Enhancing nutritional care in palliative care units: assessing nurse knowledge and quality perception in enteral nutrition practices

This study revealed that nurses’ knowledge levels regarding enteral nutrition practices were significantly influenced by receiving enteral nutrition training and the frequency of tube feeding in their units. In contrast, possessing a palliative care certificate did not have a notable effect, suggesting a need to emphasize enteral nutrition topics in certification programs. The positive association between tube feeding frequency and both knowledge and perceived care quality underscores the importance of clinical experience in improving nurses’ expertise and awareness. Conversely, the negative impact of parenteral nutrition frequency on perceived care quality suggests that nurses may view this method as more complex and challenging. The less invasive nature of enteral nutrition and its clearer contributions to patient care likely contribute to its more favorable perception among nurses.

These findings should be contextualized within Turkey’s healthcare history, where gender bias in nursing has played a significant role. Between 1954 and 2007, Turkish nursing laws required individuals to be female to enter the profession [28]. Although this restriction has since been lifted, and men are now allowed to work as nurses, nursing continues to be perceived as a predominantly female profession, limiting the representation of male nurses [29, 30]. This gender imbalance is evident in this study, where 94.63% of participants were female nurses, consistent with previous research by Kısacık et al. (2019) and Koçhan and Akın (2018), which reported that 79% and 69% of their nursing participants, respectively, were female [23, 27].

The development of palliative care in Turkey has also influenced the findings. The expansion of palliative care centers began with the Pallia Turk project, part of the National Cancer Control Program (2009–2015), leading to a noticeable increase in these centers starting in 2012–2013 [31]. However, opportunities for nurses to work in palliative care units remain limited, resulting in relatively short employment durations in these settings. This study found that the median employment duration for nurses in palliative care centers was 3 years (minimum: 1 year, maximum: 16 years). This indicates that palliative care nursing in Turkey is still in its developmental stages, with more experienced nurses likely to remain in these roles longer.

Palliative care focuses on managing symptoms and alleviating disease-related stress in terminally ill patients, with the primary goal of improving their quality of life by relieving pain, discomfort, and emotional strain [32]. Malnutrition is a common issue among palliative care patients, often worsening as the disease progresses and increasing the need for nutritional support [33]. Proper nutritional interventions can enhance patients’ overall well-being and quality of life, making enteral nutrition a vital component of high-quality care in palliative settings [32‐34]. In Turkey, studies have reported a malnutrition risk exceeding 90% in palliative care units, with enteral nutrition support rates ranging between 20% and 60% [20, 35, 36]. Given the frequent use and significant benefits of enteral nutrition, it is essential for nurses to have comprehensive knowledge and skills in this area [37].

Some studies have highlighted the positive effects of early palliative care interventions, including nutritional support. According to recent ASCO recommendations, nutritional interventions primarily serve a “supportive” rather than “palliative” role [38]. For cancer patients undergoing active treatment, nutritional support can improve adherence to chemotherapy and radiotherapy while offering clinical benefits, regardless of the route of administration. However, for patients with incurable cancer, nutritional support mainly alleviates malnutrition and hunger, with limited impact on slowing disease progression and only temporary improvements in quality of life [34]. Decisions regarding nutritional support in end-of-life care are complex, often involving religious, ethical, and emotional considerations. It is recommended that these decisions be guided by clinical benefits and tailored to each patient’s specific needs, avoiding unnecessary interventions [39]. In many cases, discontinuing artificial feeding may be the best option when its burdens outweigh the potential benefits [40].

Training in enteral nutrition equips nurses to assess patients’ nutritional needs, administer enteral nutrition, monitor complications, and educate patients and their families about enteral feeding. In this study, 62.4% of participating nurses reported having received training in enteral nutrition. Previous studies in Turkey have reported varying rates of such training among nurses, ranging from 7.8 to 62% [23, 27, 41, 42]. This variation may reflect differences in institutional policies, patient populations, or the timing of the studies. Research has shown that educational programs for nurses significantly improve their knowledge, performance, and practices related to enteral nutrition [22, 43‐45]. In the present study, nurses who received enteral nutrition training scored significantly higher on the Enteral Nutrition Practices Knowledge Form compared to those without training (p < .01). However, even among trained nurses, only 10.16% answered more than 75% of the questions correctly, while 17.18% answered less than 50% correctly. Insufficient knowledge and improper practices in providing enteral nutrition can negatively affect care quality and patient safety. Conversely, well-implemented nutritional nursing care can improve patients’ nutritional status and clinical outcomes [22, 43]. Regular and continuous education is, therefore, essential to enhance nurses’ enteral nutrition practices and improve the overall quality of care.

This study found that nurses’ knowledge regarding enteral nutrition practices was at a moderate level, aligning with previous research conducted in Turkey [23, 27]. For example, Koçhan and Akın (2018) reported that nurses had insufficient knowledge in areas such as the storage conditions of enteral products, tolerance of feeds, gastric residual volume indicating delayed gastric emptying, and medication administration in enterally fed patients [23]. Another study revealed that nurses performed better in questions related to skin problems around stomas (83.53%), feeding positions (80.59%), and interventions to prevent nausea and vomiting (73.53%). However, they struggled with questions on residual volume (88.82% incorrect), pulmonary aspiration (61.76% incorrect), and tube care (56.47% incorrect) [27, 41]. Similarly, in the current study, questions about fluid requirements during tube feeding (2.9% correct), maintaining the patency of jejunostomy tubes (9.8% correct), and medication administration (11.71% correct) received the lowest correct response rates.

For patients receiving tube feeding, fluid requirements are calculated as 1 mL/kcal unless fluid restriction is applied. Since commonly used isocaloric formulas are approximately 75% water, additional fluid support—typically at least 25% of the feeding volume—is required. The remaining fluid needs can be met with drinking water, including the water used for tube flushing [23, 46, 47]. Notably, one of the most incorrectly answered questions in this study was, “Enteral nutrition solutions completely meet fluid requirements,” with only 2.92% of nurses answering correctly. This indicates a lack of knowledge among nurses about the water content of enteral formulas and how to calculate daily fluid requirements.

Maintaining feeding tube patency is essential, as blockages can occur due to various factors. Proper flushing is critical for preventing these blockages. Tubes should be flushed with water every 4–6 h during continuous feeding and before and after each feeding during intermittent feeding. If the tube is not in use, it should be flushed every eight hours. To prevent blockages caused by drug and formula interactions, flushing before and after drug administration is also recommended [48]. In this study, while 73.17% of nurses correctly answered the question about preventing blockages in nasogastric tubes, only 9.76% correctly answered the question about maintaining patency in jejunostomy tubes. This discrepancy may be attributed to the more frequent use of PEG and NG tubes in clinical settings compared to jejunostomy tubes.

Feeding tubes are also used for administering medications, but incorrect preparation or administration can negatively impact patients [49]. Studies have shown that nurses often lack sufficient knowledge to prevent drug interactions in enteral drug administration, with varying practices in flushing protocols [50‐52]. Educational interventions have been shown to improve nurses’ knowledge, attitudes, and behaviors in this area significantly. For instance, a case-control study in Iran found that in-service training for intensive care nurses improved their practices and increased consultations with pharmacists regarding medication administration [21]. Similar findings were reported in Jordan, where training enhanced nurses’ knowledge of tube cleaning, medication preparation, and dosage form recognition [53]. In Turkey, a training program for 90 nurses across neurology clinics, palliative care units, and intensive care units improved their knowledge and attitudes regarding medication administration through enteral routes [54]. In the present study, the correct response rate for medication administration-related questions was only 11.7%. These findings emphasize the need for targeted training programs for nurses in palliative care units, particularly focusing on medication administration in patients receiving tube feeding. Such training could significantly enhance nurses’ knowledge and improve patient care outcomes.

In 2015, the Turkish Ministry of Health introduced the Palliative Care Nursing Certification Training Program, which includes 35 h of theoretical instruction and 80 h of practical training, valid for five years. The program aims to equip nurses caring for palliative care patients with essential knowledge, skills, and attitudes [55]. While the theoretical section covers topics such as “Total Parenteral/Enteral Nutrition Application,” these topics are not included in the practical training component. In the present study, 33.66% of nurses reported completing the certification training program. However, only 7.32% of these nurses correctly answered more than 75.0% of the questions on the Enteral Nutrition Practices Knowledge Form. Furthermore, holding a palliative care certificate was found to have no significant effect on the scores of the Enteral Nutrition Practices Knowledge Form or the Perceived Nutritional Care Quality Score. These findings suggest the need to enhance the certification program by expanding its focus on enteral nutrition and integrating this topic into the practical training section.

Hospitals with established Nutrition Support Teams (NST) can provide more individualized nutrition care [56]. Research shows that NSTs significantly reduce nutrition-related complications, facilitate the early detection of malnutrition, minimize calorie deficits, and lower healthcare costs [57‐59]. Globally, nutrition counseling teams are becoming more prevalent in hospitals [59]. However, a study by Kurt and Paslı Gündoğan (2023) found that 48.3% of nurses in intensive care units in Turkey reported the absence of NSTs in their institutions [60]. This underscores the need to expand NSTs across hospital settings.

In the current study, 29.8% of nurses stated they received nutrition consultation services for all patients requiring nutritional support, while 39.5% reported receiving these services for some patients. The presence of nutrition counseling teams was found to significantly influence the Perceived Nutritional Care Quality Score among groups. Interestingly, 11.22% of nurses were unaware of whether nutrition counseling services were available in their palliative care units. This lack of awareness highlights the need for better communication and training regarding unit-specific nutrition support protocols. Continuous education on the importance of nutrition support should be provided in units where such services are frequently utilized. Additionally, orientation training for new staff should include information about the unit’s nutrition support practices to ensure consistency and awareness.

This study highlights the significant impact of enteral nutrition training on improving nurses’ knowledge levels. However, the expected effect of having a palliative care certificate on knowledge levels was not observed, suggesting that certification programs may need to place greater emphasis on enteral nutrition topics. The positive influence of tube feeding frequency on both knowledge and perceived care quality underscores the importance of clinical experience in enhancing nurses’ knowledge and awareness. In contrast, the negative impact of parenteral nutrition frequency on perceived care quality suggests that nurses may perceive this method as more complex and challenging. The less invasive nature of enteral nutrition and its clearer contributions to patient care may explain the more favorable perceptions of this method. Based on these findings, developing more comprehensive and targeted training programs for both enteral and parenteral nutrition practices is essential to improve nurses’ skills and perceptions. These findings are consistent with existing literature. For example, Kurt and Ceyhan (2023) found that enteral nutrition training significantly enhanced the knowledge levels of intensive care nurses [61]. Similarly, Carrasco et al. (2023) demonstrated that educational interventions incorporating clinical simulation effectively improved nurses’ understanding of enteral nutrition practices [62]. Additionally, Yu et al. (2022) reported that implementing an enteral nutrition nursing quality control system in clinical practice not only increased nurses’ knowledge but also improved patient safety and care quality [63].