Administering enteral tube medications – room for improvement?
- Correspondence to Teresa Williams
Emergency Medicine (M516), The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia;
Implications for practice and research
■ Management of enteral tubes is common in nursing practice.
■ Administration of medication involves several skills.
■ Practices in administration of medication through enteral tubes is inconsistent and some are considered unsafe.
■ Research to provide the best available evidence is needed.
Management of enteral tubes for decompression of the stomach, provision of nutrition and administration of medications is a common nursing practice. Enteral nutrition is the preferred method of feeding for patients unable to take oral nutrition.1 Administration of medications through enteral tubes requires several skills including verifying enteral tube placement and preparing drugs for administration. The preferred method for checking enteral tube placement is by x-ray.2 This is not always available or practical, and in the absence of x-ray, a combination of methods is suggested,3 auscultation, however, should not be used.4 While pH testing is recommended, problems occur when using this method in the critically-ill patients.5 Phillips and Endacott examined the practices of acute care nurses when administering medication through enteral tubes.
This descriptive survey used a sample of acute care nurses from two Australian hospitals. The sample was selected by randomising 90% of the nurses to attain at least 300 participants per hospital. The questionnaire was tested for reliability using a test–retest method. Feedback from the pilot study was used to determine the face validity and user-friendliness of the questionnaire. The practice areas were similar for the two hospitals.
After randomisation, the sample size was 571 nurses, of whom, 32% responded to the survey. Some of the respondents did not answer all questions. Half of the 181 nurses who participated in the study practiced in intensive care units. The medication administration practices were inconsistent and some were unsafe, potentially compromising patient care. A range of methods to verify enteral tube position prior to administering enteral medication were reported with auscultation being the most common. A majority of nurses reported administering enteric-coated and slow or extended release forms of medication, and giving solid forms of medication when liquid form was available. A total of 96% of nurses reported flushing a tube after giving medication, but only 28% flushed tubes before, and 12% between each medication.
Phillips and Endacott justified why they did not select the total population, but there is no explanation as to why 300 participants at each hospital were selected. There was a low-response rate, but the returned questionnaires were anonymous so it is unknown whether there were any differences in those who responded to the survey. It is likely that some selection bias was present. The hospital staff was informed of the study, but the authors did not discuss any strategies to encourage participation. Sample size is important to ensure adequate numbers of participants for meaningful interpretation of the results.
The authors acknowledged the survey was self-reported by nurses so the consistency with actual practice was unknown. Responses may reflect what should occur rather than what did occur. It is also unknown whether evidence-based guidelines on enteral tube management were available in each of the hospitals and if the nurses' practices reflected these standards.
The questionnaire used was well designed. The questionnaire was tested for reliability, but the results of the test and re-test procedures to assess reliability were not reported. Content validity was assumed because the tool was developed from an extensive review of the literature, and it was designed to examine relevant aspects of practice relating to nurses administering enteral medication. Face validity and user-friendliness were demonstrated in the pilot study.
This survey provides some valuable insights into the current nursing practice of administrating medications through enteral tubes. The inconsistencies in practice and lack of ‘quality’ evidence available support the need for future research to be conducted in a wide range of practice areas.