Intensive care nurses' knowledge of enteral nutrition at public hospitals in Sana'a, Yemen: a cross-sectional survey [version 1; peer review: 1 approved with reservations, 1 not approved]

Background: Nurses have a pivotal role in initiating and managing enteral nutrition (EN) and monitoring any potential complications. Yet, it is unclear whether Yemeni nurses have adequate knowledge to deliver and manage enteral nutrition safely. Therefore, the aim of this study was to assess the level of ICU nurses’ knowledge regarding the management of EN. Methods: A descriptive cross-sectional study was conducted from February 2019 to March 2019. A probability sampling method was used to recruit 174 nurses from four public hospitals in the capital city of Yemen. A self-administered 17-item questionnaire related to ICU nurses' knowledge regarding EN intervention was used to collect the data. Results: Out of the 174 respondents, 60.9% were females, 48.9% were aged between 20 and 25 years and 66.1% had a 3-year nursing diploma. Most respondents (79.3%) had one to five years of working experience as nurses, while almost two-thirds (70.7%) had one to five years of working experience as an ICU nurse. Above half (59.2%) of the respondents had never attended training courses on EN management and 65.5% specified that the college or institute of nursing was the source for their knowledge about EN management. Only 10.9% of the respondents had an adequate level of knowledge, while (43.1%) of them had a moderate level of knowledge and 46.0% of them had an inadequate level of knowledge regarding the EN management. Significant associations between the level of ICU nurses' knowledge of EN management and their level of education and the sources of knowledge were detected. Conclusions: The significant gap in ICU nurses’ knowledge regarding EN management identified implies the need to upgrade and refresh of the ICU nurses' knowledge by implementing a regular training Open Peer Review


Introduction
Critically ill patients need regular enteral nutrition (EN) as an essential intervention to fulfil the body's dietary and physiological requirement 1 . EN is the recommended method of nutritional support for ICU ill patients who need extra nutritional calories because of the increased metabolic rate 2 . It is considered as a medical therapy in law; hence, it should not be initiated only after ethical considerations have been made.
Previously, delivering of EN to critically ill patients was considered as a type of supportive care and not a therapeutic intervention 3 . Based on its benefits, it is more than a supportive therapy. It has been found that EN protects critically ill patients from malnutrition and subsequently improves body immunity and healing of tissues, which decreases their physiological stress effect, peptic ulcer, rates of infection 4,5 , the inflammatory response and maintains the function and integrity of the bowel 3,6 . Although maintaining balanced feeding via EN improves patients' health-related-outcomes, overfeeding leads to an increase in the mortality rate and must be avoided 7 .
Malnutrition among ICU ill patients is a universal public health concern, with a prevalence rate ranging from 40 to 60% 8 . According to previous studies, almost 70% of ICU patients acquired malnutrition during hospitalization 9 . To overcome this serious problem, EN should be initiated as early as possible for critically ill patients to avoid any risk of morbidity and mortality, which usually increases due to long patient hunger 10 . Previous studies and nutritional guideline have recommended that EN should be started within 24 to 48 hours of patients' admission to the ICUs or after the stability of the hemodynamic state, specifically after cardiac resuscitation 11 . In other words, once critically ill patients are admitted to ICUs, delivering appropriate nutrition becomes imperative 12 .
Despite the benefits of EN to critically ill patients, this process is usually associated with many complications, particularly if performed without an adequate level of knowledge 13,14 . Inappropriate delivering and poor management of EN can result into several complications, such as tube blockage or mal-positioning, nausea, vomiting, pulmonary aspiration, overfeeding, diarrhoea, treatment-related complications and delivery-site related complications like infection and agitation 15 . ICU nurses play a significant role in preventing such complications because they are responsible for identifying patients' nutritional risk, the calories needed, initiating and managing EN and monitoring any potential complications 16,17 . Accordingly, they must be knowledgeable enough to administer EN to critically ill patients safely 14,16 . Therefore, the aim of the present study was to explore Yemeni ICU nurses' knowledge regarding management of EN. Specifically, our study aimed to answer the following two research questions: Sample and sampling method Stratified sampling was utilized to select the participants from the above-mentioned public hospitals. A list of the ICU nurses' name was obtained from each hospital. The required sample was drawn randomly from each list using a systematic random technique. All ICU nurses who had at least 6 months working experience, including both males and females with different educational qualifications, who were involved directly in ICU patients care, full-time employees and had agreed to participate were eligible to take part in this study. Nurses who included in the pilot study and those who were unwilling to participate were excluded. Based on these criteria, the eligible participants were approached by the researchers at their workplace. Out of 384 ICU nurses, 174 nurses were included in this study.

Study instrument
Based on a comprehensive review of the previous related studies, a self-administered questionnaire was developed by the researchers. The questionnaire consists of 17 questions with four possible options to be answered. The final questionnaire (see Extended data 19 for a blank copy) is divided into two sections as follow: The first section is related to the socio-demographic characteristics of the participants: age, sex, level of education, working experience as a nurse, working experience as ICU nurse, training courses on EN and sources of knowledge about EN.
The second section is related to knowledge of ICU nurses regarding EN management and is divided into three subsections: 1. Knowledge of ICU nurses regarding before EN administration, which includes eight questions with a total of 32 responses.
2. Knowledge of ICU nurses regarding during EN administration, which involves four questions with a total of 16 responses.
3. Knowledge of the ICU nurses regarding after EN administration, which involves five questions with a total of 20 responses.

Scoring system
The 17 questions related to knowledge were assessed with "Yes" and "No" options. After correction of some reverse statements, a score of 1 was given for each correct response, while a score of 0 was given for each "incorrect" response. The maximum score for all correct answers was 68. Correct answers were calculated to obtain total scores for all questions of the three subsections. A score of 50% or less was considered inadequate, 51-75% moderate, while 76% and above was considered as adequate 20 .

Validity and reliability
Three experts in the EN from hospitals and Al-Razi University were invited to participate in examining the content validity for the instrument used in this study. Their comments concerning the tool accuracy, relevance, consistency, comprehensiveness and applicability for implementation were taken in consideration. A pilot study was conducted on 40 ICU nurses. Cronbach's alpha test was performed to examine the reliability of the questionnaire items. The result of the alpha was 0.78, which is acceptable.

Data collection
A self-administered questionnaire was distributed during the period of February to March 2019. The ICU nurses in the selected hospitals were invited to fill the questionnaire. Out of 179 questionnaires distributed, 174 were completed correctly and included in the final analysis.

Data analysis
The participants' responses were entered, cleaned, checked and explored using statistical software (IBMSPSS), version 22.0. The analyzed data was described using the mean values and standard deviations for continuous variables as well as the frequency and percentages for the categorical variables. A multinomial logistic regression and Chi-square tests were conducted to find out the associations between the ICU nurses' knowledge and the selected socio-demographic variables.
A p-value of ≤0.05 was reported as statistically significant.

Ethical consideration
Ethical clearance from the Ethics Committee of Al-Razi University was obtained for the current study. Then, an official written permission was also obtained from the managers of the selected hospitals prior to conducting the study. A written consent from all involved nurses was obtained prior to conducting the study.  Table 2.

Discussion
The results of the current study revealed that the age of the majority of the ICU nurses' was 20 years old and above. This result indicate that most participants were fresh graduates who were assigned together to work in ICUs. This finding is consistent with the result of a previous study 16 which reported that over half of participants' age ranged between 26 and 35 years old. However, our result is inconsistent with the result of another study 22 which revealed that the majority of nurses' age were 35 years old and above. Furthermore, the results showed that the majority (60.9%) of the ICU nurses were female. The high proportion of female nurses could be related to the fact that the profession of nursing remains a female-dominant profession. This finding is similar to a previous study 16 that showed the majority (75%) of the participants were female nurses in the context of Egypt.
The current study revealed that more than half of the ICU nurses had a three-year nursing diploma and five years or less of work experience, either as general nurses or as ICU nurses.   Another key finding of this study is that the level of ICU nurses' knowledge regarding EN management was significantly associated with the educational level (χ2 = 13.141, P= 0.011).
In other words, a high educational level in nursing was associated with a higher level of knowledge. This could be attributed to the fact that faculties of nursing focus more on the theoretical aspect, while health institutes pay considerable attention to the practical aspect. This finding is similar to those of Abdullah et al., 24 , Shahin et al., 10 and Taha and Said 16 , who found that the educational level was positively significant associated with the level of the nurses' knowledge about EN, whereas those who had a bachelor degree achieved a higher level of knowledge compared to those with less educational level. However, our finding was inconsistent with the results of Aml, Manal and Fatamah 27 , who reported no difference in knowledge level based on nurses' educational qualifications. This discrepancy is possibly because of the differences in the curriculum of educational institutions. Furthermore, it was found that a significant association between the knowledge level and the sources of information related to EN management (χ2= 13.948, P= 0.030 Conclusions: Is there any evidence that training courses in EN management improve clinical outcomes? Based on the results of your study, the only thing the authors revealed was that low SES was associated with inadequate knowledge. Experience and training courses were not associated with improved knowledge. Therefore, the conclusion should be based on their results.

7.
Discussion: What is new in this study? What can the readers act from this paper all over the world? 8.

Is the work clearly and accurately presented and does it cite the current literature? Partly
Is the study design appropriate and is the work technically sound? Partly

If applicable, is the statistical analysis and its interpretation appropriate? Partly
Are all the source data underlying the results available to ensure full reproducibility? Partly Instead of citing the tool they have developed and used, authors must mention and cite the references and literature that had been used in developing the tool.

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Per authors, the second part of data collection instrument contains three subsections which are the before EN administration, during EN administration, and after EN administration. Accepting that this categorization is correct, it is not clear which items are under each subsection. Moreover, most of the 17 items are not related to the before, during, and after EN management, they are related to general knowledge about the EN (such as the indications, goals, benefits, complications, routs, methods, types and contents of EN formula, …….. etc.), even there is an item asking about the types of nutritional support in general (enteral, parenteral, combination, ..etc.). More suitable grouping and categorizing must be used to organize the instrument or to leave it without any categorization it will be better.
○ Validity and reliability: delete the word ' reliability' and replace it by ' internal consistency'.

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Under the data analysis subtitle, they mentioned that a multinomial logistic regression test was conducted. In fact, no multinomial logistic regression test was done. So , delete ' multinomial logistic regression'.

Results:
In results, the use of some terms (such as most, majority) in describing the results need a revision. For example: 49.40% is not a majority.
○ Table 2 presents the frequency and percentage of the participants and compares between the subgroups using the Chi-square tests. I think it will be better if the table presents the knowledge means scores and standard deviations of the subgroups and compare between them by the t or f tests. After that multiple regression can be performed.
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