reflection on this article and what you learned about nursing… reflection on this article

reflection on this article and what you learned about nursing… reflection on this article and what you learned about nursing practices related to enteral nutritionP atients in critical care units may not receive their nutritional requirement, intensifying their malnutrition state ( Kim & Choi-Kown, 2011 ; Tsai et al., 2011 ). Norman, Pichard, Lochs, and Pirlich (2008)reported that malnutrition increased mortality, morbidity, and hospital costs, and lengthened hospital stay. In addition, late initiation of nutritional support led to negative energy balance and undernutrition ( Villet et al., 2005 ; Wandrag, Gordon, O’Flynn, Siddiqui, & Hickson, 2011 ). Therefore, the administration of artificial nutrition such as parenteral nutrition and enteral nutrition (EN) will maintain patients’ nutritional need. Because EN is a cost-effective method that Jordanian Critical Care Nurses’ Practices Regarding Enteral Nutrition ABSTRACT In Jordan, there is a gap in literature regarding nurses’ practices of enteral nutrition. Thus, the purpose of this study was to assess nurses’ practices regarding enteral nutrition of critically ill adult patients. A descriptive, cross-sectional design was used to collect data through self-reported questionnaires and descriptive analyses were used to display the results of the study. The results revealed that some aspects of enteral nutrition practices were consistent with the current best evidences such as initiation time of enteral nutrition and backrest elevation. On the contrary, some aspects showed variations and inconsistency with current best evidences such as the amount of high gastric residual volume and its management. Nurses’ practices regarding enteral nutrition were not consistent with international guidelines. This inconsistency can predispose patients to underfeeding. Enhancement of research utilization is highly recommended as well as establishing evidence-based guidelines. restores gastrointestinal function with less complication, it is preferable than parenteral nutrition ( Dardai, 2009 ; Roberts, Kennerly, Keane, & George, 2003 ). Despite the known benefits of EN, recent literature revealed many issues that limit or hinder the ultimate benefit of EN. For example, Rose, McNeill, and Bennett (2009)reported that late initiation of enteral feeding, long fasting time, and improper management of gastric residual volume (GRV) contributed to underfeeding. Similarly, Kim, Shin, Shin, and Cho (2010) and Marshall and West (2004) found inadequate delivery of EN for neurosurgical patients because of factors that are related to the nurses’ practice such as procedural interruption. Thus, this study aims to examine nursing practices regarding EN, which can highlight reasons behind insufficient nutritional care. Background Enteral nutrition is a multidisciplinary team responsibility and nurses play an active role in providing EN for critically ill patients. For example, nurses insert the nasogastric tube (NGT), confirm its placement, administer the feeding, and intervene to prevent complications associated with the administration of EN ( Osborn, Wraa, & Watson, 2010 ). Before feeding, candidate the patient should be placed in a backrest elevation of 30º-45º to prevent pulmonary aspiration. Evidence has shown that in critically ill patients kept at backrest elevation less than 30 °. There is increased incidence of pulmonary aspiration ( Grape et al., 2005 ; Miller, Grossman, Hindley, MacGarvie, & Madill, 2009 ; Wip & Napolitano, 2009 ). Although radiological examination is the gold standard for assessing NGT placement ( Bourgault & Halm, 2009 ; William & Leslie, 2005 ; Yantis & Velander, 2011 ), the majority of nurses in the studies reviewed relied on the auscultation method to check the placement of the NGT. Additionally, they checked the NGT every eight hours and flushed it less frequently ( Marshall & West, 2006 ). The amount of GRV is widely used to assess gastric intolerance; however, what was considered as high GRV varied among studies ( Fulbrook, Bonger, & Albarran, 2007 ; Gupta et al., 2012 ; Marshall & West, 2006 ; Metheny, Mills, & Srewart, 2012 ). In addition, the GRV of 100 ml and less was considered as an indicator to delay EN ( Kim et al., 2010 ). Montegio et al. (2010)stated that an amount of less than 500 ml of GRV in the absence of other signs (nausea, vomiting, and abdominal distention) should not be considered as high GRV. Other studies found that nurses relied on the absence of bowel sound as an indicator for gastric intolerance ( Gupta et al., 2012 ; Roynette, Bongers, Fulbrook, Albarran, & Hofman, 2008 ), while the American Society of Enteral and Parenteral Nutrition (ASPEN) recommended the assessment of patient complaints of pain, distention, physical examination, and abdominal radiographs instead of bowel sound assessment to detect gastric intolerance (as cited in Kreymann, 2010 ). To manage gastric intolerance, nurses relied on various unreliable methods such as raising the head of the bed, stopping the feeding, and decreasing the rate of feeding ( Marshall & West, 2006 ). In another study, metoclopramide as a prokinetic agent was used to manage gastric intolerance ( Roynetee et al., 2008 ). The administration of prokinetic agents such as metoclopramide and erythromycin to manage gastric intolerance was recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) and Canadian Critical Care Clinical Practice Guidelines Committee (CCPG) (as cited in Kreymann, 2010 ). Finally, delaying the EN administration was the main factor that contributed to underfeeding ( Reid, 2006 ). Gastrointestinal surgery and pancreatitis were among the reasons that caused nurses to delay EN ( Marshall & West, 2006 ). Conversely, evidence suggests that EN is beneficial for patients with gastrointestinal surgery ( Andersen, Lewis, & Thomas, 2009 ), as well as patients with pancreatitis ( Al-Omran, Albalawi, Tashkandi, & Al-Ansary, 2010 ). Enteral nutrition is not without complications. For instance, tube obstruction is one of the common complications of EN and medication administration ( Bodoky & Kent-Smith, 2009 ). It requires nurses to act proactively by flushing the NGT to prevent tube blockage. Marshall and West (2006)found that nurses either never flushed the NGT or flushed the NGT every 4 hours. Diarrhea is another complication that is documented in enterally fed patients ( Btaiche, Chan, Pleva, & Kraft, 2010 ; Bodoky & Kent-Smith, 2009 ; Jack, Coyera, Courtney, & Venkateshc, 2010 ). In the study of Marshall and West (2006),nurses attributed the development of diarrhea to the administration of antibiotic followed by feed composition. Finally, pulmonary aspiration is a fatal complication that necessitates nurses to take preventive measures such as elevation of the head of the bed and monitoring patients for signs of aspiration. In the study by Marshall and West (2006),nurses used blue dye to detect pulmonary aspiration. Kattelmann et al. (2006)found that the blue dye is not sensitive to detect pulmonary aspiration and high doses of blue dye could increase mortality rate. In addition, McClave et al. (2002)and Opilla (2003)stated that the usage of blue dye to detect pulmonary aspiration should be avoided and critical care nurses should rely on the identification of clinical factors to stratify high-risk patients for aspiration. Previous evidence revealed variations in nurses’ practices and inconsistency with the current best evidence regarding EN. The consequences of these inconsistence practices in administering EN can predispose critically ill patients to a hypocaloric state and increase the cost of their treatment. According to the Jordanian Nursing Council (2010) , nurses should have the responsibility and accountability for their actions and practices. As leaders, they must update their knowledge and apply current evidence in their daily practices. Moreover, nurses must collaborate with other healthcare professionals to improve their profession, healthcare system, and quality of patient care. Because there is a gap in literature regarding Jordanian nurses’ practices regarding EN, it would be beneficial to investigate these areas of lacking information to establish baseline data and to evaluate current nurses’ practices in the light of the current best evidence. In addition, this study identifies the gap in nurses’ practices regarding EN and allows decision makers, educationalists, researchers, and clinical nurses to capture and improve these gaps. Thus, the aim of this study was to assess nurses’ practices regarding EN for critically ill adult patients. Methodology Study Design A descriptive, cross-sectional design was used to collect data through self-reported questionnaires from registered  nurses who work in critical care units at Jordanian hospitals. Based on the classification of the healthcare system in Jordan, three strata (public, educational, and private hospitals) were formulated. Two university hospitals, three private hospitals, and three public hospitals with more than 10 adult critical care unit beds in each were randomly selected. Sample and Sampling Nonprobability sampling method using convenience samples of registered nurses was utilized to obtain 147 critical care nurses after distributing 250 questionnaires (response rate was 58%). Nurses were eligible to participate in this study if they (a) worked as a registered nurse, (b) had at least 3 months of critical care experience, (c) provided direct care for critically ill adult patients including EN, and (d) were willing to participate in the study. Data Collection Measures Nurses’ Practice of EN Questionnaire was used to assess the current EN practices in Jordanian hospitals (see Figure 1 ). This questionnaire was developed by Marshall and West (2006 ). The questionnaire includes two sections: the first section contains seven questions about demographic data, and the second asks questions about general EN practices, management of EN intolerance, and management of EN complications (52 questions). The questionnaire’s content validity was tested by a panel of three senior nurses with a master’s degree and clinical experience in critical care units. The content validity index was (for relevancy, sufficiency, and clarity) 1.0, 0.96, and 0.89, respectively. Based on the recommendation from the panel of experts, some modifications were applied to the questionnaire and a pilot study of 17 critical care nurses was carried out. The purpose of the pilot was to test the feasibility of the study, and to guarantee that the nature of the questionnaires was clear for utilization with a broader sample. Ethical Consideration and Data Collection Procedure Ethical approval from the Academic Research Committee at the University of Jordan, Academic Research Committee at the Deanship of the Academic Research and from the Ethical Committees at each targeted institution was obtained prior to data collection. One week prior to data collection, advertisements by the principal investigator were placed in the targeted institutions. These advertisements included the purpose of the study, the time needed, and the participants’ role and rights. On the day of data collection, data collectors distributed the Nurses’ Practices of EN Questionnaire and a cover letter to the nurses in the targeted settings. The study was anonymous, therefore no name or identification information was required. Nurses were instructed to return the completed questionnaire in a sealed envelope and gave it to the data collectors. Unit managers had no role in data collection. The data collection procedure took place over a period of 4 months from March to July 2012. Statistical Analysis Descriptive analyses were used to display the result of the nurses’ responses in frequencies and percentages. This included frequency distribution, measures of central tendency, and measures of dispersion. Frequency and percentages were used to analyze the categorical variables; measures of central tendency and measure of dispersion were used to represent the continuous variables. Results Sample Characteristics A total of 250 questionnaires were distributed and 167 were returned from registered nurses employed in critical care units at the educational, public, and private hospitals. Twenty questionnaires were excluded from the analysis because seven of them were completed by practical nurses and the other 13 were uncompleted questionnaires. The remaining 147 questionnaires represent a response rate of 59%. Descriptive analyses were used to show the sample characteristics ( Table 1 ). General EN Practices The results showed that 71% of nurses placed patients in a specific position (semisetting position) prior to EN administration. The main reported reason to delay EN was high GRV (88%). To confirm the placement of the NGT, 69% of nurses relied on the auscultation method. In regard to the method that was used by nurses to administer EN, the bolus method was the most commonly used (57%) ( Table 2 ). The initiation time of feeding was reported by the majority of the study sample to be within the first 48 hours (40%). The assessment of NGT placement was performed every 8 hours (46% of nurses) and 4 hours (37% of nurses). In respect to the commenced rate, 42% and 32% of nurses commenced EN at a rate of 20 and 30 ml, respectively ( Table 2 ). Management of EN Intolerance Eighty-two percent of nurses reported that medical orders were the primary guidance to increase the EN rate. Although 71% of nurses considered the GRV as the primary indicator for EN tolerance, 33% of nurses considered 50-100 ml as high GRV. Moreover, nurses practiced various nonpharmacological techniques to manage high GRV with a slight dependence on pharmacological agents (35%). Management of the aspirated gastric content was another aspect of nurses’ management to EN tolerance. The results showed that 48% of nurses did not return the aspirated gastric content to patients, 43% of nurses returned the aspirated gastric content in full, and 9% returned up to 200 ml of aspirated gastric content ( Table 3 ). Management of EN Complications The results showed that the majority of nurses (82%) used tap water to flush the blocked NGT. The frequency of flushing the NGT varied considerably, and the majority (40%) flushed it every 4 hours. In regard to the assessment of pulmonary aspiration, 80% of nurses relied on the observation of clinical signs of pulmonary aspiration and 72% of nurses used chest x-ray films as an indicator of pulmonary aspiration. Finally, nurses believed the cause of diarrhea to be antibiotic therapy, feed composition, and feed contamination (61%, 59%, and 64%), respectively ( Table 4 ). Discussion This study highlights Jordanian nurses’ practices regarding EN and thus provides fundamental data to guide other interventional and educational programs in this field. In this study, nurses reported that they placed patients at a semi-Fowler position. Grape et al. (2005)and Miller et al. (2009)objectively measured the angle of the backrest elevation and found that the majority of patients were kept at a backrest elevation less than 30 °. However, because this study utilized a self-administered questionnaire in data collection, there is a possibility for bias in reporting clinical practice. At the sample Jordanian hospitals, the initiation time for EN was within the first 24 and 48 hours following admission to the unit. This finding was consistent with the findings of Marshall and West (2006)and Roynette et al. (2008) . In these Jordanian hospitals, physicians were the professionals responsible for the prescription of EN and they followed the SCCM and the ASPEN guidelines regarding the early initiation of EN (within 24-72 hours) after patients’ admission to critical care units (as cited in McClave et al., 2009 ). The majority of nurses reported that they delayed EN because of many factors such as high GRV, nausea and vomiting, postgastrointestinal surgery, absence of bowel sound, abdominal pain, and pancreatitis. These findings were consistent with the study by Marshall and West (2006) . Although the majority of nurses reported that they checked GRV every 4 hours and considered it as a main indicator for gastric intolerance, the amount of 50-100 ml was considered high among the majority of nurses. Considering a low amount of GRV as a high level at which nurses delayed EN was consistant previous reports ( Bollineni & Minocha, 2011 ; Kim et al., 2010 ; Metheny et al., 2012 ; Shoaib, Sindhu, Jordan, & Tauseef, 2012 ). In this study, nurses minimally relied on patient discomfort, pain, nausea, and abdominal distention as an indicator of gastric intolerance. The recommendation for practice is to assess patients for complaints of pain, distention, physical examination, and abdominal radiographs to detect gastric intolerance (as cited in Kreymann, 2010 ). Underutilization of scientific evidence may have an impact on what to consider as indicators for gastric intolerance in the practice setting. Although nurses delayed EN due to postgastrointestinal surgery, pancreatitis, and after any surgery, their practice was incongruent with the evidence that supports the early initiation of EN for patients postgastrointestinal surgery ( Andersen et al., 2011 ; Lewis, Anderson, & Thomas, 2009), patients who have any surgical operation ( Drover et al., 2010 ), and with pancreatitis ( Al-Omran et al., 2010 ). In spite of the fact that ASPEN has not recommended absence of bowel sounds as an indicator for gastric intolerance (as cited in Bankhead et al., 2009 ; Yantis & Velander, 2011 ), nurses considered it as a factor to delay EN commencement. Indeed, the majority of nurses did not delay EN in response to the administration of narcotics and neuromuscular blockage. This finding was consistent with the study by Marshall and West (2006) . These drugs play a particular role in decreasing gastric emptying ( Nimmo, Heading, Wilson, Tothill, & Prescott, 2012 ) and prokinetic agents were recommended to improve gastric motility ( Bankhead et al., 2009 ; Landzinski, Kiser, Fish, Wischmeyer, & Maclaren, (2008); William & Leslie, 2005 ). Inappropriate delay in the commencement of EN due to unreliable factors such as absence of bowel sounds, pancreatitis, and low levels of GRV will predispose critically ill patients to an undernutrition state. To manage gastric intolerance, the majority of nurses practiced nonpharmacological methods such as decreasing the rate of feeding, stopping the feeding, raising the head of the bed, and checking the placement of the NGT. Additionally, the administration of prokinetic agents was minimal and inconsistent with practice recommendations ( Marshall & West, 2006 ; Roynetee et al., 2008 ). Prokinetic agents are recommended as a method to enhance gastric motility ( Cahill, Dhaliwal, Day, Jiang, & Heyland, 2010 ). In the Jordanian hospitals, physicians are the professionals responsible for the prescription of these agents. It seems physicians did not prescribe prokinetic agents, which may have forced nurses to manage gastric intolerance by practicing unreliable strategies. In the literature, there is a debate regarding the management of aspirated gastric residual content. For instance, Juvé-Udina et al. (2009) found that returning GRV to patients was efficient in increasing gastric motility without complication. On the contrary, Williams and Leslie (2010) made a critique of Juvé-Udina and colleagues’ (2009) work and stated that there was not enough evidence to support the returning or discarding of GRV. In this study, some nurses returned the aspirated GRV in full to the patient and the others discarded it. In the studies of Chan et al. (2012) and Marshall and West (2006), the majority of nurses returned the aspirated gastric content. Since EN is a multidisciplinary care practice, other professionals may lead some aspect of EN care and physicians may have a role in deciding return or discard gastric content. Although radiological examination is the gold standard for assessing NGT placement ( Bourgault & Halm, 2009 ; William & Leslie, 2005 ; Yantis & Velander, 2011 ), in this study, the majority of nurses assessed NGT placement by using auscultation and/or aspiration of gastric content, which is similar to the finding of the studies by Marshall and West (2006) , Metheny et al. (2012) , and Roynette et al. (2008 ). In regard to the frequency of checking the NGT placement, the majority of nurses checked it every 8 hours. The cost of radiological examination and the procrastination in performing it hinder its application in critical care units and force nurses to depend on less reliable methods in confirming the NGT placement. Tube obstruction is one of the common complications of EN and medication administration through NGT ( Bodoky & Kent-Smith, 2009 ). The majority of nurses flushed the NGT every 4 hours by using tap water. In the study by Marshall and West (2006),the nurses either never flushed the NGT or flushed the NGT every 4 hours. Marshall and West (2006)and Roynette et al. (2008)found that nurses used warm water to flush the NGT. In this study, the majority of nurses practiced bolus method in the administration of EN and it could be prescribed every 4 hours; thus, nurses flushed the NGT every 4 hours after each feeding. Because tap water in the critical care units is more accessible and less expensive than sterile water, nurses used it to flush the NGT. Another important complication associated with EN is pulmonary aspiration. Nurses have a key role in preventing and detecting pulmonary aspiration. In regard to detection, the majority of the nurses reported their reactive practice through the observation of clinical signs of pulmonary aspiration and the findings from the chest x-ray film. These results were inconsistent with the finding of Marshall and West (2006),in which the majority of nurses used blue dyes to detect pulmonary aspiration. McClave et al. (2002)and Opilla (2003)stated that critical care nurses should behave in a proactive way and strictly observe patients who are at risk for the development of pulmonary aspiration. Development of diarrhea in enterally fed patients was supported by research ( Btaiche et al., 2010 ; Bodoky & Kent-Smith, 2009 ; Jack et al., 2010 ). In this study, nurses attributed the development of diarrhea to feed contamination and antibiotic therapy. This finding was inconsistent with the finding of Marshall and West (2006),in which diarrhea was attributed to antibiotics followed by feed composition. There is long-standing evidence that supports that contamination of EN equipment leads to diarrhea ( Matlow et al., 2003 ; Mtlow et al., 2006 ; Roy et al., 2005 ). In the current study, the majority of nurses used bolus method for the administration of EN to the critically ill patient. This method requires increased manual handling which increases the possibility for contamination. This may be a reason why nurses attributed the development of diarrhea to the feed contamination. In addition, nurses have a scientific rationale regarding the relationship between diarrhea and antibiotic use. In this study, nurses have a bachelor or master degree in nursing with a required course in pharmacology; thus, nurses’ responses were expected related to antibiotic use. Study Implications and Recommendations The majority of the study participants have a bachelor degree in nursing but with little preparation regarding scientific article utilization. Teaching strategies should focus on evidence-based nursing practice and training nurses to be research sensitive. In addition, establishing an evidence-based guideline or protocol that will guide nurses’ practices regarding EN is highly recommended. In regard to research, further research addressing nurses’ attitudes and knowledge regarding EN in Jordanian hospitals will be beneficial. Limitations In this study, data were collected from nurses who are working in adult critical care units in the educational, private, and public hospitals. Thus, the study findings will not be generalized to nurses in the neonatal or pediatric critical care units, general medical and surgical floors, and nurses employed in military hospitals. The selection of nurses was achieved through convenience sampling technique. The problem with this technique is that it provides little chance to control for biases. However, nurses in the three healthcare sectors were approached in the A, B, and C shift, or day and night shift according to the hospital policy. Also, formulation of inclusion and exclusion criteria helped minimize the bias associated with this sampling technique. Another limitation is related to the self-report method of data collection that has the possibility for bias in reporting clinical practice and respondent error.  Conclusion According to the results from this study, some aspects of nurses’ practices were consistent with recommended international guidelines such as the initiation of feeding time and backrest elevation. Indeed, there are gaps between recommended nursing care and the key issues in EN practices such as what constitutes a high GRV and management of GRV. As a result, nurses’ practice may contribute to a hypocaloric state for critically ill adult patients. Implementation of current research evidence in the actual daily practices and collaboration among the healthcare team could improve EN practices. Finally, an observational study is recommended to gain full insight into nurses’ practice regarding EN Health Science Science Nursing NUR 201 Share QuestionEmailCopy link Comments (0)

Our website has a team of professional writers who can help you write any of your homework. They will write your papers from scratch. We also have a team of editors just to make sure all papers are of HIGH QUALITY & PLAGIARISM FREE. To make an Order you only need to click Order Now and we will direct you to our Order Page at Litessays. Then fill Our Order Form with all your assignment instructions. Select your deadline and pay for your paper. You will get it few hours before your set deadline.