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ORIGINAL RESEARCH

Improving knowledge, attitudes, and practice of

nurses in medication administration through
enteral feeding tubes by clinical pharmacists:
a case–control study
This article was published in the following Dove Press journal:
Advances in Medical Education and Practice

Samira Hossaini Alhashemi Purpose: Administering drugs and food to patients with swallowing disabilities via enteral
Raana Ghorbani tubes requires special skills. This task is a nursing duty and vital to ensure that they do this
Afsaneh Vazin safely. An integrated program training nurses by a clinical pharmacist is likely to result in
improved quality of oral drug administration via enteral feeding tubes. This quantitative
Department of Clinical Pharmacy, Faculty
of Pharmacy, Shiraz University of Medical study was undertaken to determine the efficacy of a clinical pharmacist educational program
Sciences, Shiraz, Iran for improving nurses’ knowledge, attitudes, and practice (KAP) concerning administrating
medication via feeding tubes.
Methods: This case–control study was performed to evaluate KAP of intensive-care nurses
with regard to drug delivery through enteral feeding tubes before and after their training
program. A questionnaire focusing on nurses’ KAP was prepared by a clinical pharmacist
and reviewed by 18 nurses for its reliability. Then, an educational program was designed for
the case group. Two months later, nurses’ KAP in the case and control groups were
reevaluated. Nurses’ practice regarding drug administration through feeding tube was
observed three times.
Results: This study was carried out with 82 nurses working in six intensive-care units in two
major training hospitals in Shiraz, Iran. The overall knowledge of nurses increased signifi-
cantly after the training program in the case group, with adequate awareness regarding solid
dosage–form crushing increasing from 14% to 63.2% (P˂0.001), tube flushing and drug
dilution from 32.6% to 81.6% (P˂0.001), and knowledge about mixing crushed drugs
through a feeding tube from 23.3% to 55.3% (P˂0.001). On the contrary, there was no
change in the control group. After intervention, nurses’ attitudes in the case group had
changed significantly, and 50% of them consulted with pharmacists regarding drug
administration.
Conclusion: An in-service education program by clinical pharmacists can lead to substan-
tial improvements in administration of drugs via enteral feeding tubes.
Keywords: clinical pharmacy, drug administration, education, enteral feeding tube, KAP,
nurses

Correspondence: Afsaneh Vazin Introduction

Department of Clinical Pharmacy, Faculty Enteral feeding is recommended for malnourished patients who are unable to
of Pharmacy, Shiraz University of Medical
Sciences, PO Box 158371345, Shiraz, consume an adequate or safe oral diet. It is beneficial for critically ill or post-
Fars, Iran operative patients, as it can provide cost-effective care, which can improve gastro-
Tel +98 713 242 4128
Email [email protected] intestinal mucosal structure and function by preventing gut atrophy.1 Although

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physicians, pharmacists, and nurses are generally respon- feeding tubes before and after a training program in
sible for administration of medication via enteral tubes, Nemazee and Shahid Faghihi hospitals.
this is principally a nursing duty. To utilize digestive tubes The study population included all 82 nurses working in
appropriately, one needs to have a number of skills, six different ICUs at two major training hospitals affiliated
including verification of tube placement, tube flushing, with Shiraz University of Medical Sciences (SUMS), the
and characteristics of different drug-dosage forms by con- main referral centers for patients in southern Iran, from
sidering the associated complications, such as catheter March 2014 to May 2016. Participant collaboration was
obstruction and other side effects.2 If medications are not voluntary, and they were assured about the anonymity and
given appropriately via the enteral route, it may result in confidentiality of their data. Then, all participants provided
harmful consequences. These consequences include tube written consent to participate in the study, having been
occlusion, diarrhea, aspiration pneumonia, drug ineffi- ensured of the confidentiality of the presented information.
ciency, drug side effects, and even mortality,3 all of The local ethics committee approved the written consent
which can lead to an increase in patient usage of hospital and study protocol (code EC-9388–8458).
equipment and also length of stay, resulting in an increase A 25-question multiple-choice researcher-constructed
in costs of the health-care system. Therefore, this demands questionnaire was prepared by reviewing the
a more efficient performance by the nursing staff, in order literature.2,8–11 The questionnaire focused on the knowl-
to achieve optimum results. edge and attitudes of nurses. Questions relating to nurses’
Crushing some dosage forms like controlled-release knowledge consisted of medication preparation (two
and enteric-coated tablets is not appropriate. Grinding items), tube flushing and drug dilution (two items), drug–
these types of tablets not only changes the medication’s food or drug–drug interaction (three items), and selection
pharmacokinetics and pharmacological action but might of correct dosage forms (five items). Questions regarding
also result in toxicity, treatment failure, and tube nurses’ self-reported practice included correct tube posi-
obstruction.4 tion, medication preparation, tube flushing, drug-dosage
Health-care staff knowledge, attitudes, and practice forms, factors that obstruct enteral tubes, and drug–food
(KAP) regarding enteral medication administration is interactions. Questions concerning attitudes were on hav-
essential to reduce patient morbidity and mortality.2 ing a reliable person for inquiries about medication-
Surveys suggest that hands-on practice differs significantly administration problems (one item), ways to improve the
from guidelines, and several common practices could quality of medication-administration services (one item)
interfere with appropriate medication delivery. For exam- and factors important to the nurses in choosing the volume
ple, previous surveys have suggested that only 5%–43% of of water used for the patient (one item).
practitioners use flush tubes before or between medica- The questionnaire was reviewed by 18 ICU nurses to
tions, only 32%–51% administer drugs separately from test its reliability. There was a 2-week interval between the
one another, only 44%–64% dilute liquid medication, and test and retest. Reliability testing revealed Cronbach’s α of
only 75%–85% avoid crushing modified-release dosage 0.79 for knowledge questions and 0.68 for practice ques-
forms.3–6 tions. Some modifications were made to the questionnaire
A previous study in the intensive care units of based on feedback from nurses. The final questionnaire
Nemazee Hospital showed disparities between nurses’ required 20 minutes to complete. Questionnaires were
knowledge, self-reported practice, and proper perfor- completed by the case and control groups before the edu-
mance in drug administration through an enteral feeding cational program.
tube.7 Therefore, this quantitative descriptive study was Our checklist was developed to evaluate nurses’ practice of
conducted to determine the efficacy of a clinical phar- drug administration via enteral feeding tubes based on direct
macist educational program to improve KAP of ICU observation. This had three parts. In the first part, demographic
nurses, concerning medication administration via feed- information about patients and their medications was collected.
ing tube. In the second part, the investigator (an educated pharmacist)
wrote his observations about medication administration
Methods through enteral feeding tubes by nurses, and the third part
This case–control study was performed to evaluate KAP of was developed to evaluate nurses’ practices regarding drug
ICU nurses concerning drug delivery through enteral administration via enteral feeding tubes based on direct

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observation. Criteria selected for the checklist were also Table 1 Demographic information of nurses in the case and
extracted from an extensive literature review. The third part control groups at the commencement of the study
of the checklist consisted of 22 items (14 yes/no questions and Case Control P
six multiple-choice questions) that were divided into different group group
categories, and took about 15 minutes to completes. These n=43 n=39
categories included medication preparation (how nurses pre-
Age, years (mean ± SD) 32.34±3.78 33.12±5.12 0.43
pare and administer drugs, seven items), drug–food and drug–
Years of practice as a nurse 4.39±3.74 5.66±5.23 0.21
drug interaction (three items), tube flushing and drug dilution (mean ± SD)
(four items), safety considerations in drug administration via Years of practice in ICU 2.65±2.19 2.94±1.74 0.5
enteral feeding tubes (one item), how nurses open occluded (mean ± SD)
tubes (two items), how to determine the correct tube position Sex 0.28
Females, n (%) 26 (60.5) 27 (69.2)
(one item), type of liquid used for tube flushing and drug
Level of education 0.88
dilution (two items), crushing unsuitable drugs (one item)
Bachelor's degree, n (%) 37 (86.0) 34 (87.2)
and patient restrictions in consumption of liquid (one item). Master's degree, n (%) 6 (14.0) 5 (12.8)
Nurse practices were observed three times to remove some Notes: Independent-sample t-tests used to compare age, years of practice as
parameters, affecting nurse practices. a nurse, and years of practice in ICU, and χ2 used to compare sex and level of
education. In each test, P≤0.05 was considered significant.
Based on the results, an educational program was Abbreviation: ICU, intensive-care unit.
designed for the case group by a clinical pharmacist (a
leading author), including preparing an evidence-based this study. Five nurses in the case group could not partici-
booklet and classes for case-group nurses. After each pate in the training programs due to maternity leave, and
training session, a list of drugs that were not to be crushed hence were excluded.
and work instructions were given to the participating The relationship between sex and level of education in
nurses.12,13 Nurses in the control group did not receive both phases of the study was evaluated. There was no rela-
any education program or booklet. Two months later, KAP tionship between demographic information of the nurses and
of the nurses were reevaluated using the same question- knowledge in either phase (P>0.05). Mean scores of nurses’
naire. SPSS version 18 was used for data analysis. knowledge and practice in both groups before clinical phar-
Independent-sample t-tests were used to compare demo- macist intervention were compared. Mean scores for nurses’
graphic data between two groups. For comparison of mean baseline knowledge between the groups was not significantly
scores, paired t-tests weres used. Percentages of nurses different, except in selecting the best dosage forms, which
with correct answers before and after the educational pro- was significantly better in the case group (P˂0.05).
gram were compared in each group by McNemar’s test. Groups were compared with each other before and after
P<0.05 was considered statistically significant. pharmacist intervention regarding the main domains in this
study. Mean scores for nurses’ knowledge in each domain
Results were compared (Table 2). Mean scores increased signifi-
During the preintervention phase of this study, 43 and 39 cantly after training program in the case group: adequate
nurses participated in the case and control groups, respec- awareness regarding solid dosage–form crushing from 4.49
tively. There was no significant difference regarding ±1.03 to 7.26±0.68 (P˂0.001), tube flushing and drug dilu-
demographic information between the two groups tion from 1.12±0.73 to 1.9±0.311 (P˂0.001), and knowledge
(P>0.05). The mean age of nurses was 32 years, and 53 about mixing crushed drugs through feeding tubes from 1.00
(64.6%) were women. The vast majority of participants in ±0.845 to 2.65±0.48 (p˂0.001). On the contrary, there was
both groups had a bachelor’s degree in nursing (86.6%). no significant change in the control group.
Additionally, participants’ mean experience in an ICU and Table 2 shows numbers and percentages of nurses with
as a nurse was 2 and 5 years, respectively. Table 1 shows correct answers concerning different knowledge domains.
the characteristics of the participants. The questionnaire In contrast to the control group, the percentage of nurses
and checklist could be found in the supplementary with acceptable knowledge increased after the training
materials. program in the case group.
During the postintervention phase, 38 nurses in the Mean scores and percentages of nurses with acceptable
case group and 39 in the control group participated in practice regarding self-report or researcher observations was

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Table 2 Scores of nurses with acceptable knowledge in different domains in the case and control groups before and after clinical
pharmacist intervention
Knowledge-question domain Preintervention Postintervention P (pre- vs
postintervention)

Case Control P-value Case Control P-value Case Control

group group group group group group
n=43 n=39 n=38 n=39

Solid dosage–form crushing

Scorea 4.49±1.03 4.49±3.34 0.51 7.26±0.68 4.05±1.02 <0.001 <0.001 0.13
n (%) 6 (14.0) 5 (12.8) 0.88 24 (63.2) 6 (15.4) <0.001 <0.001 1.00

Tube flushing and drug

dilution
Scoreb 1.12±0.73 1.03±0.63 0.55 1.9±0.311 0.97±0.67 <0.001 <0.001 0.32
n (%) 14 (32.6) 8 (20.5) 0.22 31 (81.6) 8 (20.5) <0.001 <0.001 1.00

Drug–food and drug–

drug interaction
Scorec 1.00±0.845 0.79±0.69 0.24 2.65±0.48 0.77±0.74 <0.001 <0.001 0.57
n (%) 10 (23.3) 9 (23.1) 0.98 21 (55.3) 6 (15.4) <0.001 0.002 0.25

Correct dosage forms

selection
Scored 7.02±2.46 5.15±1.17 <0.001 16.58±1.15 5.07±1.83 <0.001 <0.001 0.61
n (%) 6 (14) 7 (17.9) 0.62 22 (57.9) 5 (12.8) 0.001 <0.001 0.50
Notes: Independent-sample t-tests used to compare mean scores on knowledge, and paired t-tests to compare percentages before and after intervention. In each test,
P≤0.05 was considered significant). Score data presented as means± SD. aMaximum score 8; bmaximum score 2; cmaximum score 3; dmaximum score 18.

compared between the two groups (Tables 3 and 4). As to flush the tube in both groups. In addition, nurses in both
demonstrated in Table 3, mean scores for nurses’ practice groups reported that increased collaboration between nurses
regarding their reports about different domains increased and pharmacists could improve practice.
significantly after the training program in the case group:
adequate practice regarding solid dosage–form crushing from Discussion
1.744±1.311 to 4.947±1.723 (P˂0.001), tube flushing and Our study attained desirable results in nurses' KAP with
drug dilution from 5.163±1.632 to 7.342±0.781 (P˂0.001), regard to drug administration via enteral tubes after the
mixing crushed drugs through feeding tubes onverted from training program, as mean scores on knowledge and prac-
3.070±1.653 to 5.947±1.355 (P˂0.001), and practice regard- tice significantly increased in the case group in comparison
ing verification of he feeding tube position onverted from with the control group. For critically ill patients who
7.62±1.865 to 16.474±2.06 (P˂0.001). However, there was cannot consume or have an oral diet, finding ways to
no significant change in the control group. administer drugs through the enteral feeding tube presents
Nurses’ attitudes regarding three parameters were evalu- a challenge. Although administration of medication via
ated. Answers to who is the first person to ask questions of enteral tube is specifically a nursing responsibility, they
before drug administration via feeding tubes were signifi- had limited baseline knowledge about pharmaceutical
cantly different between the two groups. In the preinterven- form, drug dosage, or interaction.4,5,10,14
tion phase, 15.8% of the case group selected their supervisors Poor knowledge about the different codes used by drug
and 59.0% of the control group selected physicians. However, companies and consequences of crushing drugs can result in
after intervention, nurses’ attitudes in the case group changed unpredictable blood levels, in addition to an increased risk of
significantly, and 50.0% of them selected pharmacists as the catheter obstruction.3 Therefore, alternative administration
first person to consult about drug administration (P˂0.001). routes have to be selected to deliver each drug to its specific
Almost all nurses selected the overall condition of a patient sites correctly. We found that <20% of the participants in this
when making decisions about the volume of water with which study had adequate awareness regarding solid dosage–form

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Table 3 Scores of nurses with acceptable practice in different domains at pre- and postintervention in the case and control groups
Practice-question domain Preintervention Postintervention P (pre- vs
postintervention)

Case Control P-value Case Control P-value Case Control

group group group group group group
n=43 n=39 n=38 n=39

Solid dosage–form crushing

Scorea 1.744±1.311 1.333±0.927 0.11 4.947±1.723 1.31±0.922 <0.001 <0.001 0.57
n (%) 4 (9.3) 3 (7.7) 0.8 13 (34.2) 3 (7.7) 0.004 0.004 1.00

Tube flushing and drug

dilution
Scoreb 5.163±1.632 4.256±1.650 0.02 7.342±0.781 4.33±1.767 <0.001 <0.001 0.37
n (%) 20 (46.5) 17 (43.6) 0.37 29 (76.3) 4 (10.3) <0.001 <0.039 <0.001

Drug–food and drug–drug

interaction
Scorec 3.070±1.653 2.846±1.288 0.50 5.947±1.355 2.85±1.329 <0.001 <0.001 1.00
n (%) 11 (25.6) 9 (23.1) 0.79 25 (65.8) 9 (23.1) <0.001 <0.001 1.00

Verifying feeding tube

position
Scored 0.744±0.621 0.615±0.633 0.35 2.763±0.490 0.59±0.637 <0.001 <0.001 0.32
n (%) 14 (32.6) 11 (28.2) 0.67 26 (68.4) 10 (25.6) <0.001 <0.001 1.00
Notes: Independent-sample t-tests used to compare mean scores on practice, and paired t-tests to compare percentages before and after intervention. In each test, P≤0.05
was considered significant. Score data presented as means ± SD. aMaximum score 8; bmaximum score 8; cmaximum score 8; dmaximum score 3.

crushing before the intervention program. As in previous verifying feeding tube position before the intervention,
surveys, when pharmacists promoted nurses’ knowledge, it after which this figure was 68.4% (P˂0.001).
resulted in a reduced percentage of medications being Feeding tubes tend to clog because of short
crushed.3,4,15 Inadequate awareness regarding medication- intervals between drug and meal administration. Mixing
dosage forms might be related to flawed academic education, drugs through an enteral feeding tube due to lack of time
in particular medication-administration techniques.16 On the not only changes therapeutic drug effects but also
other hand, lack of sufficient information in the literature and increases the risks of chemical inconsistency. Therefore,
data from manufacturers has led to the usage of empirical tubes should be flushed before and after drug administra-
recommendations.17 tion with at least 15 mL water and drugs administered
Verifying the feeding tube position before any proce- separately to prevent any possible interaction with food
dure is critical to prevent pharmacokinetic alteration of the or tube obstruction.22,23 In the current survey, only 23.3%
prescribed drug and future complications, such as respira- of nurses had acceptable knowledge on this topic before
tory aspiration.18 Various methods are available to check the intervention, after which this figure was 55.3%.
nasogastric tube location, such as pH values that aspirate Nurses need the foremost accessible source of informa-
from the feeding catheter, auscultation, and radiography. tion to improve their practice. In a previous study in our ICUs
Although radiography is the gold standard, its usage is at Nemazee Hospital, it was shown that nurses’
limited, due to radiographic exposure and additional attitudes toward medication administration via an enteral
expenses.19 Since auscultation is an unreliable method,20 tube were inappropriate: 43.1% hought that the physician
the National Patient Safety Agency in the UK and the was the best person to answer their questions and 34.1%
American Association of Critical Care Nurses have believed that the pharmacist was the best option.7 Belknap
banned this method.2 Testing aspirated pH and its color et al showed that the main source of information for 56.9% of
is an acceptable method to confirm tube location if the nurses was personal experience and that 21.7% of them
patient is not taking pH-altering agents.21 In this study, consulted with their coworkers.4 In our study, nurse
only 32.6% of nurses had acceptable practices regarding attitudes in the case group changed significantly, and half

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Table 4 Scores of nurses with acceptable practice regarding researcher observation

Practice-question domain Preintervention Postintervention P (pre- vs
postintervention)

Case Control P-value Case Control P-value Case Control

group group group group group group
n=43 n=39 n=38 n=39

Solid dosage–form crushing

Scorea 0.735±0.689 0.744±0.715 0.95 2.263±0.723 1.410±1.044 <0.001 <0.001 0.002
n (%) 6 (14.0) 6 (15.4) 0.85 20 (52.6) 9 (23.1) 0.007 0.001 0.45

Tube flushing and drug

dilution
Scoreb 4.116±1.577 3.949±1.555 0.63 10.4±2.354 3.820±1.502 <0.001 <0.001 0.17
n (%) 4 (9.3) 6 (15.4) 0.40 20 (52.6) 6 (15.4) 0.001 <0.001 1.00

Drug–food and drug–drug

interaction
Scorec 3.473±1.533 3.487±1.675 0.97 9.360±1.984 3.667±1.603 <0.001 <0.001 0.34
n (%) 10 (23.3) 11 (28.2) 0.61 22 (57.9) 11 (28.2) 0.008 0.002 1.00

Verifying feeding tube

position
Scored 7.628±1.865 7.538±2.426 0.85 16.47±2.089 7.564±2.426 <0.001 <0.001 0.32
n (%) 7 (16.3) 9 (23.1) 0.44 20 (52.6) 13 (33.3) 0.008 0.001 0.12
Notes: Independent-sample t-tests used to compare mean scores on practice, and paired t-tests to compare percentages before and after intervention. In each test, P≤0.05
was considered significant. Data presented as means ± SD. aMaximum score 3; bmaximum score 15; cmaximum score 13; dmaximum score 21.

selected pharmacists as the first person to consult about drug solid dosage–form crushing, tube flushing, and drug–
administration. drug/food interactions. This increased knowledge was con-
Mean scores and percentages of nurses with acceptable sistent with previous findings.9,10,24
practice regarding researcher observations was signifi- Advantages of the current study were having a control
cantly improved in the control group. Training how to group and a logical time interval between the two phases of
dilute medication is an important aspect, and tap water is the study to reduce time trends.10,24,25 In contrast to previous
not appropriate to prepare prescriptions, due to research,2,3,17,26,27 this study not only depended on self-
contamination.22 In addition, leaving drugs in purified report but also assessed nurse practices through concealed
water or saline for long periods till dissolved might expose observation. This might have helped to reduce potential bias
medication to environmental conditions, altering chemical and to show the fact that there is a theory–practice gap due to
structure due to hydrolyzation in humid sites.17 The rain- nurse stress in applying immediate care to patients in
ing program led to improved nurse practices — from 9.3% ICUs.17The main limitation in our study was the small num-
to 52.6% — in the drug-dilution domain (P<0.001) regard- ber of nurses who participated in the surveys. Nevertheless,
ing researcher observation. In 2011, a survey was con- in comparison with findings in other settings, where it was
ducted using a random sample of acute-care nurses at reported that in addition to acute-care nurses,9,10 even com-
two large metropolitan hospitals in Melbourne, Australia. munity pharmacists28 had poor knowledge on correct medi-
A majority reported administering enteric-coated and cation administration via enteral feeding tubes, our results
slow- or extended-release forms of medication, and giving can be generalized in different health-care settings. Finally,
solid forms of medication when liquid form was available. patient morbidity and mortality should be measured as clin-
Nearly all (96%) reported flushing a tube after giving ical end points in future studies.
medication, 28% before, and 12% always flushed between
each medication.2 The education program by the clinical Implications for practice
pharmacist significantly improved nurses’ knowledge in This study provides insight into improvements in KAP of
all features, including correct dosage-form selection, nurses working in an ICU before and after education

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Dovepress Hossaini Alhashemi et al

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