Adherence to standard nursing protocols on nasogastric tube feeding in a secondary referral hospital in Ghana: comparing self-ratings by professional and auxiliary nurses

Feeding in order to meet the body’s dietary and physiological needs is a vital component of human survival [1]. In critical medical conditions, patients are unable to feed as they ought to due to a weakened state or other pathological conditions. Moreover, conditions such as pharyngeal tumours block passage of food into the gastrointestinal tract thus demanding feeding through NG tube. Likewise, neck injuries and a state of partial or complete unconsciousness (coma) are indications for nasogastric (NG) tube feeding.

To maintain patients’ physiological and nutritional status, assisted feeding in the form NG tube feeding is often the option and nurses play a critical role in the management of patients on this kind of medical therapy [2]. NG tube feeding, which is a type of enteral tube feeding, involves the delivery of nutritionally complete feed via a tube into a gut [2]. This feeding approach is used for patient who are unable to meet their nutritional requirements orally due to reasons stated earlier. In the medical literature different types of enteral routes of feedings have been documented which include: nasogastric, nasoduodenal, nasojejunal, oesoghaostomy, gastrostomy and jejunostomy routes. This study focused mainly on nasogastric route of feeding because it is commonly used in Ghana.

According to Delaune & Ladner [3], nasoenteral insertion of a gastric feeding tube is the simplest and most often used method of tube feeding. It has been found that enteral route of feeding has the advantage of helping in digestive system function; enteral feeding is also cheap and has more nutritional benefits to the patients compared to parenteral nutrition [4].

Nasogastric tube feeding is the most frequently used method of enteral feeding particularly if feeding is to be used for relatively shorter period. In view of this, the nurses’ knowledge and skill on the insertion of nasogastric tube and subsequent care are important to ensure patient safety [5, 6].

Adherence to standard protocols in the management of NG tube feeding is particularly critical in resource poor settings in Africa where quality of healthcare delivery and safety remain significant challenges [7, 8]. El-Meanawi [9] in a study in Egypt revealed that, 62% of nurses had unsatisfactory knowledge on nasogastric tube feeding. According to El-Meanawi [9] nurses’ knowledge and practices regarding nasogastric tube feeding at the medical and surgical departments were not enough with some unsafe practices [9].

In Ghana, professionals and auxiliaries nurses  are taught the standard nursing protocol for NG tube feeding as per the Nursing and Midwifery Council (NMC) curriculum for nursing trainees. Professional nurses are further taught the procedure for insertion of the NG tube and are permitted to perform this procedure especially in rural areas where there are no medical doctors to perform this role. On the other hand, auxiliary nurses (also called nurse-assistants clinical (NAC) and nurse-assitants preventive (NAP)) are basically supposed to assist professional nurses in NG tube insertion and its management. However, the reality is that in Ghana, due to human resource constraints, auxiliary nurses often outstep their mandate to perform these relatively advanced nursing procedures.

There is currently paucity of empirical data on NG tube feeding and related challenges at clinical settings in Ghana. Moreover, adherence to standard protocols in NG tube feeding has not been explored from the perspectives of nursing staff who play a critical role in NG tube feeding, hence the need for this study. This study thus explored self-rated adherence levels to standards on NG tube feeding by professional and auxiliary nurses and the related barriers impeding compliance with these standard protocols.

Even though a number of studies have been conducted on NG tube feeding in the reviewed literature [9, 13‐16], there remain dearth of literature on the comparative differences in adherence by professional and auxiliary nurses particularly within the context of low resourced countries such as Ghana. Moreover, in many previous studies the emphasis has been limited to knowledge levels and skills of clinicians on NG tube feeding [17] without a further exploration on the extent to which these clinicians adhere to the standards they claim to know.

On the whole, this study discovered that the extent to which nurses perceived their adherence to the standard nursing protocols on NG tube feeding was largely low. Counter intuitively, professional nurses appeared to score even lower self-ratings on adherence than their auxiliary counterparts (p = 0.005). A univariate ordered logistic regression test further confirmed the differences (OR = 2.76, p = 0.031). This revelation either suggests perhaps professional nurses were more honest in their responses as compared to auxiliary nurses or indeed the professional nurse knew the standards but for one reason or the other they are unable to follow them to the latter on routine basis. Also, perhaps because auxiliary nurses usually have relatively shorter and less detailed training in advanced nursing procedures such as NG tube feeding they might have displayed ignorance by rating themselves higher on practices that are below the standard practice.

Care rendered by professional nurses relative to auxiliary nurses has been found to significantly associate with the odds of better patient care [18]. A study by Aiken et al. [18] involving adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland concluded that a reduction in the proportion of professional nurses taking care of patients is associated with a 11% increase in the odds of death while substituting one nurse assistant for a professional nurse for every 25 patients is associated with a 21% increase in the odds of dying among these patients.

This empirical revelation, albeit not contextualized in Ghana, is compelling and raises the question whether or not the trend is relevant to the Ghanaian context where the number of auxiliary or assistant nurses outnumber professional nurses in many healthcare facilities in Ghana. As at 2016 a total of 13,239 registered general nurses (i.e. professional nurses) worked within the public health sector compared to 18,107 enrolled nurse (i.e. auxiliary nurses) [19].

Since this current study did not independently verify the self-ratings by the staff it remains a challenge to conclude that indeed professionals necessarily did not follow standard practices in NG tube feeding relative to their auxiliary colleagues. Perhaps the auxiliary nurses did not answer the questions honestly due to the bias of social desirability.

In addition, these results could be attributed to the fact in many resource poor health systems due to inadequate numbers of professional nurses, auxiliary nurses turn to assume the roles and duties of professional nurses and over time develop better competencies and proficiencies as alluded to in the literature [20]. Future researchers are therefore encouraged to explore beyond these subjective reports with an independent verification of staff self-ratings through onsite observations and scoring over time. Until this independent assessment is done findings of this current study remain subjective self-ratings by participants.

Apart from the professional category of respondents, factors such as number of years of work experience, exposure to NG tube feeding training workshops and marital status were found to be important predictors of nurses’ self-ratings on their adherence to standard nursing protocols on NG tube feeding. Similar studies in the past have alluded to the relevance of continuous professional development trainings towards improving professional practice at clinical sites [7, 21, 22]. For instance, a study by Bloomer et al. [20] found that years of clinical experiences has a positive correlation with the tendency to follow standard protocols in clinical practice and render better quality care. Higher self-ratings on adherence was observed among single staff than those who were married. This observation cannot immediately be explained even though the suspicion is that perhaps staff who are single are more likely to have relatively less family responsibilities since a positive association between family and work life has been implied in previous studies [7, 23, 24]. Gender, age, religion and educational qualification did not significantly influence adherence to standard nursing protocols on NG tube feeding contrary to similar previous studies [7, 23, 24] where these factors were strong predictive factors. Perhaps differences in study designs, settings and respondents accounted for these contrasting findings with some of the literature.

In terms of the barriers constraining adherence, lack of in-service training on NG tube feeding was the cogent constraint identified by 91% of the respondents. This constrain has been reported in similar studies on Ghana [7, 21, 25‐28] and other countries [6, 17, 29]. Limited health budgets to support staff in this regard has culminated into lower frequencies of trainings for staff resulting in many clinicians practising with obsolete knowledge. Beyond the limited in-service trainings, deficits in health sector human resources remains a major challenge for many resource poor countries in Africa including Ghana [19, 30]. Unfortunately, these constraints continue to militate against quality of health service delivery by health staff including their ability to adhere fully to standard clinical practice as demonstrated in this study.

Inadequate number of nurses per work shift was identified by respondents as a prime challenge in adhering to standard protocols on NG tube feeding, similar to previous findings [6, 7, 25, 31]. As at 2016 the total number of health sector workforce was 102,019 serving close to 30 million Ghanaians [19]. In Ghana, the nurse patient ratio, at the time of conducting this study, was 1: 627 [32], and in the Volta region (where this study was conducted) the nurse patient ratio was 1:674 marginally above  the national average. Available administrative records from the study hospital also confirmed the nurses’ claim of low staff strengths given that there were a total of 166 nursing personnel serving an average OPD attendance of about 900 [33]. On the whole, the findings of this study suggest the need to address existing shortage of  nurses as part of efforts towards improving adherence to standard nursing practices and overall quality of care rendered to patients.

Overall, self-rated adherence to standard nursing protocols on NG tube feeding by the sampled nursing staff was low. Self-rated adherence to pertinent standard nursing protocols was relatively lower among professional nurses than auxiliary nurses even though the former had higher educational qualification, more years of work experience and benefited more from workshops on NG tube feeding. These dynamics perhaps explain why professional nurses perceived their current practices as sub-standard. However, because these responses were largely subjective self-ratings, interpretation of the findings should be done with caution.

The major constraints identified by nurses regarding adherence to standard protocols on NG tube feeding were lack of routine workshops and trainings on NG tube feeding; shortage of nurses per shift; inadequate NG tube feeding protocols on the wards; inadequate supply of NG tubes and limited opportunities to care for patients on NG tube feeding.

In summary, findings from this study suggest interventions should be geared towards routine in-service trainings for nursing staff on NG tube feeding, and displaying more protocols and guidelines on NG tube feeding in relevant wards. In addition, there is the need to revisit activities of professional and auxiliary nurses on the wards to ascertain the real dynamics of task shifting among nursing staff.