Undergoing surgery requires an optimal nutritional status to support physical, cogni- tive and relational recovery. Patients with (risk for) undernutrition require nutritional support. Nurses are in key positions at outpatient clinics and at in-hospital surgical departments to address the nutritional status of the patients and to deliver evi- dence-based nutritional care tailored to individual needs. Despite the pivotal role of nurses in nutritional care, evidence is lacking on how nurses should deliver nutritional care for these patients. Adequate delivery of nutritional care by nurses will empower patients to take their own role and improve patients’ nutritional intake and nutrition- al status. In the direct preoperative period, patients are recommended to fast from solid foods and clear liquids to prevent aspiration-related pulmonary complications. This guideline is used worldwide in perioperative care. Since the 1960’s, fasting from midnight is implemented as practical recommendation in daily care for patients undergoing surgery. Therefore, this thesis first developed and evaluated nutritional nursing interventions for patients undergoing surgery. Secondly, adherence to and applicability of fasting recommendations are determined. This summary describes the main research findings, and the main messages from the discussion for nutritional care for surgical patients.
The phases of the MRC Framework for development and evaluation of complex inter- ventions were followed to generate evidence on delivery of preoperative nutritional support for undernourished surgical patients in nurse-led outpatient clinics (43). Per phase of this framework studies were performed on an outpatient nursing nutritional intervention for undernourished surgical patients. An overview of these studies are shown in figure 1.
In chapter 2, a systematic literature review was done to evaluate the effective- ness of nutritional support using regular diets as first step in the development phase of the MRC framework (136). Six articles describing five interventions were summa- rized. These interventions aimed to fulfil nutrient requirements, and mainly included counselling and advice, follow-up meetings and encouragements, and subscribing oral nutritional supplements (ONS). All interventions were delivered by dieticians, and there was no involvement of nurses, despite their primary role in outpatient clinic settings. Patients who received this type of nutritional support had significant improvements in nutritional status, nutrient intake and quality of life. Patients who had dietary counselling had better improvements compared to patients who only received ONS. The components of nutritional support derived from the systematic review study formed the basis of a nursing nutritional intervention to be delivered at outpatient clinics for undernourished patients planned for surgery. `
In chapter 3 we developed an outpatient nursing nutritional intervention within the MRC framework. Intervention Mapping (IM) was used to develop the proposed intervention (137). A research panel followed the six steps of IM (259). During the need assessment in the first step, nutritional care needs and current nutritional care delivery were determined from both nurses and undernourished patients’ perspec- tives. It appeared that both patients and nurses were unaware of the consequences of undernutrition, and nurses were unaware of their role in nutritional support.

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