Nurses' Competency and Challenges in Enteral feeding in the Intensive Care Unit (ICU) and High Dependency Units (HDU) of a referral hospital, Malawi.

Critical illness may cause hyper-metabolism and adequate nutrition is required to limit muscle wasting, respiratory and gastrointestinal dysfunction and alterations in immunity1,2. In critical illness, feeding behaviours change; patients may experience physical obstruction to swallowing or inability to ingest food. This calls for nurses' attention to be focused on the provision of alternatives to oral intake. One of these alternatives is the provision of enteral (tube) feeding. Enteral feeding includes delivering a complete feed via nasogastric or orogastric tube into the stomach or percutaneous tubes into the jejunum or duodenum3. This feeding is associated with a reduced period of hospital stay, reduced mortality, lower costs and fewer complications as compared to parenteral feeding4,5. Enteral feeding is a common practice at the referral hospital studied. Nasogastric tube feeding using intermittent regimen; where feed is given and stopped at regular intervals, is the standard method used. Studies have emphasised the role of nurses in nutritional support. Nurses are an important link in nutritional support because they are responsible for administering nutritional formulas6. Contrary to this, many studies have reported that although nutrition is a significant concern in hospitals, has low priority and literature on this subject is very scanty7,8. Minimal attention has been paid to how enteral feeding is administered by nurses9. There are wide variations in the management of nutritional support which may be related to knowledge gaps, or the use of multiple sources of information,10 or to a lack of standardization in the care environment11. Maintaining consistencies in feeding the critically ill has been identified as a problem secondary to the inadequate knowledge of the nurses5. Currently in Malawi, there is no scientific data about nurses' tube feeding competency and challenges faced when providing enteral feeding. With such lack of evidence it was hypothesized that there is inadequate level of competency in tube feeding among nurses. Therefore, a survey of the nurses was required to determine their current level of competency and challenges. A survey was done to assess the nurses' level of knowledge in enteral feeding, to describe their current practice in enteral feeding documentation and to determine challenges experienced in enteral feeding practice. In this study “enteral feeding” was used interchangeably with “tube feeding. ” The conceptual model guiding the study was drawn from the American Association of Critical Care Nurses (AACN) Synergy Model for Patient Care. This model defines nursing practice based on the needs of the patient. The model contends that when nurse competencies relate to patient needs, and the characteristics of the nurse and patient synergise, optimal patient outcomes can result12. Nursing practice is determined by the needs of patients and their families and reflects an integration of knowledge, skills and experience13. The author contends that each patient brings unique needs and characteristics to the clinical situation. Therefore to meet patient needs, nurses must apply certain characteristics and competencies to patient care. These competencies are identified as: clinical judgment, advocacy and moral agency, caring practices, collaboration, systems thinking, responses to diversity, facilitation of learning, and clinical inquiry12. This model was chosen because of its relevance in recognising nurse competencies as important and that when nurse competencies and patient needs synergise, optimal patient outcome can result14. Design This was a non experimental descriptive survey using quantitative method of a self administered questionnaire and a retrospective case file review.