Enhancing Nutritional Care in Palliative Care Units: Assessing Nurse Knowledge and Quality Perception in Enteral Nutrition Practices

doi:10.21203/rs.3.rs-4155845/v1

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Research Article

Enhancing Nutritional Care in Palliative Care Units: Assessing Nurse Knowledge and Quality Perception in Enteral Nutrition Practices

https://doi.org/10.21203/rs.3.rs-4155845/v1

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Background: Sufficient and well-balanced nutrition is pivotal in sustaining essential functions among patients in palliative care units.

Aim: To determine the knowledge levels of nurses working in palliative care units regarding enteral nutrition practices and their perceptions of nutritional care quality in their units.

Methods: This descriptive, cross-sectional study was conducted in 25 palliative care units located in Izmir, Türkiye, between June and September 2022. The study sample consisted of 205 nurses working in palliative care units. Data were collected using a general information form, an Enteral Nutrition Practices Knowledge Form, and the Nurses' Perceived Nutrition Care Quality Assessment Scale. STROBE checklist was used.

Results: The study found that the majority of participating nurses (94.6%) were female, with 78.5% holding bachelor's degrees. The median knowledge score for enteral nutrition: 15 (range: 2-27), perceived care quality score: 36 (range: 9-45). Those with enteral nutrition training had significantly higher knowledge scores (p <.001); palliative care certificate showed no difference (p = .846). Nurses lacking nutrition counseling knowledge had lower perceived care quality scores (p = 0.001). Monthly tube feeding applications correlated positively with knowledge scores (r = .173, p = .013), unlike professional experience duration (p= .126) and time spent in palliative care (p = .839).

Conclusion: Nurses working in the palliative care unit find the quality of nutrition care provided to patients in their clinics to be sufficient, and the level of knowledge regarding enteral nutrition is at a moderate level. However, in questions related to nursing care such as fluid requirements during enteral nutrition with enteral solutions that affect both nutritional care and medical treatment, maintaining the opening of the jejunostomy tube, and enteral drug administration, correct response rates were low. Low correct response rates on specific issues highlight a need for targeted educational interventions.

enteral nutrition

knowledge

nurses

nutritional care quality

palliative care units

palliative care nurses

The rapid advancements in medicine and technology, along with the increasing human lifespan, have ushered in an era where individuals are living longer with chronic and life-threatening illnesses [1–3]. As a result, healthcare professionals are encountering palliative care patients with chronic and life-threatening illnesses more frequently [2, 3]. Palliative care, encompassing holistic support for individuals of all ages enduring severe health-related suffering, especially those nearing the end of life, is crucial [4] According to the World Health Organization (WHO), "Palliative care is an approach that aims to improve the quality of life for patients and their families facing problems associated with life-threatening illnesses. It involves the early identification and impeccable assessment and treatment of pain and other physical, psychosocial, and spiritual issues to prevent and alleviate suffering [2]. Its goal is to ensure terminal patients can live their remaining days in comfort [4, 5].

Adequate and balanced nutrition is crucial for maintaining essential functions in palliative care patients. However, symptoms like discomfort, nausea, oral ulcers, diarrhea, and vomiting can severely impact their nutritional intake, leading to deficiencies [3]. Malnutrition in these patients can result in loss of body mass, weakened immunity, and organ dysfunction, ultimately affecting disease progression, reducing quality of life, and increasing hospitalization duration and mortality risk [6, 7]. Therefore, palliative care patients should be assessed for the risk of malnutrition, and early nutritional support should be initiated as needed [5]. Therefore, assessing palliative care patients for malnutrition risk and providing early nutritional support is imperative [5].

Nurses are integral members of the multidisciplinary palliative care team, playing key roles in enhancing patients' quality of life and ensuring adequate nutrition [8–10]. Their responsibilities, though varying based on hospital policies, typically involve tasks such as inserting and maintaining nasogastric feeding tubes, assessing calorie needs, initiating and adjusting nutrition plans, and promptly identifying and addressing any changes in patients' conditions [8, 11, 12]. Nurses' lack of knowledge about enteral nutrition [13–15], noncompliance with feeding guidelines [13], and practice inconsistencies all contribute to malnutrition in critically ill patients, including those in palliative care units [7, 8, 10].

Enteral nutrition, delivering essential nutrients via tube feeding to patients unable to eat orally, is widely utilized in palliative care units [3, 17]. Consequently, nurses in these units are expected to possess adequate knowledge of enteral nutrition. Despite numerous studies examining nurses' enteral nutrition knowledge levels [11, 18–21], research on the nutritional care perceptions of palliative care nurses is limited [10, 22, 23]. Particularly in Turkey, where studies on nutrition and nursing in palliative care are scarce, there's a need to assess nurses' knowledge and perceptions in this context.

The aim of this study to determine the knowledge levels of nurses working in palliative care units regarding enteral nutrition practices and their perceptions of nutritional care quality in their units.

Design

This study is a cross-sectional, descriptive, quantitative research.

Setting and sample

This descriptive cross-sectional study was conducted in the 25 palliative care units within public hospitals in İzmir, Turkey, between June and September 2022. The study population consisted of 237 nurses working in palliative care units. There was no sample selection process because the entire universe was to be used as the study sample. The inclusion criteria for the sample comprised individuals who had served as nurses in palliative care units for a minimum duration of six months and demonstrated willingness to engage in the study. Nurses who refused to participate in the study and filled out the questionnaire incompletely were excluded from the study. The study sample comprised 205 nurses. The rate of participation in the study was 86.5%.

Data collection

After a verbal explanation of the study goals, informed consent form was obtained from the nurses who agreed to participate in the study. Palliative nurses filled out the data collection forms under the supervision of the researchers. Data collection was carried out in their units. The completion of the forms took approximately 8–10 minutes.

Data collection tools

The knowledge level of nurses regarding enteral nutrition practices was determined using the Information Form on Enteral Nutrition Practices developed by Koçhan and Akın (2018) [20]. This form consists of two sections: the first contains questions about enteral nutrition practices, and the second contains questions about indications for enteral nutrition, enteral nutrition solutions and complications, the duration of enteral solution administration, and questions to assess enteral nutrition knowledge. This form yields a minimum of 0 points and a maximum of 27 points [20]. The perceived quality of nutritional care was assessed using the third section of the "Scale for Evaluating the Importance of Nutritional Assessment, Knowledge Level of Nutritional Care, and Perceived Quality of Nutritional Care in Nurses," developed by Theilla et al. [21] and validated by Kısacık et al. (2019). Each section of the scale can be evaluated separately. The score range that can be obtained from this section of the scale is 9–45. A higher score from this section, consisting of nine items, reflects that nurses evaluate the quality of nutritional care provided to patients in their units more positively [24]. The data collection flowchart of the study is presented in Fig. 1.

Data analysis

The collected data were analyzed using the Statistical Package for Social Sciences (SPSS) 22.0

software. Descriptive statistics were performed, including means, standard deviations, medians,

minimum-maximum values, and frequency measurements. Conformity to a normal distribution of measurable variables was calculated with the Shapiro-Wilk test. Non-normally distributed data were analyzed using the Mann-Whitney U test for comparisons between two groups and the Kruskal-Wallis test for more than two categories. Fisher's Exact test was used when the Chi-Square test could not be applied for comparing categories. In correlation analyses for non-normally distributed data, the Spearman correlation test was used. The level of significance was set at p < .05.

The majority of nurses are female (94.6%) and bachelor's degree graduates (78.5%). About 37.56% of nurses stated that they have never received any training on enteral nutrition, while 66.34% do not have a palliative care certificate. In 19.51% of the units where they work, no nutrition counseling is provided, while in 29.76% of units, counseling is provided for all patients receiving nutritional support, and in 39.51% of units, counseling is provided for some patients receiving nutritional support. Additionally, 11.22% of participants stated that they do not have knowledge about the nutrition counseling practices implemented in their units (Table 1).

Table 1

Palliative care nurses sociodemographic and institutional characteristics
				n	%
Gender	Men			11	5.3
Gender	Women			194	94.6
Education	Health Vocational High School			8	3.9
	Associate degree			15	7.3
	Bachelor's degree			161	78.5
	Master degree			21	10.2
Palliative Care Certification	Yes			69	33.6
Palliative Care Certification	No			136	66.3
Enteral Nutrition Training	Yes			128	62.4
Enteral Nutrition Training	No			77	37.5
Nutritional Counseling	Yes	All patients receiving nutritional support.		61	29.7
	Yes	Some patients receiving nutritional support.		81	39.5
	No			40	19.5
	I have no knowledge			23	11.2
The most commonly used method of nutritional support	ONS			37	18.0
	Tube feeding		PEG	71	34.6
	Tube feeding		NG	61	29.7
	Parenteral			36	17.5
ONS: Oral nutritional support, NG: Nasogastric tube, PEG: Percutaneous endoscopic gastrostomy

The median age of the participants is 36 ± years (Min: 21, Max: 51), the median professional experience is 14 years (Min: 1, Max: 34), the median palliative care unit experience is 3 ± years (Min: 1, Max: 16). The median values of Nutritional Care Quality Perception Score and Knowledge Level Total Score were determined as 36± (Min: 9, Max: 45), 15± (Min: 2, Max: 27), respectively (Table 2).

Table 2

Monthly nutritional support numbers, knowledge levels, and perceived nutritional care quality scores
	Median	Minimum	Maximum
Work Experience Duration	14	1	34
Palliative Care Experience Duration	3	1	16
Montly ONS Frequency	10	0	200
Montly Tube (NG + PEG) Feeding Frequency	10	0	70
Montly Parenteral Frequency	6	0	120
Nutritional Care Quality Perception Score	36	9	45
Knowledge Level Total Score	15	2	27
ONS: Oral nutritional support, NG: Nasogastric tube, PEG: Percutaneous endoscopic gastrostomy

The responses to questions related to knowledge levels regarding enteral nutrition practices are presented in Table 3. It is observed that questions related to fluid requirements, maintaining the patency of the jejunostomy tube, enteral administration of medications, and types of tubes used during enteral nutrition with liquid solutions were answered correctly at rates lower than 25%. However, questions related to the use and maintenance of feeding sets/bags, nursing interventions to prevent gastrointestinal complaints during enteral nutrition with solutions, storage conditions for enteral products, care for NG tubes and PEG, infusion rates for NJ feeding, and nursing interventions to prevent NG tube obstruction were answered correctly at rates higher than 75%. The median score of the Enteral Nutrition Practices Knowledge Form was determined as 15 (Min: 2-Max: 27) (Table 3).

Table 3

Knowledge levels regarding enteral nutrition practices (n = 205)
	Right (%)
1. Which type of solutions should be preferred for enteral nutrition?	127(61.9)
2. Which of the following statements is correct regarding continuous enteral feeding?	17(8.2)
3. How many hours can enteral nutrition solutions remain in the feeding set?	121(59.0)
4. Which of the following indicates delayed gastric emptying in enteral feeding?	69(33.6)
5. How often should gastric residual volume be checked in intermittent enteral feeding to assess the tolerance of the given nutrition?	91(44.3)
6. How often should the enteral nutrition bag and set be changed in tube-fed patients?	181(88.2)
7. Where and for how long should enteral nutrition products be stored after opening?	159(77.5)
8. What is the maximum amount of enteral nutrition product that can be given in one feeding in bolus intermittent feeding?	54(26.3)
9. What is the maximum duration for each meal in intermittent enteral feeding?	77(37.5)
10. To prevent possible pulmonary aspiration in patients receiving enteral nutrition, how many degrees should the patient's head be elevated during and after enteral feeding?	131(63.9)
11. Nursing interventions to prevent abdominal distension and nausea/vomiting during enteral feeding are listed below. Which one is incorrect?	166(80.9)
12. Which of the following interventions regarding medication administration in patients receiving enteral nutrition is incorrect?	24(11.7)
13. Which nursing interventions are important to plan to prevent blockages in a nasogastric tube in an enterally fed patients?	150(73.1)
14. What can develop if the enteral feeding solution is given cold to a patient receiving enteral nutrition?	175(85.3)
15. Which of the following interventions to prevent nausea and vomiting in enterally fed patients is incorrect?	179(87.3)
16. Which of the following interventions is incorrect for preventing bacterial growth in feeding bags and tubes during enteral nutrition?	174(84.8)
17. Which of the following methods is not used to confirm the placement of a nasogastric tube in a patient with a nasogastric tube?	168(81.9)
18. In patients requiring nutritional support who cannot take food orally, parenteral nutrition should be preferred initially.	94(45.8)
19. Enteral feeding solutions completely meet fluid requirements.	6(2.9)
20. If a patient is being fed through a jejunostomy tube, drinking water should be given through the jejunostomy tube to maintain tube patency.	20(9.7)
21. Enteral feeding can be applied in cases such as intestinal obstruction, paralytic ileus, severe enteritis and peritonitis, severe diarrhea, and malabsorption.	135(65.8)
22. In the nasojejunal feeding method, since the nutrition solution is given directly to the intestine, complaints due to rapid gastric emptying (Dumping syndrome) may develop.	154(75.1)
23. Polyurethane and silicone tubes should be preferred in patients undergoing enteral nutrition.	165(80.4)
24. Hypertonic enteral nutrition solutions may cause diarrhea.	92(44.8)
25. Rapid and excessive administration of hypertonic nutrition solutions can cause dehydration.	102(49.7)
26. Polyvinyl tubes should be preferred in patients where the risk of complications is low and enteral nutrition is applied.	21(10.2)
27. In patients with a PEG catheter, the catheter insertion site (stoma) is cleaned using 0.9% NaCl or antiseptic solution.	161(78.5)
Enteral Nutrition Practices Knowledge Form – Section 1 = Median: 11(Min: 1-Max:17) Enteral Nutrition Practices Knowledge Form - Section 2 = Median: 5(Min: 0-Max:10) Total Score of the Knowledge Form on Enteral Nutrition Practices = Median: 15(Min: 2-Max:27)

When the correct answer rates given to the Information Form on Enteral Nutrition Practices are evaluated; 0.98% (n = 2) of the participants answered < 25% of the questions, 23.41% (n = 48) answered 25–50%, 68.29% (n = 140) answered 50–75% and 7.32% (n = 15) answered > 75% correctly (Fig. 2).

There was no statistically significant difference between the correct answer rates on the Enteral Nutrition Practices Knowledge Form and the presence of a palliative care certificate. However, the rate of correct answers was higher for those who received enteral nutrition training compared to those who did not (p = .008) (Table 4). Nurses who received enteral nutrition training had a higher total score on the Enteral Nutrition Practices Knowledge Form compared to those who did not (p < .01). However, there was no statistically significant difference in the Nutritional Care Quality Perception Scores between the two groups (p = .190). Regarding the presence of a palliative care certificate, there was no statistically significant difference in the total knowledge score on the Enteral Nutrition Practices Knowledge Form (p = .846) or the Nutritional Care Quality Perception Score (p = .496).

Table 4

Distribution of correct answer rates based on palliative care certificate and enteral nutrition training status
The Correct Answer Rates	Palliative Care Certification
	Yes		No		p
	n	%	n	%	p
<%25.0	2	2.9	0	0	.129
%25.0–50.0	19	27.5	29	21.3
%50.0–75.0	42	60.8	98	72.0
>%75.0	6	8.7	9	6.6
Total	69	100.0	136	100.0
	Enteral Nutrition Training
<%25.0	2	1.5	0	0	.008*
%25.0–50.0	20	15.6	28	36.3
%50.0–75.0	93	72.6	47	61.0
>%75.0	13	10.1	2	2.6
Total	128	100.0	77	100.0
Fisher’s Exact testi, p < .05*

The presence of a nutrition consultant in the unit did not have a statistically significant impact on the total score of the Enteral Nutrition Practices Knowledge Form (p = .543). However, there was a statistically significant difference in the Nutritional Care Quality Perception Score among groups (p < .05). According to the results of the Posthoc test (Tamhane-2 test), the group with a nutrition consultant in their unit had a higher Nutritional Care Quality Perception Score compared to those who did not have nutrition consulting (p = .01). The results of the Posthoc test (Tamhane-2 test) indicate that the group with a nutrition consultant in their unit had a higher Nutritional Care Quality Perception Score compared to those who did not have nutrition consulting (p = .01). This suggests that the presence of a nutrition consultant in the unit is associated with a higher perceived quality of nutritional care among nurses, and this difference is statistically significant (Table 5).

Table 5

The impact of palliative care certificate, enteral nutrition training, and nutrition counseling on the total knowledge score related to enteral nutrition practices and the perception score of nutritional care quality
		Enteral Nutrition Practices Knowledge Form Score		Nutritional Care Quality Perception Score
		Median(Min-Max)	p	Median(Min-Max)	p
Palliative Care Certification	Yes	15 (2–22)	.846	36 (9–45)	.496
Palliative Care Certification	No	15 (7–27)	.846	36 (10–45)	.496
Enteral Nutrition Training	Yes	16 (2–27)	< .001^a*	36 (9–45)	.190
Enteral Nutrition Training	No	14 (7–21)	< .001^a*	36 (13–45)	.190
Nutritional Counseling	Yes	15(8–27)	.543	37(9–45)	.001^b*
	No	15(2–22)		35(19–43)
	I don’t know	15(7–20)		32(13–44)
^aMann-Whitney U Test, ^bKruskal Wallis Test, ^cSpearman Korelasyon Testi, * p < .05

The correlations between the Total Knowledge Score Related to Enteral Nutrition Practices and the Perception Score of Nutritional Care Quality, as well as monthly tube feeding frequency, monthly ONS (Oral Nutrition Support) frequency, monthly parenteral nutrition frequency, professional experience duration, and duration of working in palliative care, were examined. It was found that there is a positive correlation between the monthly tube feeding frequency and the Total Knowledge Score Related to Enteral Nutrition Practices (r = .173, p = .013), while there was no statistically significant correlation with the other variables (Table 4).

Table 6

The correlation between the perception score of nutritional care quality and the total knowledge score related to enteral nutrition practices
		Nutrisyonel Nutritional Care Quality Perception Score	Total Score of the Information Form on Enteral Nutrition Practices
Montly Tube Feeding Frequency	r^c	.048	.173
Montly Tube Feeding Frequency	p	.497	.013*
Monthly ONS Frequency	r	− .036	.011
Monthly ONS Frequency	p	.613	,876
Monthly Parenteral Nutrition Frequency	r	− .105	.038
Monthly Parenteral Nutrition Frequency	p	.137	.588
Palliative Care Experience Duration	r	.14	− .10
Palliative Care Experience Duration	p	.839	.888
Professional Experience Duration	r	.107	− .56
Professional Experience Duration	p	.126	.429
Nutritional Care Quality Perception Score	r	1	.089
Nutritional Care Quality Perception Score	p	-	.202
Total Score of the Knowledge Form on Enteral Nutrition Practices	r	.089	1
	p	.202	-
	n	205	205
ONS: Oral nutritional support

The aim of this study was to examine the knowledge levels of nurses working in palliative care units regarding enteral nutrition practices, as well as their perceptions of the quality of nutritional care in their units. Receiving enteral nutrition training and the monthly frequency of tube feeding in the unit where nurses work had a significant effect on the overall score of the Enteral Nutrition Practices Knowledge Form. However, having a palliative care certificate did not have a significant effect on this score. The findings also highlighted that the perceived quality of nutritional care was above average and was influenced by whether the unit received nutrition counseling units. In Turkey, there used to be a requirement that individuals must be female to become a nurse according to the nursing law in effect between 1954 and 2007 [25]. However, the current law allows men to work as nurses, but for many years, nursing was predominantly considered a profession for women, which limited the number of male nurses [26, 27]. This historical gender bias is reflected in your study, where the majority (94.63%) of the volunteers who participated in the study were female nurses. Furthermore, the expansion of palliative care centers in Turkey began with the Pallia Turk project, which was part of the National Cancer Control Program from 2009 to 2015. The number of these centers started to increase in 2012–2013 [28]. As a result, nurses in Turkey have had limited opportunities to work in palliative care units or centers, and their duration of employment in these settings has generally been relatively short. Your study found that the median duration of employment in a palliative care center for nurses was 3 years (minimum: 1 year, maximum: 16 years). This suggests that palliative care nursing is a field that is still developing in Turkey, and nurses with more experience may be more likely to work for longer periods in palliative care settings. These historical and contextual factors highlight the gender dynamics and the emerging field of palliative care nursing in Turkey.

Palliative care focuses on managing symptoms and disease-related stress in terminally ill patients. The goal of palliative care is to improve the quality of life for these patients while relieving them from pain, symptoms, and stress [29]. Malnutrition is common in palliative care patients and can be influenced by various factors. As the disease progresses in these patients, nutritional disorders become more common, leading to the need for nutritional support [30]. Proper nutritional interventions can support overall well-being and improve the overall quality of life [31]. Therefore, enteral nutrition is considered an essential component of providing quality care to patients in palliative care settings [29, 30, 31]. Studies conducted in Turkey report a malnutrition risk of over 90% in palliative care units and enteral nutrition support rates of approximately 20–60% [17, 32, 33]. Given the frequency of enteral nutrition use and its significant potential benefits for patients, it is important for nurses to have comprehensive and adequate knowledge in this area. [34].

It is expected that nurses being trained in enteral nutrition would enable them to assess patients' nutritional needs, administer enteral nutrition, monitor complications, and provide education on enteral nutrition to patients and their families. In the present study, 62.4% of the participating nurses reported receiving training in enteral nutrition. Previous studies conducted in Turkey have reported varying results regarding nurses' status of receiving enteral nutrition training, ranging from 7.8–62% [20, 24, 35, 36]. This variation could be attributed to factors such as the policies of the institution/department where the study was conducted, the patient population served by the institution/department, and the year in which the research was carried out. Studies have shown that educational programs designed for nurses can significantly improve their practices, performance, and knowledge level related to enteral nutrition [19, 37, 38, 39]. In this study, nurses who received enteral nutrition training had a higher total score on the Enteral Nutrition Practices Related Knowledge Form compared to those who did not receive training (p < 0.01). However, even among those who received training, only 10.16% answered > 75% of the questions correctly, and 17.18% answered < 50% of the questions correctly. Insufficient knowledge and incorrect practices by nurses in providing enteral nutrition to patients can negatively affect both the quality of care and patient safety, while well-implemented nutritional nursing care can improve patients' nutritional status and clinical outcomes [19, 37]. Therefore, it is recommended to plan regular and continuous education to enhance nurses' enteral nutrition practices and improve the quality of care.

In this study, it can be said that nurses' knowledge level regarding enteral nutrition practices is at a moderate level. This result is similar to previous studies conducted in Turkey [20, 24]. In a study by Koçhan & Akın (2018), it was shown that nurses had insufficient knowledge in areas such as storage conditions of enteral products, tolerance of the feed given to enterally fed patients, gastric residual volume indicating delayed gastric emptying in enteral nutrition, and medication administration in enterally fed patients [20]. In another study, it was found that nurses answered questions related to skin problems around stomas (83.53%), feeding position (80.59%), and interventions to prevent nausea and vomiting (73.53%) more correctly. However, they mostly couldn't answer questions about residual volume (88.82%), pulmonary aspiration (61.76%), and tube care (56.47%) [24;35]. In this study, the questions related to fluid requirements during tube feeding (2.9%), maintaining the patency of jejunostomy tubes (9.8%), and medication administration (11.71%) during tube feeding were the least correctly answered questions.

For patients receiving tube feeding, if fluid restriction is not applied, fluid requirements are calculated as 1 mL/kcal. Since most of the isocaloric formulas commonly used in these patients consist of approximately 75% water, additional fluid support is needed, typically at least 25% of the used feeding product. The remaining amount in the calculated fluid requirement can be completed with drinking water to meet the patient's fluid needs. The amount of water used in tube irrigations is also included in this calculation [20, 40, 41]. It's worth noting that one of the questions with the highest number of incorrect answers in this study was "Enteral nutrition solutions completely meet fluid requirements." Only 2.92% of the nurses in the study answered this question correctly. This indicates that nurses may not have sufficient knowledge about the content of enteral nutrition products and determining daily fluid requirements.

In tube feeding, the patency of the feeding tube cannot be maintained due to various factors, and blockages may occur. Proper flushing is required to prevent blockages and maintain patency. In continuous feeding, the tube should be flushed with water every 4–6 hours, and in intermittent feeding, before and after each feeding, and if the tube is not in use, it should be flushed every eight hours. In addition, to prevent potential blockages due to drug and formula interactions, it is recommended to flush the tube before and after drug administration [42]. In this study, the question about preventing blockages in nasogastric tubes was answered correctly by 73.17%, while the question about maintaining patency in jejunostomy tubes was only answered correctly by 9.76%. This may be due to the fact that PEG and NG tubes are commonly used in the units where the nurses work, while jejunostomy tubes are not frequently used.

Nutrition tubes can also be used for administering orally administered medications. Incorrect preparation and/or administration of medication in these processes can affect patients [43]. In the literature, there are studies that report that nurses are not sufficient in preventing drug interactions in enteral drug administration and that the flushing procedures vary [44–46]. It has been shown that the knowledge level, behavior, and attitudes of nurses on this subject can be significantly improved with an educational intervention. In a case-control study conducted in Iran, in-service training provided to nurses working in intensive care units improved their knowledge level, attitudes, and behaviors related to tube-mediated drug administration and increased the rate of consultation with pharmacists regarding medication administration [18]. In another case-control study conducted in Jordan, similar to previous studies, it was found that education provided to intensive care nurses improved their knowledge in areas such as tube cleaning, medication preparation, and recognition of dosage forms [47]. In a study conducted in Turkey, training provided to ninety nurses working in a neurology clinic, palliative care unit, and intensive care unit improved the nurses' knowledge and attitudes regarding medication administration through enteral routes [48]. In the current study, the correct response rate for questions related to medication administration is quite low (11.7%). Therefore, it is recommended to provide training to nurses working in palliative care units regarding medication administration in patients with tube feeding.

In 2015, the Turkish Ministry of Health introduced a Palliative Care Nursing Certification Training Program, comprising 35 hours of theory and 80 hours of practical training over a five-year validity period. The program aims to equip nurses caring for palliative care patients with essential knowledge, skills, and attitudes [49]. While the theoretical part of the training program includes the topic of "Total Parenteral/Enteral Nutrition Application," this topic is not covered in the practical training section. In the current study, 33.66% of nurses reported that they received a certificate by completing the certification training program. However, only 7.32% of the nurses correctly answered questions on the Enteral Nutrition Practices Knowledge Form by more than 75%. It was also determined that having the palliative care certificate did not have a significant effect on the scores of the Enteral Nutrition Practices Knowledge Form and Nutritional Care Quality Perception score (p > .05). Therefore, it is considered beneficial to enhance the content related to enteral nutrition in the palliative care certificate training programs and add this topic to practical lessons.

In hospitals where nutrition support teams (NST) are established, nutrition support can be applied in a more individualized manner [50]. It has been shown that the implementation of nutrition support by NST significantly reduces nutrition-related complications, enables early detection of malnutrition, reduces calorie deficits in patients, and reduces costs [51, 52, 53]. Nutrition counseling teams are becoming increasingly common in hospitals worldwide [53]. In a study conducted by Kurt and Paslı Gündoğan (2023) in intensive care units in Turkey, 48.3% of the participating nurses reported that their institutions did not have NST [54]. This indicates the need for the more widespread use of nutrition support teams in hospital settings.

In study, 29.7% of the nurses reported receiving consultation services from the nutrition team for all patients requiring nutritional support, while 39.5% reported receiving such services for some patients. It has been observed that the presence of nutrition counseling in the unit where the participant works significantly differentiated the Nutritional Care Quality Perception Score among groups. Although the percentage (11.22%) of nurses who were not aware of the presence of nutrition counseling in the palliative care unit where they work may seem proportionally low, it is an important finding. The lack of knowledge about the nutrition support protocol in the unit where the nurse works is a point that needs attention. Continuous training on the importance of nutrition support should be conducted in units where such support is frequently applied, and providing information about the unit's nutrition support practices during orientation training for those new to the unit is recommended.

Strengths and limitations

A strength of the current study is that it used validated evaluation tools to collect comprehensive data on nurses' knowledge and perceptions of enteral nutrition. It carried out thorough data analysis, investigating correlations between variables with a variety of statistical techniques. These results provide relevant information for improving the delivery of enteral nutrition care in palliative settings and designing focused educational interventions. The study also identified contextual elements that enriched the interpretation within wider societal and healthcare contexts, such as gender bias and Turkey's changing palliative care landscape.

Accessing a significant percentage of the study population in Turkey's Izmir provience provided valuable insights into the local context. However, relying solely on data collected from a single province limits the generalizability of the findings. The study, which included 205 palliative care nurses, may not adequately represent the diversity and heterogeneity of the nursing profession in palliative care units. Furthermore, the dependence on self-reported data increases the possibility of bias, as nurses' behaviors regarding enteral feeding may differ from their self-reports. These limitations highlight the need for caution when applying the study's findings to other regions or groups, as well as the need of future research efforts that use broader sampling methodologies and objective assessments of nursing practices.

Nurses play a crucial role in implementing nutritional interventions, contributing significantly to the quality of nutrition care. This study revealed that nurses demonstrated moderate levels of knowledge regarding enteral nutrition practices, with lower correct answer rates for certain aspects such as fluid requirements and tube maintenance. The study found a positive correlation between nurses having received enteral nutrition training and higher knowledge scores. The presence of a nutrition consultant in units was associated with a higher perceived quality of nutritional care among nurses. The study found also a positive correlation between monthly tube feeding frequency and knowledge scores related to enteral nutrition practices. This study sheds light on nurses' enteral nutrition practices in palliative care units, offering valuable insights for clinical development. Ongoing training programs, formation of nutrition support teams, and dissemination of best practices in enteral nutrition are crucial for enhancing care quality in palliative units. Focused educational interventions are crucial for improving nurses' proficiency in enteral nutrition administration, particularly in fluid requirements, tube maintenance, and medication administration. Moreover, the presence of nutrition counseling teams positively influences perceived nutritional care quality, emphasizing the significance of interdisciplinary collaboration for better patient outcomes.

WHO World Health Organization

NST Nutrition Support Team

ONS Oral Nutritional Support

NG Nasogastric Tube

NJ Nasojejunal

PEG Percutaneous Endoscopic Gastrostomy

Acknowledgements

Our sincere thanks go to all participants of the study.

Author contributions

The listed authors meet the criteria for authorship and agree with the content of the manuscript. Study conception and design: ZB, GBM, Data collection: KT, Data analysis and interpretation: ZB, Drafting of the article: ZB, GBM. Critical revision of the article: GBM. All authors supervised critically reviewed the manuscript and checked spelling and grammar. All the authors read and approved the final manuscript.

Funding source

No funding was received for conduction this study.

Data availability statement

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

Non-Interventional Clinical Studies Ethics Committee of Health Sciences University Tepecik Training and Research Hospital (Approval no. 2022/01-26, Approved date: 17.01.2022) approved the proposal. The study was conducted following the Declaration of Helsinki. The participants were informed of the study's goal and given the assurance that their nonparticipation or withdrawal would not affect them negatively. The written consent forms were obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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Enhancing Nutritional Care in Palliative Care Units: Assessing Nurse Knowledge and Quality Perception in Enteral Nutrition Practices

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