Barriers to the Adherence of ICU Nurses to the Tube Feeding Protocol: A Qualitative Study

doi:10.21203/rs.3.rs-4998036/v1

Download PDF

Research Article

Barriers to the Adherence of ICU Nurses to the Tube Feeding Protocol: A Qualitative Study

https://doi.org/10.21203/rs.3.rs-4998036/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

The heightened metabolic demands of critically ill patients on ventilators necessitate proper tube feeding for optimal recovery. Despite nurses being primarily responsible for administering tube feeding, evidence indicates a lack of adherence to evidence-based practices. This study aims to identify the barriers preventing ICU nurses from adhering to the tube feeding protocol.

Methods

This qualitative study utilized conventional content analysis. Participants included ICU nurses from Sina Hospital, Tabriz, Iran, in 2024. A combination of purposeful and snowball sampling was employed, achieving data saturation after 19 interviews. Data were collected through semi-structured interviews and analyzed using the Zhang & Wildemuth method.

Results

The analysis identified three primary barriers to adherence: the gap between theoretical knowledge and clinical practice, organizational and interpersonal challenges, and resistance to change.

Conclusion

The findings highlight that barriers to adherence are multifaceted, deeply rooted in organizational contexts. Policymakers and clinical educators can use these insights to develop targeted interventions. Future nurses can reflect on these findings to enhance their professional development and adjust protocols to bridge identified gaps. Additionally, organizational values and interventions for nursing staff should be revised to address these barriers effectively.

Enteral Nutrition

Intensive Care Units

Nurses

Qualitative Research

Proper nutrition is crucial for meeting the dietary and physiological needs of critically ill patients, who often have heightened energy requirements due to their conditions (1). Tube feeding, which involves delivering nutrients through a feeding tube from the nose to the stomach, is the preferred method for providing nutritional support to patients unable to eat orally(2). However, inadequate management of tube feeding can lead to severe complications such as pulmonary aspiration, nutritional intolerance, mechanical obstruction, and accidental respiratory placement (3). Respiratory aspiration remains a significant cause of morbidity and mortality among hospitalized patients and nursing home residents(4)

Nurses play a vital role in the safe administration of tube feeding, ensuring tube patency, and delivering prescribed feeds and medications (5). Evidence-based approaches are recommended to improve nutritional and clinical outcomes for patients, as adherence to clinical practice guidelines results in better tube feeding outcomes in ICU (6). A study conducted in Egypt revealed that only about three fifths of nurses had a high level of knowledge about enteral nutrition. Additionally, less than half of the nurses exhibited a positive attitude, and fewer than three quarters demonstrated adequate performance in administering enteral nutrition in pediatric intensive care unit (7). Studies have highlighted discrepancies between recommended guidelines and actual bedside practices (8). Additionally, some studies have identified a gap between theoretical knowledge and practical application among nurses regarding nasogastric tube placement and the management of feeding-related complications(9, 10). A multicenter study in China found that many nurses still rely on traditional methods for inserting and testing the placement of nasogastric tubes, which differ from international guidelines (11).

It is essential to determine whether nurses have adopted safe practices. Although established guidelines exist for tube feeding, identifying barriers beyond improper practices in the ICU is necessary (12, 13). These barriers, which can be individual, social, or organizational, impede the implementation of prescribed guidelines and create a gap between guidelines and actual practices(14). Evaluating performance and identifying barriers has been a contentious issue in personnel management and organizational activities, emphasizing the need for mutual understanding of performance expectations. Therefore, this study aims to determine the barriers to ICU nurses' adherence to the tube feeding protocol.

Study Design

It is a qualitative research employing a conventional content analysis approach. This particular method is typically chosen in situations where there is limited existing research or theories about the phenomenon being studied. Given that the assessment of barriers is influenced by both the context and the period, the researchers opted for conventional approach (15).

Setting

The study was conducted at Sina Educational and Medical Center in Tabriz, Iran, a general and referral hospital that also serves as a specialized center for burns and poisoning. The hospital has seven ICUs, including surgical, poisoning, burns, infectious, and three general ICUs. Nurses working in these units have a minimum of six months of experience in internal or surgical departments and have been scientifically and practically approved by hospital supervisors. In Iran, nurses graduate from either a state university or an independent university after completing a four-year course.

At this hospital, nursing officials annually update the guidelines for common nursing procedures based on the latest references, specific settings, and recorded issues. These updated guidelines are then communicated to all departments. Nursing and supervisors' reports are required to compare nurses' performance with these guidelines.

Participants

The Participants included nursing graduates with bachelors or master's degrees who had a minimum of six months of experience. The nurses themselves scheduled the interview times and chose the interview location based on their preferences. Sampling took place between January 2024 and July 2024.

The sampling method was purpose-based and tried to select nurses with maximum diversity in terms of age, gender, work experience, department, university of graduation, and interest in the field. If a participant gave an example of another nurse, that nurse was also invited to study in the form of a snowball (numbers 14). Sampling continued until data saturation and until the levels of all codes were complete and there was no need for new codes (N = 19).

Collecting data

Interviews were conducted using semi-structured, in-depth individual interviews with open-ended questions, lasting between 45 to 60 minutes. The interviews began by building rapport and establishing trust with the participants, followed by completing the informed consent form and personal profile questionnaire. The purpose of the study was communicated, and the nurses were asked the following questions, as outlined in the interview guide:

How do you administer the tube feeding?
How closely do you adhere to the tube feeding guidelines?
What are the barriers to adhering to the tube feeding protocol?
What problems and challenges do you face during tube feeding administration?

During the interviews, the researcher asked clarifying questions as needed. Additionally, data was collected through note-taking in the field. The first author also observed certain participants during the gavage process to gather further information.

Data Analysis:

The interviews that were recorded were transcribed word by word and typed up promptly. Coding of the data began simultaneously with the data collection. The codes were then classified. The process of analyzing the content in this research adhered to the recommendations outlined by Zhang and Wildemuth (15) in the following manner:

1. Data Preparation: Interviews were transcribed verbatim, including all non-verbal cues such as pauses and expressions.
2. Determining the Analytical Unit: Themes were identified as the analytical units, primarily consisting of individual sentences, but also paragraphs or single words.
3. Developing Categories and a Coding Scheme: Using the constant comparative method, semantic units were categorized based on commonalities and differences. Codes were grouped by similarity to form the study's framework, derived directly from interview data and field notes.
4. Testing the Coding Scheme: The first three interviews were independently analyzed by the first and second authors. An external reviewer compared their analyses, and due to significant resemblance, the first author continued with the coding process.
5. Coding All the Text: Coding was performed continuously, with new concepts and themes emerging or merging. Consistency was evaluated by separately coding one interview (participant no. 18) and comparing results to ensure reliability.
6. Drawing Conclusions: Conclusions were derived from the coded data through discussions and debates among the authors, comparing and defining the characteristics and range of each subclass

Rigor

In order to guarantee the trustworthiness of the data, we implemented the four criteria outlined by Guba and Lincoln (16). We established credibility by validating the nurses' statements through interview summaries, asking detailed questions during interviews to ensure accurate interpretation of their statements, and having the research team review the manuscripts. To ensure dependability, the first and second authors, both experienced in qualitative studies, extracted codes and categories. The data was continually and comparatively analyzed, and the research analysis process was consistently reviewed to enhance confirmability. Maximum variance sampling and inclusion of a wide range of participants in terms of age, gender, etc., ensured the transferability of the study data to other researchers in the same environment.

In this study, interviews were conducted with 19 nurses and one educational supervisor. Most of the nurses were female (N = 16). The ages of the nurses ranged from 25 to 46 years, and their work experience ranged from 1 to 20 years (Table 1). Data analysis revealed three main themes and eight sub-themes (Table 2), which are discussed below:

Table 1

Demographic characteristic of nurses (N = 19)
Number	Gender	Age	Work experience
1.	Female	40	16
2.	Male	40	15
3.	Male	28	4
4.	Female	25	2
5.	Female	41	19
6.	Female	41	18
7.	Female	39	15
8.	Female	25	8
9.	Female	33	10
10.	Female	40	16
11.	Female	41	18
12.	Female	25	3
13.	Female	25	3
14.	Female	33	9
15.	Female	27	14
16.	Female	25	3
17.	Male	33	8
18.	Female	45	20
19.	Female	23	1

Table 2

Themes and Sub-Themes and attributes emerged from the data.
Themes	Sub-Themes
The Gap Between Theory and Practice	Knowledge Barriers
	Practical Barriers
	Rapid Changes in Guidelines
Organizational and Interpersonal barriers	Insufficient Supervision
Organizational and Interpersonal barriers	Human and Social Factors
Resistance to Change	Attitude Towards Change
	Uncertainty in Protocols
	Adherence to Routine Practices

Theme 1: The Gap between Theory and Practice

This theme highlights the disparity between academic knowledge and practical application in clinical settings. Nurses often find it challenging to bridge the gap between what they learned in their academic training and the realities of their daily practice.

Sub-theme: Knowledge Barriers

Nurses emphasized the necessity of having up-to-date knowledge to follow the latest guidelines. However, they felt their knowledge was not ideal due to being away from academic settings and not engaging in continuous study. One nurse expressed, "It's been years since I last opened a book. How can I be expected to know the latest guidelines?" (P. 11) Additionally, nurses often perceived themselves as knowledgeable while viewing their colleagues as less informed, leading to a lack of motivation to update their own knowledge. Another nurse remarked, "With all this academic stagnation around, what can I say?" (P. 8)

Sub-theme: Practical Barriers

Nurses frequently face heavy workloads and limited time to review and incorporate the latest evidence into their practice. Time constraints were a common issue. One nurse stated, "With three intubated patients, I don't have time to carefully administer tube feeding drop by drop." (P. 3) Another nurse shared, "My patient has a jejunostomy, and the feeding rate needs to be very slow. But with a syringe, I can't control the rate well. The patient suffers during feeding." (P. 1)

Sub-theme: Rapid Changes in Guidelines

Nurses identified rapid changes in guidelines as another barrier to adherence. They felt that frequent updates made it difficult to keep up. One nurse commented, "One day they say do it this way, the next day they say do it another way. It's confusing." (P. 2) Insufficient communication of the latest changes in guidelines was also mentioned as a barrier. A nurse recounted, "A student asked how much residual volume should be before not giving tube feeding. I said 50. Then the instructor said no, it's 100. I confidently said I read the guideline, but when I went to check, I saw a new guideline saying it's 100." (P. 13)

Theme 2: Organizational and Interpersonal barriers

This theme addresses the lack of effective oversight and guidance from supervisors and management. Effective supervision and management are crucial for ensuring adherence to protocols and guidelines.

Sub-theme: Insufficient Supervision

Nurses highlighted that supervision and follow-up by supervisors significantly increase adherence to guidelines. However, they also pointed out that the lack of sufficient supervision often serves as a justified excuse for non-compliance. One nurse shared, "I've been a nurse here for twenty years. Not once has anyone come to check if I'm following the guidelines for tube feeding." (P. 18) This lack of oversight was attributed to the weak scientific and practical knowledge of supervisors. Another nurse remarked, "If you ask our head nurse what tube feeding is, she'll look at the ceiling. Why would she care if I'm doing it right or not?" (P. 15)

Sub-theme: Human and Social Factors

Various human and social factors, such as stress, fatigue, poor communication with patients or their families, and ethical and professional conflicts, can significantly affect a nurse's performance. One nurse explained, "With these long shifts, high workload, standing for long periods, and painful varicose veins, it's hard to do tube feeding properly." (P. 9) These factors create a challenging work environment that hinders adherence to protocols and impacts the overall quality of care.

Theme 3: Resistance to Change

This theme explores the reluctance of nurses to adapt to new practices and guidelines. Resistance to change can significantly impact the implementation of new protocols and procedures.

Sub-theme 1: Attitude towards Change

The attitude of nurses towards tube feeding and its impact on their performance and behavior during the feeding of critically ill and intubated patients is crucial. A positive and correct attitude towards tube feeding can significantly improve performance and patient care. However, some nurses exhibit a dismissive attitude towards the importance of tube feeding, especially in cases they perceive as less critical. One nurse remarked, "A few scoops of formula powder, what difference does it make to bed 6 (a patient in end-stage coma for six months)?" (P. 17)

Sub-theme 2: Uncertainty in Protocols

Nurses expressed uncertainty about the benefits of new guidelines due to a lack of trust in the authorities. This skepticism stems from inconsistent information and changes in the guidelines. One nurse shared, "Previously, the kitchen provided formula, saying it met the patient's energy and mineral needs. Later, they brought ready-made powder, saying it was more nutritious. One really doesn't know what's right. Is it the supervisor's preference or genuine concern for the patient?" (P. 2) This lack of trust creates confusion and hinders adherence to new protocols.

Sub-theme 3: Adherence to Routine Practices

Many nurses resist changing their practices based on new evidence, especially if they have been practicing a certain way for a long time. This adherence to old routines is a significant barrier to compliance with new guidelines. One nurse explained, "When you get used to something, it's hard to change and start doing it differently from tomorrow." (P. 4) Another nurse highlighted the constant changes in policies, saying, "Every day a new rule, a new policy, one day they bring a shaker, another day powder, another day they measure formula." (P. 7) This constant flux in guidelines and practices contributes to resistance and reluctance to adopt new methods.

The findings of this study highlight several critical barriers that ICU nurses face in adhering to tube feeding protocols. These barriers can be broadly categorized into three main themes: the gap between theory and practice, organizational and interpersonal barriers, and resistance to change.

One of the major challenges in nursing, particularly in the context of tube feeding, is the disparity between academic knowledge and practical application. Nurses often struggle to apply theoretical knowledge in real-world settings due to various scientific, practical, and social barriers. The necessity of having up-to-date knowledge to follow the latest guidelines was frequently mentioned by nurses (17).

In Pakistan, a study discovered that the majority of intensive care nurses possessed a moderate understanding of tube feeding. The study also revealed a noteworthy correlation between the nurses' level of education and the sources from which they obtained their knowledge about tube feeding. These findings underscore the importance of continuous training for nurses, especially those working in ICUs (17). Research in Turkey demonstrated that the average knowledge score of nurses about tube feeding doubled after training (18). Similarly, a study in Australia highlighted the effectiveness of training in improving the performance of nurses in this field. These studies collectively emphasize the critical need for ongoing education and training to bridge the gap between theoretical knowledge and clinical practice (19).

ICU nurses frequently face the dual challenges of heavy workloads and limited time, which significantly hinder their ability to review and incorporate the latest evidence into their practice. This issue is well-documented in the literature, with numerous studies highlighting the demanding nature of ICU settings and the high patient-to-nurse ratios that leave little room for continuous professional development (20, 21).. For instance, Ahmed et al. found that a majority of nurses were unfamiliar with the current guidelines for enteral feeding, underscoring the gap between recommended practices and actual bedside care (22). This disconnect not only affects the quality of patient care but also highlights the urgent need for institutional support in providing time and resources for ongoing education and training. By addressing these workload and time constraints, healthcare institutions can better equip nurses to stay updated with evidence-based practices, ultimately improving patient outcomes.

Rapid changes in tube feeding guidelines have been identified as a significant barrier to adherence among ICU nurses. Studies have shown that frequent updates to these guidelines can lead to confusion and inconsistencies in practice. For instance, O'Leary-Kelley and Bawel-Brinkley highlighted that the constant evolution of nutrition support protocols often results in nurses struggling to keep up, thereby reducing adherence and increasing the risk of errors (23). Similarly, McKnight and Carter discussed how the rapid changes in hospital nutritional guidelines contribute to confusion among nursing staff, making it challenging to maintain consistent practices (24).

A positive and correct attitude towards tube feeding can significantly enhance both performance and patient care. When nurses recognize the importance and effectiveness of tube feeding, their confidence and adherence to protocols increase, leading to improved patient outcomes. This positive attitude fosters a more proactive approach to patient care, ensuring that nutritional needs are met efficiently and effectively. Recent studies corroborate this notion. For instance, Ramuada et al. found that nurses with a positive attitude towards enteral nutrition were significantly more likely to adhere to feeding protocols. This adherence not only optimizes nutritional support but also minimizes complications associated with improper feeding practices. By cultivating a positive attitude towards tube feeding, healthcare institutions can empower nurses to deliver higher quality care, ultimately enhancing patient recovery and well-being (25).

Nurses' uncertainty regarding protocols, particularly in ICU settings, can significantly impact adherence to tube feeding guidelines. This uncertainty often stems from inconsistent updates and communication about the protocols, leading to confusion and variability in practice. A study by Preiser et al. highlighted that clear and consistent guidelines are crucial for improving adherence and ensuring optimal patient care in critical care environments (26)

Adherence to routine practices remains a significant barrier to the implementation of new evidence-based guidelines among ICU nurses. Many nurses, especially those with long-standing practices, find it challenging to adapt to new methods. This resistance is often rooted in familiarity of established routines. A study by Smith et al. found that despite recognizing the benefits of evidence-based practices, nurses often struggle to integrate new protocols due to ingrained habits and the constant flux of guideline (27).

The study identifies several critical barriers that ICU nurses face in adhering to tube feeding protocols. These barriers include the gap between theoretical knowledge and practical application, organizational and interpersonal challenges, and resistance to change. The findings underscore the importance of continuous education and training to bridge the gap between theory and practice. Additionally, addressing workload and time constraints, providing institutional support, and fostering a positive attitude towards tube feeding are essential for improving adherence to protocols. Clear and consistent guidelines are crucial for ensuring optimal patient care and minimizing complications associated with improper feeding practices.

Implications for Nursing Practice

Regular training programs should be implemented to keep ICU nurses updated with the latest guidelines and best practices in tube feeding. Healthcare institutions need to provide adequate time and resources for nurses to engage in continuous professional development. This includes addressing workload and time constraints that hinder nurses from staying updated with evidence-based practices. Developing and maintaining clear, consistent, and easily accessible guidelines for tube feeding can help reduce confusion and variability in practice. Regular updates and effective communication about these guidelines are essential. Encouraging a positive attitude towards tube feeding among nurses can enhance adherence to protocols and improve patient outcomes. This can be achieved through motivational programs and highlighting the benefits of proper tube feeding practices. Strategies should be developed to help nurses adapt to new evidence-based guidelines. This includes providing support for nurses to transition from established routines to new practices and addressing any uncertainties they may have regarding protocols. By implementing these strategies, healthcare institutions can empower ICU nurses to deliver higher quality care, ultimately enhancing patient recovery and well-being

Acknowledgments

We want to show our appreciation to the nurses who dedicated time to interview. Additionally, we would like to thank the Deputy of Research and Technology at the Medical Sciences University of Tabriz for providing financial assistance. Furthermore, we express our thanks to the Clinical Research Development Unit of Sina Educational, Research, and Treatment Center at Tabriz University of Medical Sciences, Tabriz, Iran for their invaluable support in conducting this research. Our gratitude also extends to the Shahid Madani Hospital's Charity for their intellectual and mental support for this research. This charity, with registration number 5140, offers financial aid to patients in need and also collaborates in educating patients, promoting client wellness, and supporting research studies.

Ethical Considerations

This article stems from a research project assigned the approved code IR.TBZMED.REC.1399.378, with the endorsement of the regional ethics committee in biomedical research. Both verbal and written consent were obtained, and participants were informed about the voluntary nature of their involvement and the confidentiality of their information.

Clinical trial number: not applicable.

Authorship contribution statement

Faranak Jabbarzadeh: Formulated the problem statement, Contributed to writing the manuscript, contributed to data analysis. Elnaz Asghari: Managed and coordinated the project, Conducted data analysis, and contributed to writing the manuscript, Arefeh Davoodi: Contributed to writing the manuscript, Contributed to critical review the manuscript.

Conflict of interest

None of the authors had a conflict of interest.

ALL Sources of Support

This study was derived from a thesis in Medical-Surgical Nursing (MSc) authorized by Tabriz University of Medical Sciences with the ethics code TBZMED.1394.526. We greatly appreciate the cooperation of the Office of Research and Technology at Tabriz University of Medical Sciences

Clinical trial number: not applicable

Funding Source:

Research Deputy of Tabriz University of Medical Science supported this study financially.

Data availability statement

The data related to the results of this study are available upon request from the corresponding author

Patient consent statement

All participants willingly enrolled in the study and provided written consent after being fully informed about the research objectives and procedures . Informed consent has been obtained from all participants in this study

Moisey LL, Merriweather JL, Drover JW. The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated. Critical Care. 2022;26(1):270.
Nightingale JM. Insertion, Types and Care of Enteral Feeding Tubes. Intestinal Failure: Springer; 2023. p. 489-512.
Elmahdi A, Eisa M, Omer E. Aspiration pneumonia in enteral feeding: A review on risks and prevention. Nutrition in Clinical Practice. 2023;38(6):1247-52.
Plotnikov G, Levy Y, Trotzky D, Nassar A, Bushkar Y, Derazne E, et al. Characteristics of older adults receiving enteral feeding at a geriatric medical center. BMC geriatrics. 2024;24(1):628.
Soon L, Tong PC, Chung LJ, Tan SL, Goh QL. Medication Administration via Enteral Feeding Tubes: A Survey of Nurses’ Knowledge and Practice. Malaysian Journal of Pharmacy (MJP). 2022;8(1):26-31.
Turan M, Cengiz Z, Olmaz D. Evidence-Based Investigation of Nurses' Nutrition Interventions in Intensive Care Patients Regarding Enteral Nutrition. Dimensions of Critical Care Nursing. 2024;43(3):123-9.
Mohamed Abo Elezz H, Mohamed Adly R, Refaat Tantawi H. Assessment of nursing performance toward enteral feeding at pediatric critical care units. Egyptian Journal of Health Care. 2021;12(4):1159-78.
Maya A, EK MM, Taylor J, Larson S, Islan S, Petroze R. Decision making surrounding mode of initial enteral feeding in critically ill pediatric patients. IJ Pediatr Res. 2022;8:086.
Rihab S, Abdelmajid N. Is Theory-Practice Gap Existe? 2023.
Wabuyele CK, Ajayi C, Kalu L. Educational material: inserting and removing nasogastric tube for adults and children. 2022.
Xu L-c, Huang X-j, Lin B-x, Zheng J-y, Zhu H-h. Clinical nurses’ nasogastric feeding practices in adults: a multicenter cross-sectional survey in China. Journal of International Medical Research. 2020;48(4):0300060520920051.
Eckmann K. A description of feeding practices with critically ill patients in the adult intensive care unit in the South African public healthcare sector.
Njuguna JW. Nurses' Knowledge, Attitude, and Practice on Enteral Feeding of Critically Ill Patients at Kenyatta National Hospital: University of Nairobi; 2023.
Darawad MW, Alfasfos N, Zaki I, Alnajar M, Hammad S, Samarkandi OA. ICU nurses' perceived barriers to effective enteral nutrition practices: a multicenter survey study. The open nursing journal. 2018;12:67.
Zhang Y, Wildemuth BM. Qualitative analysis of content. Applications of social research methods to questions in information and library science. 2009;308(319):1-12.
Guba EG, Lincoln YS. Fourth generation evaluation: Sage; 1989.
Khan M, Akhtar Z, Shahzadi A, Naz S, Bibi B. Critical care nurses' knowledge about enteral tube feeding at public sector hospital, Lahore. J Health Pol Manage. 2022;5(2):11-3.
Kurt H, Ceyhan Ö. The Effect of Enteral Nutrition Education Given To Intensive Care Nurses on Their Level Of Knowledge. Sağlık Bilimleri Dergisi. 2023;32(1):34-42.
Kim H, Chang SJ. Implementing an educational program to improve critical care nurses' enteral nutritional support. Australian Critical Care. 2019;32(3):218-22.
Banda Z, Simbota M, Mula C. Nurses’ perceptions on the effects of high nursing workload on patient care in an intensive care unit of a referral hospital in Malawi: a qualitative study. BMC nursing. 2022;21(1):136.
Maghsoud F, Rezaei M, Asgarian FS, Rassouli M. Workload and quality of nursing care: the mediating role of implicit rationing of nursing care, job satisfaction and emotional exhaustion by using structural equations modeling approach. BMC nursing. 2022;21(1):273.
Semanew Y, Ahmed A, Hussien A, Seid A, Anteneh S. Enteral tube feeding practice and associated factors among nurses working in South Wollo Zone Specialized and General Hospitals, Wollo, Ethiopia 2022. Frontiers in Nutrition.11:1399651.
O’Leary-Kelley C, Bawel-Brinkley K. Nutrition support protocols: enhancing delivery of enteral nutrition. Critical care nurse. 2017;37(2):e15-e23.
McKnight KA, Carter L. From trays to tube feedings: overcoming the challenges of hospital nutrition and glycemic control. Diabetes Spectrum. 2008;21(4):233-40.
Ramuada LG. Assessment of knowledge, attitude and practice of nurses regarding Enteral Nutrition at a Military hospital: Stellenbosch: Stellenbosch University; 2017.
Preiser J-C, Arabi YM, Berger MM, Casaer M, McClave S, Montejo-González JC, et al. A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice. Critical Care. 2021;25(1):424.
Salma I, Waelli M. Mapping research findings on change implementation in nursing practice: A scoping literature review. Nursing Open. 2023;10(2):450-68.

No competing interests reported.

Download PDF

Editorial decision: Revision requested
06 Sep, 2024
Editor assigned by journal
06 Sep, 2024
Submission checks completed at journal
06 Sep, 2024
First submitted to journal
29 Aug, 2024

You are reading this latest preprint version

Barriers to the Adherence of ICU Nurses to the Tube Feeding Protocol: A Qualitative Study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Introduction

Method

Study Design

Setting

Participants

Collecting data

Data Analysis:

Rigor

Results

Theme 1: The Gap between Theory and Practice

Sub-theme: Knowledge Barriers

Sub-theme: Practical Barriers

Sub-theme: Rapid Changes in Guidelines

Theme 2: Organizational and Interpersonal barriers

Sub-theme: Insufficient Supervision

Sub-theme: Human and Social Factors

Theme 3: Resistance to Change

Sub-theme 1: Attitude towards Change

Sub-theme 2: Uncertainty in Protocols

Sub-theme 3: Adherence to Routine Practices

Discussion

Conclusion

Implications for Nursing Practice

Declarations

References

Additional Declarations

Status:

Version 1