo;apple juice on arrival\u0026rsquo; protocol to reduce excessive clear fluid fasting times in paediatric patients. Anaesth Intensive Care 52:328\u0026ndash;334. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0310057x241263112\u003c/span\u003e\u003cspan address=\"10.1177/0310057x241263112\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMerchant RN, Chima N, Ljungqvist O, Kok JNJ (2020) Preoperative Fasting Practices Across Three Anesthesia Societies: Survey of Practitioners. JMIR Perioper Med 3:e15905. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2196/15905\u003c/span\u003e\u003cspan address=\"10.2196/15905\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWong ANY, Ragg PG, Chong SW, Morton H, Oliver L (2022) Multicenter Survey on Staff Understanding of Preoperative Fasting Guidelines. J Perianesth Nurs 37:369\u0026ndash;373. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jopan.2021.05.004\u003c/span\u003e\u003cspan address=\"10.1016/j.jopan.2021.05.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDepartment of Paediatric Anaesthesia N-SCH, Rawlani SS, Dave NM, Karnik PP (2022) The Preoperative Fasting Conundrum: An Audit of Practice in a Tertiary Care Children\u0026rsquo;s Hospital. Turk J Anaesthesiol Reanim 50:207\u0026ndash;211. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5152/tjar.2022.21132\u003c/span\u003e\u003cspan address=\"10.5152/tjar.2022.21132\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNye A, Conner E, Wang E, Chadwick W, Marquez J, Caruso TJ (2019) A Pilot Quality Improvement Project to Reduce Preoperative Fasting Duration in Pediatric Inpatients. Pediatr Qual Saf 4:e246. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/pq9.0000000000000246\u003c/span\u003e\u003cspan address=\"10.1097/pq9.0000000000000246\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIsserman R, Elliott E, Subramanyam R, Kraus B, Sutherland T, Madu C et al (2019) Quality improvement project to reduce pediatric clear liquid fasting times prior to anesthesia. Paediatr Anaesth 29:698\u0026ndash;704. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/pan.13661\u003c/span\u003e\u003cspan address=\"10.1111/pan.13661\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRicci Z, Colosimo D, Saccarelli L, Pizzo M, Schirru E, Giacalone S et al (2024) Preoperative clear fluids fasting times in children: retrospective analysis of actual times and complications after the implementation of 1-h clear fasting. J Anesth Analg Crit Care 4:1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s44158-024-00149-3\u003c/span\u003e\u003cspan address=\"10.1186/s44158-024-00149-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThomasseau A, Rebollar Y, Dupuis M, Marschal N, Mcheik J, Debaene B et al (2021) Observance of preoperative clear fluid fasting in pediatric anesthesia: oral and written information versus text message information. A before-and‐after study. Paediatr Anaesth 31:557\u0026ndash;562. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/pan.14145\u003c/span\u003e\u003cspan address=\"10.1111/pan.14145\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBuchanan H, Newton JT, Baker SR, Asimakopoulou K (2021) Adopting the COM-B model and TDF framework in oral and dental research: A narrative review. Community Dent Oral Epidemiol 49:385\u0026ndash;393. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/cdoe.12677\u003c/span\u003e\u003cspan address=\"10.1111/cdoe.12677\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoang AN, Eades C, Harris FM, Cheyne H (2024) Barriers and enablers toward healthy eating and weight gain among pregnant women in Vietnam: A qualitative study with analysis informed by the theoretical domains framework and COM-B model. Appetite 203:107710\u0026ndash;107710. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.appet.2024.107710\u003c/span\u003e\u003cspan address=\"10.1016/j.appet.2024.107710\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMecoli MD, Sahu K, McSoley JW, Aronson LA, Narayanasamy S (2024) The use of point of care gastric ultrasound and anesthesia management in pediatric patients with preoperative fasting non-adherence scheduled for elective surgical procedures: a retrospective study. BMC Anesthesiol 24:1\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12871-024-02628-0\u003c/span\u003e\u003cspan address=\"10.1186/s12871-024-02628-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCane J, O\u0026rsquo;Connor D, Michie S (2012) Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci 7:1\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1748-5908-7-37\u003c/span\u003e\u003cspan address=\"10.1186/1748-5908-7-37\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHennink MM, Kaiser BN, Marconi VC (2016) Code Saturation Versus Meaning Saturation. Qual Health Res 27:591\u0026ndash;608. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1049732316665344\u003c/span\u003e\u003cspan address=\"10.1177/1049732316665344\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMichie S, van Stralen MM, West R (2011) The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci 6:42\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1748-5908-6-42\u003c/span\u003e\u003cspan address=\"10.1186/1748-5908-6-42\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGale NK, Heath G, Cameron E, Rashid S, Redwood S (2013) Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 13:1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1471-2288-13-117\u003c/span\u003e\u003cspan address=\"10.1186/1471-2288-13-117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatey AM, Islam R, Francis JJ, Bryson GL, Grimshaw JM (2012) Anesthesiologists\u0026rsquo; and surgeons\u0026rsquo; perceptions about routine pre-operative testing in low-risk patients: application of the Theoretical Domains Framework (TDF) to identify factors that influence physicians\u0026rsquo; decisions to order pre-operative tests. Implement Sci 7:52\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1748-5908-7-52\u003c/span\u003e\u003cspan address=\"10.1186/1748-5908-7-52\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMchugh ML (2012) Interrater reliability the:kappa statistic. Biochemia Med 22:276\u0026ndash;282\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHennink M, Kaiser BN (2021) Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Soc Sci Med 292:114523\u0026ndash;114523. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.socscimed.2021.114523\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2021.114523\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang B, Pan S, Zheng J, Li B, Miao Y, Liu G (2025) Optimizing pediatric preoperative fasting management: a survey of practices and real durations in Chinese hospitals. BMC Anesthesiol 25:1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12871-025-03064-4\u003c/span\u003e\u003cspan address=\"10.1186/s12871-025-03064-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePaul PA, Joselyn AS, Pande PV, Gowri M (2022) A cross sectional, observational study to evaluate the surgeons\u0026rsquo; knowledge and perspective on preoperative fasting guidelines in a tertiary care teaching hospital in Southern India. J Anaesthesiol Clin Pharmacol 38:434\u0026ndash;439. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/joacp.joacp_413_20\u003c/span\u003e\u003cspan address=\"10.4103/joacp.joacp_413_20\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYimer AH, Haddis L, Abrar M, Seid AM (2022) Adherence to pre-operative fasting guidelines and associated factors among pediatric surgical patients in selected public referral hospitals, Addis Ababa, Ethiopia: Cross sectional study. Ann Med Surg (Lond) 78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.amsu.2022.103813\u003c/span\u003e\u003cspan address=\"10.1016/j.amsu.2022.103813\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTingting Y, Sufang L, Yanan X, Pei N (2023) Clinical translation status and research progress of preoperative fasting and drinking prohibition guidelines for children undergoing elective surgery. Chin J Mod Nurs 29:1676\u0026ndash;1680. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3760/cma.j.cn115682-20220614-02865\u003c/span\u003e\u003cspan address=\"10.3760/cma.j.cn115682-20220614-02865\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRamamurthi A, Neupane B, Deshpande P, Hanson R, Vegesna S, Cray D et al (2025) Applying Large Language Models for Surgical Case Length Prediction. JAMA Surg. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamasurg.2025.2154\u003c/span\u003e\u003cspan address=\"10.1001/jamasurg.2025.2154\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaettig SJ, Filipovic MG, Hebeisen M, Meierhans R, Ganter MT (2023) Pre-operative gastric ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study. Anaesthesia 78:1327\u0026ndash;1337. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/anae.16117\u003c/span\u003e\u003cspan address=\"10.1111/anae.16117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChinese Hospital (2024) Management 44:6\u0026ndash;10\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAcademic E (2015) ;:54\u0026ndash;58\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKakemam E, Arab-Zozani M, Raeissi P, Albelbeisi AH (2022) The occurrence, types, reasons, and mitigation strategies of defensive medicine among physicians: a scoping review. BMC Health Serv Res 22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-022-08194-w\u003c/span\u003e\u003cspan address=\"10.1186/s12913-022-08194-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaungaard N, Skovvang PL, Assing Hvidt E, Gerbild H, Kirstine Andersen M, Lykkegaard J (2022) How defensive medicine is defined in European medical literature: a systematic review. BMJ Open 12:e057169. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjopen-2021-057169\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2021-057169\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSami R, Salehi K, Sadegh R, Solgi H, Atashi V (2022) Barriers to rational antibiotic prescription in Iran: a descriptive qualitative study. Antimicrob Resist Infect Control 11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13756-022-01151-6\u003c/span\u003e\u003cspan address=\"10.1186/s13756-022-01151-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChinese Hospital (2025) Management 45:1\u0026ndash;5\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang N, Zhang Q, Li C, Huang Y, Hu J, Wang J et al (2025) Barriers and facilitators of implementation sustainability of evidence-based practice for peristomal irritant contact dermatitis: A descriptive qualitative study. Int J Nurs Sci 285\u0026ndash;292. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijnss.2025.04.002\u003c/span\u003e\u003cspan address=\"10.1016/j.ijnss.2025.04.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWong CI, Desrochers MD, Conway M, Stuver SO, Mahan RM, Billett AL (2023) Improving Home Caregiver Independence With Central Line Care for Pediatric Cancer Patients. Pediatrics 151. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1542/peds.2022-056617\u003c/span\u003e\u003cspan address=\"10.1542/peds.2022-056617\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Barriers, Child, Facilitators, Preoperative fasting, Qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-8291324/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8291324/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperative fasting is critical for reducing intraoperative aspiration risk; however, pediatric fasting durations frequently exceed guideline recommendations such as the 6-4-2 fasting regimen (minimum fasting times of 6 h for solid food and infant formula, 4 h for breast milk, and 2 h for clear fluids). A significant evidence gap exists regarding barriers to and facilitators of adherence to these guidelines among pediatric healthcare practitioners in China. This study aimed to identify key barriers and facilitators influencing the implementation of pediatric preoperative fasting guidelines from the perspectives of anesthesiologists, nurses, and surgeons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative descriptive design was employed. Using purposive sampling, 22 practitioners (8 surgeons, 8 anesthesiologists, and 6 nurses) were recruited from six tertiary grade A hospitals in mainland China. Semi-structured interviews were conducted between January and March 2025. Data were analyzed thematically, guided by the integrated the Capability, Opportunity, Motivation and Behaviour model(COM-B)and the Theoretical Domains Framework (TDF).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree components from the COM-B model and seven domains from the TDF were identified as barriers to pediatric preoperative fasting guideline adoption. The most prominent barriers mapped to the Opportunity component: lack of policy support, unpredictable surgical scheduling, insufficient training resources, communication challenges and a conservative culture. Interprofessional role conflicts between anesthesiologists and surgeons were also prominent. Additional Capability barriers included practitioners lack of knowledge and insufficient collaborative practices. Motivation barriers encompassed child anxiety and non-cooperation during fasting periods, lack of leadership engagement, and practitioner indifference. Conversely, facilitators aligned with four TDF domains under Capability and Motivation included healthcare professionals' strong communication and assessment skills, and the development of action plans. Additionally, all three professional groups demonstrated a profound sense of moral responsibility, strong professional beliefs, and clear role identity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEffectively addressing the implementation challenges of pediatric preoperative fasting guidelines in China’s healthcare context requires systematically integrating existing facilitators while tackling barriers. Multifaceted intervention strategies are recommended, including establishing an anesthesiologist-led multidisciplinary collaboration framework, optimizing clinician-caregiver communication tools and processes, allocating necessary technological and human resources, strengthening hospital-wide policy support, and clarifying professional authority and responsibilities to resolve interprofessional conflicts.\u003c/p\u003e\n\u003cp\u003eClinical trial number: Not applicable\u003c/p\u003e","manuscriptTitle":"Facilitators and Barriers to Implementing Pediatric Preoperative Fasting Guidelines Among Chinese Healthcare Practitioners","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-15 11:03:26","doi":"10.21203/rs.3.rs-8291324/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fad62a37-6d83-4f16-a9b1-dca35fb5d319","owner":[],"postedDate":"December 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T12:25:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-15 11:03:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8291324","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8291324","identity":"rs-8291324","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}