Investigating critical care nurses' perception regarding enteral nutrition

YNEDT-02844; No of Pages 6 Nurse Education Today xxx (2014) xxx–xxx

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Nurse Education Today journal homepage: www.elsevier.com/nedt

Investigating critical care nurses' perception regarding enteral nutrition☆ Muhammad W. Darawad a,⁎, Sawsan Hammad a,1, Mahmoud Al-Hussami a,2, Eman Haourani a,3, Ahmad E. Aboshaiqah b,4, Ayman M. Hamdan-Mansour a,c,5 a b c

Faculty of Nursing, The University of Jordan, Amman 11942, Jordan College of Nursing–King Saud University, Riyadh 11492, Saudi Arabia Department of Nursing, Al Farabi College, Riyadh 11514, Saudi Arabia

a r t i c l e

i n f o

Article history: Accepted 25 November 2014 Available online xxxx Keywords: Enteral nutrition Nurses Jordan Education

s u m m a r y Background: Evidences showed that nurses lack the needed knowledge to administer nutritional care. Besides, nutritional information was found to be incomplete in patients' record, and nurses' responsibilities regarding EN were not well understood. In Jordan, literature regarding nurses' perceptions of EN is scarce. Aim: To investigate critical care nurses' perceptions regarding enteral nutrition (EN) of critically-ill adult patients. Methods: A descriptive, cross-sectional, comparative design was used to collect data from 151 Jordanian critical care nurses utilizing the Nurses' Perception of Enteral Nutrition Questionnaire. Results: Nurses in private hospitals scored the highest in regard to responsibility and support from documentation. Education, internet, and nursing school were the primary sources of EN knowledge. Besides, female nurses differ significantly from male nurses in regard to the perception of responsibility of EN. Conclusion: Awareness of responsibility, supportive documentation system, and implementation of the current evidences of EN in the actual daily practices can be used to improve EN practices. © 2014 Elsevier Ltd. All rights reserved.

Introduction Critically-ill patients were found to be malnourished with an exacerbation of malnutrition status during hospitalization due to underprescription of nutritional requirement (Kim and Choi-Kown, 2011). Rose et al. (2009) reported the factors that may have contributed to such malnutrition including delaying the initiation of enteral feeding, prescribing less energy and protein than patient's body requirement, and other factors related to the delivery of feeding such as long fasting time and improper management of gastric residual volume. Thus, providing effective enteral nutrition (EN) is crucial to optimize criticallyill patient's nutritional status. Evidences showed that EN decreased the frequency of upper intestinal intolerance and nosocomial pneumonia

☆ The authors acknowledge the University of Jordan for funding this study. Also, sincere thanks to the participants and to the directors of nursing within the participating hospitals. ⁎ Corresponding author. Tel.: +962 6 5355000x23162 (work). E-mail addresses: [email protected] (M.W. Darawad), [email protected] (S. Hammad), [email protected] (M. Al-Hussami), [email protected] (E. Haourani), [email protected] (A.E. Aboshaiqah), [email protected], [email protected] (A.M. Hamdan-Mansour). 1 Tel.: +962 6 5355000x23108 (work). 2 Tel.: +962 6 5355000x23138. 3 Tel.: +962 6 5355000x23176 (work). 4 Tel.: +966 503154993 (work). 5 Tel.: +962 6 5355000x23159 (work).

(Kompan et al., 2004), reduced mortality rate, length of hospital stay, and length of mechanical ventilation (Barr et al., 2004). For effective administration of EN, healthcare professionals who are responsible for administering this care need to have a sufficient knowledge and clear responsibilities. However, this is not the case according to the literature. For instance, Kim and Choue (2009) reported that nurses had inadequate knowledge of nutritional assessment despite having a positive attitude toward nutritional care of their patients. Similarly, Mowe et al. (2008) stated that the Scandinavian doctors and nurses had inadequate nutritional practices because of limited knowledge concerning nutritional assessment, detection of patients at risk for malnutrition, and nutritional management. Enteral nutrition is a multidisciplinary team responsibility, and having a clear description of responsibilities could be beneficial. On the other hand, unclear responsibilities of EN and lake of knowledge were found to be the main barriers for implementing a good EN care (Beck et al., 2002; Lindorf-Larsen et al., 2007). Health care is continuously changing in all aspects including EN. Therefore, it is crucial for healthcare professionals to be updated with the current evidences. However, nurses were found to underutilize the scientific journals due to many barriers such as poor quality of research, insufficient time, lack of organizational support, lack of knowledge, and lack of confidence (Moreno-Casbas et al., 2011; Timmens et al., 2012). Moreover, nurses' sources of knowledge varied considerably. For instance, the main source of knowledge to administer EN

http://dx.doi.org/10.1016/j.nedt.2014.11.023 0260-6917/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article as: Darawad, M.W., et al., Investigating critical care nurses' perception regarding enteral nutrition, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.11.023

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M.W. Darawad et al. / Nurse Education Today xxx (2014) xxx–xxx

was consultation with colleagues among Swedish and American nurses (Persenius et al., 2006; Thiel and Ghosh, 2008), procedure manual among Indian nurses (Gupta et al., 2012), and education among Jordanian nurses (Al-Ghabeesh et al., 2012). Another important factor that may affect nurses' EN care is the documentation system, which was found to provide nurses with moderate support to implement their EN care (Persenius et al., 2006). Despite the presence of competent staff, patients' nutritional data were found to be incomplete in their records (Krakau et al., 2010; Persenius et al., 2008). Such incomplete EN data could be attributed to insufficient time and knowledge, and frequent documentation requirements (Ofi and Sowunmi, 2012), along with the poorly constructed documentation system (Karkkainen et al., 2005). Other causes include inadequate nursing reviews, supervision, and staff development; limited nurses' competence, motivation, and confidence; and ineffective nursing procedures (Cheevakasemsook et al., 2006). This incomplete documentation of EN care may lead to miscommunication, assumptions, and misinterpretation of patients' information among nutritional support team members, which requires implementation of a precise and correct documentation system (Howard et al., 2006). Persenius et al. (2006) studied nurses' perception of knowledge of responsibility, sources of knowledge, responsibility, satisfying knowledge, and support from documentation system regarding EN in relation to nursing process. However, their study had a methodological limitation regarding sample size (44 nurses), unclear hospital classification system, and lack of comparison between male and female nurses regarding different aspects of EN. Measuring critical care nurses' perception of EN is believed to affect patient care through identifying the lacking nutritional practices, and providing a baseline that can be used to improve nurses' practice of EN through reviewing and revising the necessary practices (Gupta et al., 2012). In addition, Jordanian critical care areas are similar to the international facilities, though Jordanian critical care nurses' perception regarding EN is unknown. Therefore, this study aims to investigate Jordanian nurses' perception of knowledge of responsibility, satisfying knowledge, and support from the documentation system regarding EN in relation to nursing process. Specifically, this study is going to answer the following questions: 1 What is the perception of Jordanian nurses regarding knowledge of responsibility, sources of knowledge, responsibility, satisfying knowledge, and support from documentation focusing on EN in critical care units? 2 What are the differences in the perceptions of sources of knowledge, responsibility, satisfying knowledge, and support from documentation regarding EN among nurses who are working in private, public, and educational hospitals in Jordan? 3 What are the differences in perceptions of responsibility, satisfying knowledge, and support from documentation regarding EN among Jordanian male and female nurses?

Methodology Design A descriptive, cross-sectional, comparative design was used to collect data from registered nurses who were working in critical care units at Jordanian hospitals, using self-administered questionnaire. According to the Jordanian Ministry of Health (2011), the hospitals in Jordan can be alienated in four categories (educational, private, public, and military). Based on this classification, four strata were formulated, and three hospitals (with at least 10-bed capacity critical care unit) from each category were randomly selected except for the educational hospitals in which two hospitals were selected (there are only two educational hospitals in Jordan). The military hospitals refused to conduct this study in their institutions as they do not allow outside scientists.

Therefore, two university hospitals, three private hospitals, and three public hospitals were selected. Sampling A nonprobability sampling method using a convenience sample of registered nurses was utilized to collect data. To be included, participants had to (a) be working as a registered nurse, (b) have clinical experience in the critical care unit of at least three months, and (c) provide direct care for patients and administer EN. A total of 250 questionnaires were distributed, but only 167 were returned (response rate was 66%). Sixteen incomplete questionnaires were excluded from the analysis as they were incomplete. Measurement The instrument of this study was constructed in two parts. The first part contained the demographic data sheet that included questions regarding participant's gender, age, years of nursing experience, years of experience in the current organization, years of experience in the critical care units, educational level, and hospital type. The second part measured nurses' perception of EN in critical care units using the Nurses' Perception of EN Questionnaire, which has five main subscales with a total of 35 items (Persenius et al., 2006). The first subscale measures nurses' perception regarding the knowledge of responsibility for EN, and has 10 items; the first six items have three choices (yes, no, and don't know), and items (7–10) ask about the healthcare professional who is responsible for prescribing the amount, type, rate, and probiotics of EN (physician, nurse, or dietitian). The second subscale measures nurses' perception of the sources of knowledge regarding EN (10 sources) using 5-point Likert scale ranging from (1) “very small extent” to (5) “very great extent”. The mean score of each item was calculated out of five, with a score less than 3 considered as low, (3–3.9) moderate, and (4–5) high. The third subscale measures nurses' perception of the extent of their responsibility regarding EN, the fourth subscale measures nurses' perception of the extent of their satisfaction of knowledge regarding EN, and the fifth subscale measures nurses' perception of the extent of support that they had from documentation regarding EN. The third, fourth, and fifth subscales include five items each, using 5-point Likert scale ranging from (1) “very small extent” to (5) “very great extent”. The total score (out of 25) for the perception of responsibility, satisfying knowledge, and support from documentation subscales was obtained by summation of the individual five items, and the value of less than 15 being considered as low, (15–19) moderate, and (20–25) high. Besides, the mean scores for the individual five items regarding nurses' perception of responsibility, satisfying knowledge, and support from documentation were calculated (out of five), with a score less than 3 considered as low, (3–3.9) moderate, and (4–5) high. Prior to data collection, a panel of three nurses with master's degree who had an experience in critical care units was invited to assess the content validity of the questionnaire. Based on their recommendations, minor modifications were applied to the questionnaire. Also, a pilot study was conducted to test the internal consistency reliability, and to assess the feasibility of the study and the readability of the questionnaire. The Cronbach's alpha coefficients for the questions related to the perception of responsibility, satisfying knowledge, and support from documentation were 0.92, 0.95, and 0.92 respectively. Data Collection After obtaining the ethical approval from the participating hospitals, trained data collectors, who were from outside those hospitals, met the head nurses and charge nurses at the participating units and provided them with detailed explanation about the study aims and procedure. Then, a list of available nurses was prepared from the selected units.



At the time of data collection, participants were interviewed face to face and invited to voluntarily participate, and those who agreed to participate were given the questionnaire package in a sealed envelope. Participants were given the choice to fill out the questionnaire during their break time or to take it home, and special drop box locations were assigned for this purpose. Nurses were notified to return the questionnaire in a sealed envelope to the data collectors. Data collectors distributed the questionnaires to the nurses and were available to answer participants' questions and inquiries. The data collection procedure took place over a period of four months from March to July, 2012.

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Table 1 Descriptive statistics of nurses' knowledge of responsibility for nutrition, N = 151. Item

Yes (%)

Are there any written guidelines regarding EN 62 (41) 65 (43) Is there a nurse responsible for nutrition in 51 (33.8) 92 (61) your ward Is there a nutritional team on your ward 38 (25.2) 108 (72) Is there a nutritional team at the hospital 105 (70) 33 (22) Are there key person to consult at the hospital 80 (53) 42 (28) Are there key person to consult outside the 34 (23) 65 (43) hospital

Ethical Considerations

Item (who prescribes)

Physician N (%)

Prior to data collection, ethical approval was sought from the Academic Research Committee at the University of Jordan and from the Ethical Committee at each targeted institution. Voluntary and anonymous participation was guaranteed (no personal identification were collected). Also, identification numbers were assigned to participating nurses rather than their names to access actual research information, which was restricted to research team. Moreover, the study objectives were explained by a cover letter, and those who agreed to participate were given the study questionnaire package. Returning the filled out questionnaire was considered as an implied consent.

The amount of EN The type of EN The rate of EN Probiotics of EN

149 (98.6) 150 (99.3) 146 (96.7) 136 (90)

Statistical Analysis The SPSS version-17.0 for windows was used for data entry and analysis. Descriptive and inferential statistical analyses were used to answer research questions. Kruskal–Wallis test was used to test the differences between nurses in the educational, private, and public hospitals regarding the sources of knowledge. A parametric test (Student's t-test) was used to examine the differences between male and female nurses in their perceptions of responsibility, extent of satisfying knowledge, and support from documentation regarding EN. Finally, analysis of variance (ANOVA) tests were used to examine the differences between nurses in the educational, private, and public hospitals in their perceptions of responsibility, extent of satisfying knowledge, and support from documentation regarding EN.

Results Sample Characteristics Female nurses represented 51% of the total sample. Participants' age ranged from 23–50 years (M = 28, SD = 5.4), and their clinical nursing experiences ranged from 1–25 years (M = 5.7 years, SD = 4.9). Also, years of employment at current organization ranged from 1–23 years (M = 4.6 years, SD = 4.5), and years of employment in critical care units ranged from 1–19 years (M = 4 years, SD = 3.6). With regard to education, the majority of nurses (93%) had a bachelor's degree in nursing. In respect to the allocation of nurses in the three healthcare sectors, 40%, 30%, and 30% of the participants were employed at the educational, private, and public hospitals, respectively.

Nurses' Perception Regarding Their Knowledge of Responsibility for EN Table 1 shows the descriptive data for the nurses' knowledge of responsibility for EN. According to the results, 41% of the nurses reported that they had guidelines for EN in their units. Although 70% of nurses reported that there was a nutritional team in their hospitals, 72% reported that there was no nutritional team at their units. Moreover, the majority (90–99.3%) of the nurses reported that the prescription of the amount, type, rate, and probiotics of EN was the physicians' responsibility.

No (%)

Nurse N (%)

Don't know (%) 24 (16) 8 (5.3) 5 (3) 13 (8) 29 (19) 52 (34)

Dietitian N (%)

1 (0.7) 1 (0.7) 0 (0.0) 1 (0.7) 4 (2.6) 1 (0.7) 3 (2) 12 (8)

Nurses' Perception Regarding the Sources of Knowledge Regarding EN Descriptive analyses were utilized to identify nurses' responses to the 10 sources of knowledge regarding EN. The lowest mean scores were for the in-service education and scientific journal articles (M = 2.1), while the highest mean scores were for the education and internet as sources for knowledge (M = 2.6) (Table 2). Moreover, Kruskal–Wallis test was used to test the differences between nurses in the three healthcare sectors regarding the source of knowledge, in which the results showed no statistically significant differences between nurses (Table 2). Perception of Responsibility, Satisfying Knowledge, and Support From Documentation Regarding EN Descriptive statistical analyses were used to identify nurses' responses to the perceptions of responsibility, satisfying knowledge, and support from documentation regarding EN in relation to nursing process in the three healthcare sectors (Table 3). Nurses' mean score was 2.75 (SD = 0.95) for responsibility, 2.72 (SD = 0.89) for satisfying knowledge, and 2.89 (SD = 0.88) for support from documentation. The result revealed that the perception of responsibility, satisfying knowledge, and support from documentation regarding EN were highest among nurses in the private hospitals (Table 3). Differences in Nurses' Perception of Responsibility, Satisfying Knowledge, and Support From Documentation Regarding EN Based on Hospital Type Responsibility, satisfying knowledge, and support from documentation were normally distributed, and Levene's test revealed that the assumptions of homogeneity of variances for these three variables were met. The results of ANOVA tests showed significant differences in Table 2 Differences in sources of knowledge among nurses in the three health care sectors. Sources of knowledge

Consulting colleagues In-service training Lectures Specialists Literature Education Nursing school Courses Intranet and internet Scientific journal article

Total

Kruskal–Wallis test

M (SD)

χ2

df

P-value

2.4 (1.08) 2.1 (1.13) 2.2 (1.08) 2.3 (1.06) 2.2 (1.0) 2.6 (1.03) 2.5 (1.15) 2.3 (1.08) 2.6 (1.15) 2.1 (1.01)

0.42 5.22 0.48 0.09 0.25 5.79 0.66 1.12 2.16 0.54

2 2 2 2 2 2 2 2 2 2

0.81 0.07 0.79 0.96 0.88 0.06 0.72 0.57 0.34 0.76


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Table 3 Total and individual item mean scores of nurses' perception of responsibility, satisfying knowledge, and support from documentation, N = 151. Item

Responsibility Assessment Goal Planning/implementation Prevention of complications Evaluation Satisfying knowledge Assessment Goal Planning/implementation Prevention of complications Evaluation Support from documentation Assessment Goal Planning/implementation Prevention of complications Evaluation

Private N = 45

Public N = 46

Educational Total N = 60 N = 151

M (SD)

M (SD)

M (SD)

M (SD)

3.14 (0.85) 2.87 (0.92) 3.24 (1.06) 3.18 (0.96) 3.13 (1.06) 3.27 (1.05) 2.9 (0.93) 2.71 (1.04) 2.93 (1.09) 2.89 (0.91) 2.87 (1.03) 3.13 (1.19) 3.3 (0.90) 3.22 (1.2) 3.33 (1.02) 3.07 (1.00) 3.33 (0.97) 3.27 (1.03)

2.14 (0.92) 2.17 (0.95) 2.33 (0.94) 2.43 (1.19) 2.54 (1.19) 2.61 (1.16) 2.7 (0.98) 2.57 (0.95) 2.72 (1.11) 2.63 (0.195) 2.89 (1.17) 2.96 (1.15) 2.63 (0.85) 2.61 (1.08) 2.59 (1.05) 2.8 (0.86) 2.61 (0.90) 2.57 (0.93)

2.73 (0.97) 2.53 (1.21) 2.73 (1.18) 2.6 (1.11) 2.8 (1.14) 3.02 (1.24) 2.56 (0.79) 2.35 (1.11) 2.42 (0.94) 2.55 (0.96) 2.75 (1.00) 2.72 (1.05) 2.8 (0.83) 2.82 (1.01) 2.75 (1.04) 2.83 (0.92) 2.85 (1.00) 2.88 (1.02)

2.75 (0.95) 2.52 (1.08) 2.76 (1.13) 2.72 (1.12) 2.82 (1.15) 2.97 (1.19) 2.72 (0.89) 2.52 (1.05) 2.66 (1.05) 2.68 (0.95) 2.83 (1.06) 2.91 (1.14) 2.89 (0.88) 2.87 (1.12) 2.87 (1.07) 2.89 (0.93) 2.92 (1.00) 2.9 (1.03)

respect to responsibility (F (2, 148) = 6.96, P = 0. 001) and support from documentation (F (2, 148) = 6.07, P = 0. 003). In regard to knowledge, there was no statistically significant differences (F (2, 148) = 2.04, P = 0.133) (Table 4). Scheffé post hoc criterion for significance were utilized to carry out the multiple group comparisons, which revealed a significant difference between nurses in the private hospital and nurses in the other two hospital types in regard to responsibility and support from documentation. Nurses in the educational and public hospitals did not differ from each other. Gender Differences Regarding Nurses' Perception of Responsibility, Satisfying Knowledge, and Support From Documentation Student's t-test was used to examine the difference between male and female nurses regarding their perceptions of responsibility, satisfying knowledge, and support form documentation regarding EN. Results showed a statistically significant difference in scoring of responsibility between male and female nurses (t (149) = 2.508, P = 0.013), where female nurses scored significantly higher (M = 14.75, SD = 4.8) than male nurses (M = 12.82, SD = 4.6). Furthermore, there were no statistically significant differences between male and female nurses regarding satisfying knowledge and support from documentation (Table 5). Discussion The current study investigated nurses' perception regarding EN knowledge, sources of knowledge, responsibility, satisfying knowledge, and support from documentation. Being among the first studies in Jordan in the area of EN, the results of this study will aid in filling the Table 4 ANOVA tests for perception of responsibility, satisfying knowledge, and support from documentation system, N = 151. Variable

Private N = 45

Public N = 46

Educational N = 60

ANOVA

M(SD)

M (SD)

M (SD)

df

13.68 (4.87) 12.78 (3.99) 14.13 (4.13)

2148 6.96 0.001⁎ 2148 2.04 0.133 2148 6.07 0.003⁎

15.68 (4.24) 12.08 (4.60) Responsibilitya 14.53 (4.51) 13.76 (4.88) Knowledgeb Documentationc 16.22 (4.50) 13.17 (4.23) a

The extent of nurses' responsibility regarding EN. The extent of satisfying knowledge regarding EN. c The extent of support from documentation regarding EN. ⁎ Significant at P b 0.05. b

gap regarding the lack of information about Jordanian nurses' perception regarding EN, and can be used as baseline for future studies, and can be utilized in education, administration, and practices of EN. The majority of nurses reported that either there were no EN guidelines or they were not aware about the availability of such guidelines. The guidelines are available in the participating hospitals, which are similar to the international guidelines. The source of those guidelines was from the accreditation institutions (accredited hospitals) and the hospital policy and procedure manual (non-accredited hospitals). This result was inconsistent with the finding of Persenius et al. (2006), Fulbrook et al. (2007), and Roynette et al. (2008) in which the majority of the participants reported the availability of EN guidelines or protocol. It seems that there are limitations in the dissemination of the EN guidelines in the critical care units that aim to orient nurses regarding the presence and usage of the EN guidelines, and nurses were not aware about the presence of the EN. Nursing administrators need to make this issue as part of the nursing orientation along with frequent checks that nurses know the guidelines and they are following them. The availability of EN guidelines that are based on the current evidences is crucial for critical care nurses to perform EN consistently (Woien and Bjork, 2006; Reeves et al., 2012). In the current study, the majority of the nurses reported the presence of the nutritional support team (NST) in their hospitals, while their units lack this team. Such lack of NST at unit level is consistent with literature (Fulbrook et al., 2007; Persenius et al., 2006; Roynette et al., 2008). It seems that nurses misunderstood the concept of NST and considered the dietitian team as a NST. The outcome of the presence of NST will be reflected on patients, nurses, and organizations. For instance, Schneider et al. (2004) asserted on the need for NST to improve patient outcome, safety, and decrease the cost of health services. Hospital administrators need to consider the importance of providing such teams and make them equipped in order to fully support EN nursing care. Unsurprisingly, physicians were found to have the ultimate responsibility for the prescription of the EN amount, type, rate, and probiotics. This finding echoes the findings of Marshall and West (2006) and Persenius et al. (2006). The prescription of the EN type, rate, amount, and probiotics is the responsibility of physicians in the Jordanian hospitals, and the role of nurses is to carry out the order and to monitor patients' responses to EN. However, nurses still need to know the principles for such decisions for interaction and observation for patients' best outcomes. Of concern, the highest mean scores of the sources of knowledge were for previous education and internet, followed by nursing school. In spite of this, education and nursing school still had low mean scores. Such result is consistent with a previous study about the primary source of knowledge among Jordanian nurses (Al-Ghabeesh et al., 2012). However, Persenius et al. (2006) and Thiel and Ghosh (2008) found that consultation with colleagues was the main source of knowledge for nurses. In Jordanian universities, other schools such as the medical and the agriculture schools are responsible for the courses of nutrition. This fact justifies the low mean scores of the education and nursing school as sources of knowledge regarding EN. Besides, Jordanian hospitals lack Table 5 The differences of responsibility, satisfying knowledge, and support from documentation between male and female, N = 151. Variable

F

P Responsibilitya Knowledgeb Documentationc

Male N = 75

Female N = 76

Student's t-test

M (SD)

M (SD)

df

t-value

P-value

12.82 (4.6) 13.65 (3.9) 14.32 (3.9)

14.75 (4.8) 13.55 (5.0) 14.60 (4.9)

149 149 149

2.508 0.138 0.396

0.013⁎ 0.89 0.69

a

The extent of nurses' responsibility regarding EN. The extent of satisfying knowledge regarding EN. c The extent of support from documentation regarding EN. ⁎ Significant at P b 0.05. b



internet and intranet in their institutions and, if there is any, reliance on these as sources of knowledge is questionable and requires further investigation to assess the quality of these sources. The lowest score was regarding the in-service education and the scientific journal articles. The finding of scientific journal underutilization was supported by several studies (Breimaier et al., 2010; Moreno-Casbas et al., 2011; Timmens et al., 2012; Uysal et al., 2010). In those studies, the barriers for underutilization of scientific journal were the quality of research, communication of findings, insufficient time, lack of organizational support, lack of interest, lack of knowledge, lack of confidence, and little participation in research activities. To provide quality EN care for critically-ill patients and to apply evidencebased practices, eliminating the barriers of research utilization and enhancement of the accessibility of the scientific journal article are of great benefit. Regarding EN, there are four major international societies (the American Society of Enteral and Parenteral Nutrition [ASPEN], the European Society for Clinical Nutrition and Metabolism [ESPEN], the British Association of Enteral and Parenteral Nutrition [BAPEN], and the Canadian Critical Care Clinical Practice Guidelines Committee [CCPG]) that make regular reviews of the guidelines. In Jordan, it is crucial to have a national society to carry out the same role, or to adopt one of these societies' guidelines to provide quality EN care. Up to the author's knowledge, this is the first study to compare the three healthcare sectors in Jordan in respect to the nurses' perceptions of EN responsibility, satisfying knowledge, and support from documentation. In the current study, there were significant differences regarding nurses' perception of responsibility of EN, where nurses in private hospitals scored higher than nurses in the educational and public hospitals. Although nurses in the private hospitals had the highest score regarding EN responsibility, they still had a moderate responsibility. It seems that the policy in the private hospitals was more accessible to the nurses or it was established in a way that has clearer description of responsibilities. Nurses in the public and educational hospitals may be unaware about the EN policy or the availability of such policy, which needs further description of the role and responsibilities of each member involved in the EN care. The result of the nurses' perception regarding the satisfying knowledge of EN showed a low mean score with no significant differences among nurses in the three healthcare sectors. This is consistent with the general findings in literature that nurses lack nutritional knowledge that allows them to perform EN competently (Mowe et al., 2008; Kim and Choue, 2009). As mentioned previously, nurses relied on education and internet as sources of knowledge to provide EN care. Underutilization of scientific research in Jordanian hospitals regarding EN nursing care may have contributed to the perception of the low level of satisfying knowledge among nurses. In regard to nurses' perception of the support from documentation system, results revealed significant differences. Although nurses in private hospitals scored higher than nurses in the educational and public hospitals, they had moderate support form documentation. Precise and correct documentation is crucial to avoid miscommunication, assumptions, and misinterpretation of patients' information among nutritional support team members (Howard et al., 2006). In the current study, it seems that the documentation system in private hospitals was clearer, patient-oriented, and provided more support for nurses to document nursing activities, while the documentation system in the educational and public hospitals needs further modifications to establish standardized documentation. Other reasons could be related to the policy of documentation, the frequent reviews of the documented material by a responsible professional, the nurse–patient ratio, workload, accreditation, and the clear and updated policy and procedure manual. Concerning the gender difference regarding EN, it was noteworthy that female nurses scored higher perception of EN responsibility than male nurses, but they still have low level of responsibility. On the other hand, no significant differences were found regarding the perception of satisfying knowledge and documentation support. Up to the

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authors' knowledge, this is the first study that compares male and female nurses in this field. Female nurses were found to be more autonomous than male nurses (Iliopoulou and While, 2010), which may enhanced their perceptions of EN responsibility in female participants in this study. Implications and Recommendations One of the important practice recommendations is the necessity for evidence-based guidelines, multidisciplinary approach of EN care, and formulation of nutritional support teams at the critical care units. Enhancements of nurses' accessibility to the EN sources of knowledge such as scientific journal articles and international guidelines, along with refreshment programs that upgrade the sense of responsibility among both male and female nurses are highly recommended. The findings of this study revealed that the primary source of knowledge was from education. Thus, nursing schools should focus their teaching strategies on the evidence-based nursing practice, and should have the leading role for educating nutrition courses. Besides, providing the newly-hired nurses with training programs regarding EN policies and practices, with periodic review of nurses' knowledge is recommended. Future research studies are recommended to examine to what degree the protocols, policies, and guidelines are based on the current evidences. Finally, nurses' knowledge and documentation system regarding EN in Jordanian hospitals are areas that need further examination and a qualitative study is essential to understand the individual/organizational factors behind the sense of low responsibility toward EN. Limitations Using a convenience sampling technique is considered a limitation that provides little chance to control for bias. However, nurses in the three healthcare sectors were approached in the different shifts of their duty. Also, formulation of inclusion and exclusion criteria helped to decrease the bias associated with this sampling technique. Another limitation is related to the self-reported method of data collection, in which there is a possibility for bias in reporting clinical practice and respondent error. Conclusion The current study is among the first studies regarding EN in Jordanian hospitals. Physicians had the leading role in all aspects of EN care. Education, internet, and nursing school were the primary sources of knowledge regarding EN. Female nurses were found to have more perceived responsibility, and nurses in private hospitals had moderate level of responsibility and support from documentation toward EN. In general, nurses were not satisfied about their level of knowledge regarding EN. Updating knowledge, awareness of responsibilities, supportive documentation system, implementation of the current evidences in the actual daily practices, and collaboration among healthcare team could be used to improve EN practices. References Al-Ghabeesh, S., Abu-Moghli, F., Salsali, M., Saleh, M., 2012. Exploring sources of knowledge utilized in practice among Jordanian nurses. J. Eval. Clin. Pract. 1365–2753 http://dx.doi.org/10.1111/j.1365-2753.2012.01869.x. Barr, J., Hecht, M., Flavin, K.E., Khorana, A., Gould, M.K., 2004. Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol. Chest 125 (4), 1446–1457. Beck, A.M., Balkinas, U., Camilo, M., Furst, P., Gentile, M., Hasunen, K., Ovesen, L., 2002. Practices in relation to nutritional care and support-report from the Council of Europe. Clin. Nutr. 21 (4), 351–354. Breimaier, H.E., Halfens, R.J., Lohrmann, C., 2010. Nurses' wishes, knowledge, attitudes and perceived barriers on implementing research findings into practice among graduate nurses in Austria. J. Clin. Nurs. 20 (11–12), 1744–1756. http://dx.doi.org/10. 1111/j.1365-2702.2010.03491.x.


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