Assessing neonatal nurses: transitioning preterm infants to oral feeding - a multicenter cross-sectional study

Prematurity, as defined by the World Health Organization (WHO), occurs when infants are born before completing 37 weeks of gestation or within 259 days from the start of the mother’s last menstrual period [1‐3]. There are an estimated 13.4 million babies worldwide who are born prematurely each year [4, 5]. Approximately 10% of preterm deliveries occurring between 32 and fewer than 37 weeks of gestation are documented in Egypt. This significant difference may lead to a greater number of admissions to the neonatal intensive care unit (NICU) annually [6]. Prematurity is the leading cause of mortality and morbidity among children under the age of 5 globally. It is linked to numerous negative health outcomes that affect survival and quality of life later in life [7‐9]. Preterm infants often experience significant oral feeding difficulties, primarily because of the underdevelopment of their central nervous system, cardiovascular and respiratory systems, and musculature of the mouth [10]; approximately 40–70% of preterm infants experience feeding difficulties. These challenges often result in prolonged hospital stays, as these infants require extended care to support their growth and development until they are stable enough for discharge [11‐13].

Oral feeding is a complex and dynamic process vital for preterm infant growth and development during their stay in the NICU. This critical milestone requires the coordination of various systems, including the oral-motor, neurological, cardiorespiratory, and gastrointestinal systems. Efficient and safe oral feeding depends on the proper functioning and integration of these systems to ensure that the infant can feed effectively [14]. Preterm infants with immature oral feeding abilities can adversely affect their development and increase the risk for aspiration, hypoxemia, bradycardia, pneumonia, and even mortality [15]. Currently, the most significant issue concerning premature infants is the transition to oral feeding. Independent oral feeding is a critical milestone that must be achieved before hospital discharge [16]. Furthermore, achieving an effective transition to oral feeding could decrease the length of hospitalization, alleviate the family’s financial burdens and foster emotional bonding between parents [17].

The transition from tube feeding to full oral feeding in preterm infants is influenced by several factors, including the infant’s physiological stability and overall neurodevelopmental maturity. This maturity encompasses behavioral organization and the coordination of rhythmic sucking, swallowing, and breathing. Effective cardiorespiratory regulation is also critical. Additionally, specific infant characteristics, such as low birth weight, gestational age at birth, and overall neonatal condition, are crucial. These factors can guide healthcare professionals in determining the appropriate timing and method for introducing oral feeding to preterm infants [18].

As the primary caregivers in the NICU, neonatal nurses play an essential role in evaluating preterm infants’ readiness cues for beginning oral feeding [19]. To effectually support preterm infants’ transition to oral feeding, neonatal nurses need comprehensive knowledge about various areas, such as appropriate timing and feeding position, nonnutritive sucking, readiness for feeding, oral stimulation exercises and cue-based feeding [16]. Nurses training about evidence-based nursing interventions that include oral motor stimulation and nonnutritive factors helps preterm infants develop feeding skills and early transition to oral feeding [20]. Therefore, assessing nurses’ performance regarding the transition to oral feeding for preterm infants is the first step toward improving feeding difficulties for preterm infants.

Although several studies have evaluated the process of transition from tube to oral feeding in preterm infants and the implementation of evidence-based intervention protocols [21‐24], there is a noticeable scarcity of research assessing the performance of neonatal nurses in relation to oral feeding for preterm infants. Thus, this study aimed to assess neonatal nurses’ performance in terms of the transition to oral feeding in preterm infants working in the neonatal intensive care unit.

Prematurity is a major health problem because it is a leading cause of infant morbidity and mortality in developing countries like Egypt [9]. Accurate data on the prevalence of prematurity is lacking due to Egypt’s poor recording system. However, in spite of existing guidelines and the implementations of evidence-based protocols regarding evaluating transitioning to the oral feeding process among premature neonates, it remains an ongoing challenge as the number of studies evaluating the knowledge of neonatal nurses in Egypt about the transition to oral feeding of preterm infants is limited. In addition, overzealous feeding practice and negative oral simulation may result in disorganization of the oro-motor function, which leads to feeding problems [21‐24]. This is the first multi-central study conducted in Egypt to assess the knowledge and performance of the nurses regarding the transition to oral feeding in preterm infants working in the neonatal intensive care unit.

The performance of neonatal nurses regarding the transition to oral feeding among preterm infants was assessed in terms of knowledge, practices, and attitudes.

Table 1 presents the characteristics of the 553 nurses who participated in the study. The majority of the nurses (39.6%) were aged between 30 and 40 years, with a mean age of 33.67 years (SD = 7.3). In terms of experience, 36.2% of the nurses had between 7 and 13 years of experience, with a mean of 10.37 (SD = 5.5) years. Regarding sex, 55.7% of the participants were female, and 44.3% were male. The educational level of the nurses varied, with 44.8% having a technical health institution degree, 29.3% holding a Bachelor of Nursing degree, and 25.9% having a diploma. Most of the nurses (61.7%) were married, while 38.3% were unmarried. Slightly more than half of the nurses (56.1%) reported having attended training courses about feeding transition, while 43.9% had not. The nurse-to-neonate ratio varied, with 42% of nurses caring for two neonates, 39.2% caring for three neonates, and 18.8% caring for one neonate. Additionally, 65.6% of the nurses were employed full-time, and 34.4% were employed part-time. Finally, 69.6% of the nurses perceived their workload as overloaded, while 30.4% considered their workload to be balanced.

Figure 2 presents the nurses’ knowledge about various aspects related to the transition to oral feeding in preterm infants. The results indicate that a significant proportion of nurses had unsatisfactory knowledge in several areas. Specifically, 72.7% of the nurses had unsatisfactory knowledge about oro-motor function, 73.6% lacked adequate knowledge about the suck-and-swallow pattern, and 67.6% had unsatisfactory knowledge about nonnutritive sucking. Additionally, 63.3% of the nurses demonstrated unsatisfactory knowledge regarding physiological instability and disease severity, while 60.6% had unsatisfactory knowledge about the appropriate position for preterm infants during feeding. However, 59.7% of the nurses provided satisfactory knowledge about the feeding methods. These findings suggest that a substantial number of nurses in this study had knowledge gaps in various aspects related to the transition to oral feeding in preterm infants, which could impact their ability to provide optimal care and support during this critical phase.

Table 2 presents the overall knowledge, practices, and attitudes of the 553 nurses regarding the transition to oral feeding in preterm infants. The results showed that 64.6% of the nurses had unsatisfactory total knowledge, while only 35.4% demonstrated satisfactory knowledge. In terms of practice, 58.6% of the nurses reported unsatisfactory practices, and 41.4% had satisfactory practices related to the transition to oral feeding. Regarding attitudes, 55% of the nurses exhibited a positive attitude, while 45% had a negative attitude toward this aspect of care. These findings suggest that a significant proportion of nurses in the study had knowledge deficits and suboptimal practices concerning the transition to oral feeding in preterm infants. However, it is encouraging to note that more than half of the nurses had a positive attitude, which could facilitate the implementation of targeted educational interventions and support measures to improve their knowledge and practices in this crucial area of neonatal care.

Additionally, correlations between the total knowledge, total practice, and total attitude scores of the nurses regarding the transition to oral feeding in preterm infants were calculated. The results indicate a statistically significant positive correlation between total knowledge and total practice (r = .260, p < .001), suggesting that nurses with higher knowledge levels tended to practice better related to this aspect of care. Similarly, a significant positive correlation was observed between total knowledge and total attitude (r = .215, p < .001), indicating that nurses with greater knowledge were more likely to have a positive attitude toward the transition to oral feeding. Furthermore, a significant positive correlation was found between total practice and total attitude (r = .156, p < .001), suggesting that nurses with more satisfactory practices tended to exhibit a more positive attitude.

Based on the binary logistic regression analysis (Table 3), several coefficients were found to be statistically significant, indicating that they have a meaningful impact on the likelihood of achieving a “satisfactory” total practice rating. Males are significantly more likely to achieve a “satisfactory” rating than females are, as indicated by a positive coefficient (0.449) with a p value of 0.027. Individuals with a diploma or education from a health institution are less likely to have a “satisfactory” rating than are those with a bachelor’s degree, with negative coefficients of -1.127 and − 0.764 and p values of 0.00007 and 0.0015, respectively. Unmarried individuals are also less likely to achieve a “satisfactory” rating, as shown by a coefficient of -0.679 and a p value of 0.0025. A nurse-to-neonate ratio of three or two significantly decreased the likelihood of a “satisfactory” rating compared to a ratio of one, with coefficients of -0.857 and − 0.876 and p values of 0.0028 and 0.0017, respectively. Part-time employment significantly increases the likelihood of achieving a “satisfactory” rating, with a coefficient of 0.932 and a p value of 0.000019. Finally, individuals with unsatisfactory knowledge are less likely to achieve a “satisfactory” rating, as indicated by a coefficient of -0.929 and a p value of 0.000013, while a positive attitude significantly increases the likelihood of achieving a “satisfactory” rating, with a coefficient of 0.529 and a p value of 0.0102. These significant coefficients highlight the factors that most strongly influence the outcome, and by understanding these relationships, actionable steps can be taken to improve the likelihood of achieving a “satisfactory” total practice rating.

The ROC curve generated from the model had an AUC value of approximately 0.76, suggesting that the model has good performance in distinguishing between the two classes. An AUC of approximately 0.76 indicates that the model has good discriminatory ability, making it a reliable tool for predicting “Total Practice” as either “satisfactory” or “unsatisfactory”, Fig. 3.

The findings from this cross-sectional study underscore significant gaps in the knowledge, practice, and attitudes of nurses working in the NICU regarding the transition to oral feeding among preterm infants. The current results indicate that a substantial proportion of nurses lack adequate knowledge in several critical areas related to this transition. Specifically, the majority of nurses demonstrated unsatisfactory knowledge of oro-motor function, the suck-swallow-breathe pattern, and nonnutritive sucking. Additionally, a significant percentage of nurses exhibited insufficient understanding of physiological instability and disease severity. However, 59.7% of the nurses displayed satisfactory knowledge regarding feeding methods.

These knowledge deficits are concerning because they could hinder neonatal nurses’ ability to provide optimal care and support during the critical-to-oral-feeding transition among preterm infants. Effective management of this transition requires comprehensive understanding and skills in these key areas to guarantee that preterm infants receive optimal care and achieve effective attainment regarding oral feeding.

These study findings are consistent with previous research by Aykanat and Gözen [14], who reported in their descriptive, cross-sectional study that the correct responses were particularly low for items associated with cue-based feeding, intervention to promote oral-motor development, nonnutritive sucking, and infant positioning during oral feeding. These findings align with our findings that a majority of nurses lack sufficient knowledge in these crucial areas. This similarity is likely due to the study being conducted under similar conditions. Also, supported by Buloze [31] conducted a study on nurses with similar characteristics and reported that most nurses had acceptable knowledge related to nonnutritive sucking and feeding methods, supporting our findings. Furthermore, Girgin et al. reported that a majority of neonatal nurses lacked knowledge related to cue-based feeding interventions, oral motor stimulation, and positioning techniques [24]. These results may be due to the fact that most nurses did not attend training courses previously about feeding transition, similar to our study. In a qualitative study by Brantes and Curado [32], neonatal nurses recognized the importance of continuing education and training in assessing oral feeding skills.

Throughout our study, we evaluated nurses’ knowledge, practices, and attitudes regarding oral feeding transition. Approximately two-thirds of the nurses had unsatisfactory total knowledge, highlighting the need for educational interventions. The practices of these nurses also mirrored this trend, with 58.6% of the nurses reporting unsatisfactory practices. This indicates a clear gap in the application of knowledge to practice, which is crucial for effective patient care. Despite these challenges, it is encouraging to note that more than half of the nurses exhibited a positive attitude concerning the transition to oral feeding.

The majority of nurses’ positive attitudes are promising indicators. An individual’s attitude can have a significant impact on his or her willingness to engage in educational opportunities and improve practices. This positive disposition could be leveraged to implement targeted educational programs designed to address knowledge and practice gaps. Such interventions could foster an environment of continuous learning and improvement, ultimately enhancing the quality of care provided to preterm infants [33].

These results are supported by a quasi-experimental single-group study by Naz et al. [12], which studied 36 nurses. The majority of them had a diploma in nursing, 4–10 years of experience, and belonged to the 31–45 years age category, which aligns with our nurses’ age and experience. The study showed that the majority of the nurses practiced incompetent practices prior to training.

Similarly, Çelen et al. [19] reported that most nurses had poor practices in supporting oral feeding in preterm infants before any intervention. These results are supported by the finding that more than half of the nurses did not receive education on preterm infant feeding, similar to our results. Also, Buloze [31] conducted a study on nurses with similar characteristics and stated that nurses working in tertiary referral hospitals have shown an acceptable level of knowledge and a positive attitude related to the feeding transition of infants with low birth weight. Another qualitative study conducted by Astuti et al. [34] concluded that neonatal nurses play a pivotal role in enhancing OFP among premature infants. A descriptive study in Egypt highlighted that nurses’ knowledge of trophic feeding practices is essential for improving preterm infant outcomes [35]. In addition, nurses must be skilled in developmental stimulation to enhance oral feeding readiness in preterm infants [36].

Furthermore, the current results highlight the interconnected nature of knowledge, practices, and attitudes among nurses, as evidenced by the correlations between the studied variables. The significant positive correlations between total knowledge and total practice (r = .260, p < .001), total knowledge and total attitude (r = .215, p < .001), and total practice and total attitude (r = .156, p < .001) emphasize the importance of a holistic approach to education and training. Enhancing knowledge is likely to lead to improved practices and more positive attitudes, creating a virtuous cycle that benefits both nurses and their patients.

These findings suggest that improving knowledge through education could directly enhance clinical practices and highlight the importance of knowledge in shaping attitudes, which in turn can influence practices. Additionally, improving practices can reinforce positive attitudes, creating a supportive environment for ongoing learning and improvement [37]. Similarly, Girgin et al. [22] reported that providing training to nurses on the transition to oral feeding in infants increased knowledge level. Nursing intervention support is needed in caring for infants with delayed oral feeding skills through teamwork among nurses, families and parents [34]. Moreover, before conducting an education program, Beissel et al. [38] indicated that nurses’ performance related to oral feeding was poor. Additionally, Salah and Hassan [39] showed a positive correlation between nurses’ knowledge, practices and attitudes, reinforcing the interconnectedness of these elements in clinical settings. This similarity is likely due to the study being conducted in the same geographic area and involving nurses with similar characteristics.

The results of the binary regression analysis provide compelling evidence that several key factors significantly influence the practice levels of neonatal nurses regarding the transition to oral feeding in preterm infants. The model demonstrated a good fit for the data, reinforcing the validity of the findings (it has an AUC value of approximately 0.76, suggesting that it has a good level of performance). Males are significantly more likely to achieve a “satisfactory” rating than females are, suggesting a sex disparity in practice quality. Additionally, we highlight the importance of higher education in achieving better practice outcomes. A nurse-to-neonate ratio of three or two significantly decreases the likelihood of a “satisfactory” rating compared to a ratio of one, underscoring the importance of adequate staffing levels for better practice outcomes. Part-time employment significantly increases the likelihood of achieving a “satisfactory” rating, suggesting potential differences in practice quality between full-time and part-time practitioners. Nurses with unsatisfactory knowledge are less likely to achieve a “satisfactory” rating, while a positive attitude significantly increases the likelihood of achieving satisfactory knowledge and attitude in practice quality.

These findings are consistent with previous studies. Salah and Hassan [39] noted that a positive attitude significantly improves practice levels. Abo El Magd Fathi et al. [26] who conduct study in Egypt as our study, emphasized that higher education levels and increased nursing experience enhance practice levels related to sensorimotor stimulation to improve oral feeding in preterm infants. Similarly, Naz et al. [12] reported that attending training courses boosts nurses’ skills. Girgin and Gözen [14] highlighted that a heavy workload negatively impacts nurses’ skills, underscoring the importance of a supportive working environment. The success of achieving oral feeding readiness is influenced by the therapeutic care environment and caregiver competence [40]. Additionally, Li et al. [41] reported that caregivers’ knowledge improves their oral feeding skills for preterm infants with dysphagia. Nurses are vital for effectively improving preterm oral feeding readiness, as they provide efficient nursing care to improve the oral feeding transition power of infants [38].

This study highlights significant gaps in the knowledge, practice, and attitudes of neonatal nurses regarding the transition to oral feeding in preterm infants. The findings revealed that a substantial proportion of nurses lacked adequate knowledge of critical areas, such as oro-motor function, the suck-swallow-breathe pattern, and nonnutritive sucking. These knowledge deficits potentially hinder the ability of nurses to provide optimal care during this crucial transition. However, the generally positive attitude among nurses suggests a strong foundation for implementing targeted educational interventions to enhance their knowledge and practices, ultimately improving care for preterm infants.

Addressing these gaps through comprehensive educational programs and ongoing support will be essential for ensuring high-quality care for preterm infants during this vital phase of their development.