A Qualitative Study Investigating the Current Practices, Obstacles, and Needs of Enteral Nutrition Support among Registered Dietitians Managing Non-Critically Ill Hospitalized Patients in Riyadh, Saudi Arabia Open Access

Malnutrition is an overwhelming condition that is highly prevalent among hospitalized patients [1]. Nutrition support is the primary approach that used to prevent/treat malnutrition besides optimizing nutritional status [2]. Enteral nutrition (EN) is considered the standard nutritional support strategy for patients with limited ability to maintain their nutritional requirements orally [3]. However, hospital settings present several challenges for providing EN support [3]. Therefore, proper EN planning and monitoring are crucial to overcome challenges and maximize benefits [2, 3].

EN therapy is a complex process that is subjected to multiple interrelated factors and varies significantly among patients [2]. The patient’s medical status is one of the major factors that considerably influence the EN support [2]. According to the American Hospital Association’s guidelines, patients are categorized based on their condition as undetermined, good, fair, serious, and critical [4]. Based on that, critical patients with life-threatening conditions are usually admitted to intensive care units for intensive monitoring [5]. In contrast, patients with more stable vital signs and less disease severity are usually admitted to regular hospital floors (noncritical areas). However, each hospitalized patient has unique metabolic/immune responses to injury, illness, or surgery, which modulate the nutritional status and influence the treatment plan [6, 7].

Dereliction in managing the EN complex process may contribute to several adverse complications [3, 7]. For that reason, EN practices must be grounded on evidence-based data to assure adequacy and reduce complications [8]. Modern medicine has implemented several approaches to enhance the quality of healthcare services and increase survival rates [8, 9]. Clinical guidelines are one of the core efforts that are implemented to improve healthcare services [9]. Several international guidelines are published to provide a basic framework of evidence that supports the best EN practices for hospitalized patients [7, 10, 11]. However, despite the wide availability of EN-related international guidelines, no recommendations or guidelines are tailored specifically for the unique healthcare environment in Saudi Arabia. The hospitals’ care practices, characteristics, and settings are different in Saudi Arabia compared to other countries. Accordingly, to improve the national EN practices and increase the quality of care for the non-critically ill population, specifically tailored national guidelines are considered essential evidence that should be developed and followed. However, a prior understanding of the current EN practices and local needs, along with highlighting the faced obstacles while delivering EN, is important to direct the process of establishing a practical EN-related national guideline.

This study used a qualitative approach by conducting multiple focus group sessions to gain an in-depth understanding of the current EN practices for the non-critically ill population and explored the registered dietitians’ (RD) needs/obstacles while delivering EN to this population. In this article, non-critically ill patients referred to hospitalized patients who do not require intensive care unit admission. A purposive sampling approach was used to select the eligible participants. The participation eligibility was limited to RD practicing EN for more than 1 year in Riyadh’s hospitals (government and private). Riyadh is the capital city of Saudi Arabia, with the highest number of hospitals (49), including specialized centers and medical cities [12]. Participants were recruited via email and call invitations with a brief explanation of the study’s purpose.

Focus group sessions were conducted online via Zoom private rooms (Zoom is a video-audio communication platform); all sessions were audio-recorded for data analysis. The records are kept in a secure device with limited accessibility to researchers only. Session moderators are RDs and trained to conduct neutral discussions. During the preparation phase, the moderators received two training sessions from a researcher with prior focus group moderating experience. Moreover, a senior researcher supervised the first two sessions for quality monitoring and guidance. In each session, an assistant was responsible for taking field notes for the main discussed points to aid in the analysis process. Additionally, in order to promote self-disclosure, participants were stratified into groups based on their workplaces, years of experience, and educational level. Each session lasted 90–120 min, and the focus group sessions were conducted until data saturation was reached.

Demographic data were obtained from participants during the preparation phase. In addition, to direct the flow of focus group discussions, Krueger and Casey’s five categories were used to design the preformulated open-ended questions [13]. Questions are categorized into opening, introductory, transition, key, and ending questions. The focus group discussions consisted of 22 questions (1 opening, 1 introductory, 1 transition, 18 key, and 1 ending). Additionally, the EN international guidelines were used to conceptualize the key questions’ theme. However, the specific key questions were formulated according to the general theme of the American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines and standards of care [14], in addition to the researchers’ clinical experience.

Audio records were subsequently used to transcribe sessions for data analysis. The final transcripts include only the relevant and valuable points. Translation from Arabic to English was performed as needed during the transcription process. Data saturation was assessed by highlighting the new information in each session, and the absence of new information in a complete session was used as an indicator for data saturation [15]. After reaching data saturation, two independent researchers separately identified themes via coding analysis. Furthermore, the inter-rater agreement was manually evaluated.

Five focus group sessions that consisted of 24 RDs were conducted online via Zoom private rooms. Demographic data regarding years of experience, educational level, professional title, and international/national accreditation were obtained (Table 1). Most of the participants are females, and 75% of them work in governmental hospitals. Experience-wise, 70.8% of the participants are bachelor’s degree holders with 2–5 years of clinical experience. In addition, 95.8% of the participants work in hospitals accredited by the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) accreditation, while 62.5% work in hospitals with the Joint Commission International (JCI) accreditation.

The majority of data were obtained during the first and third focus group sessions. However, the absence of new information was noticed in the fifth focus group session, which indicated data saturation. As a result, ten practice-related themes were identified via coding analysis, in addition to four obstacle-related themes and four need-related themes. All defined themes were divided into subthemes during the data analysis (Tables 2, 3).

The availability of general and specialized EN-related protocols/guidelines to guide local practices was one of the main highlighted points while discussing EN practices. Based on participants’ feedback, the theme was divided into three subthemes: internally developed guidelines/protocols, external adoption of international guidelines/protocols, and guidelines/protocols are not available (Table 2). The majority of participants reported the availability of some basic, not specific EN-related protocols in their workplaces, which were either developed internally by the hospital regulatory management or adopted from international guidelines, such as ASPEN or European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines. Furthermore, some of them linked these protocols’ availability to accreditation requirements. In contrast, only a few reported the lack of any EN-related protocols in their workplaces.

Several heterogeneous patterns were observed by digging into the specific aspects of EN practices. Heterogeneity in the screening process and nutritional referral systems was one of the first noticed aspects (Table 2). More than half of the participants use an internally created screening tool (not validated) to nutritionally screen hospitalized patients. In contrast, only a few participants reported the use of validated screening tools, such as the Malnutrition Universal Screening Tool (MUST). Eventually, the nutritional screening score will serve as a foundation for the nutrition-services referrals. The rest of the participants, on the other hand, claimed that nutritional screening is not conducted where they work, and the referral system relies entirely on the physicians’ referrals. Concerning the medical record charting, the majority of participants use the Subjective, Objective, Assessment, and Plan (SAOP) note documentation style, while a few use the Assessment, Diagnosis, Intervention, and Monitoring/Evaluation (ADIME) style note or manual notes.

Most participants agreed on the lack of clear protocols that guide the EN process in terms of eligibility criteria, timing, initiation, access site, and delivery route. As a result, the availability or the lack of protocols to guide the EN process was recognized as subthemes (Table 2). Most of the participants highlighted that EN eligibility decisions are usually based on the physician’s or RD’s clinical judgment/personal experience rather than clearly defined standards. In addition, according to the observation of some participants, the only clear indication for EN is aspiration risk or swallowing difficulties, whereas other indications such as malnutrition, severe underweight, or poor oral intake are usually a matter of debate between multidisciplinary team members and frequently overlooked by physicians. For the access site decisions, most of the participants agreed that it is mainly a physician’s responsibility, with no clear role for the RD. On the other hand, a homogeneous pattern was observed in the delivery route practices, when the majority reported bolus feeding as the primary delivery route for non-critically ill patients, unless other indicated.

Challenges in calculating the nutritional requirements for non-critically ill patients were frequently highlighted during discussions. Participants’ practices were divided into two subthemes: the RD’s clinical judgment or the use of internally developed/adopted protocols (Table 2). Two-thirds of the participants reported that nutritional requirement specialized protocols are not available in their workplaces; instead, they usually depend on international guidelines mostly (ASPEN and ESPEN) guidelines or personal experience. In contrast, the other one-third declared the availability of internally developed nutritional requirements related protocols. However, according to the observation of some participants, the international nutrient reference values and predictive equations are sometimes not applicable to the Saudi population.

The EN ordering process was extensively highlighted during discussions, and three subthemes emerged (Table 2). Most of the participants agreed that the hospital’s policies mandate a physician’s approval before implementing the RD’s recommendations. In contrast, some participants reported that their recommendations are directly implemented, while only one participant claimed that RD’s recommendations are approved directly, except for fluid orders.

Safety precaution protocols to avoid aspiration and overfeeding were highlighted during discussions, in which three subthemes were defined (Table 2). Almost all participants reported the availability of aspiration precaution protocols, while only a few reported the presence of overfeeding prevention protocols. On the other hand, a few participants reported the lack of specific protocols in both aspects, besides claiming that RDs mostly have no role in aspiration precautions or overfeeding prevention.

EN monitoring frequency and regulatory protocols varied significantly between participants, and four subthemes were noticed (Table 2). Most of the participants agreed on the absence of clear follow-up frequency-related protocols in their workplaces, and it is mostly based on personal diligence. On the other hand, a few participants stated that monitoring frequency is usually based on the nutritional risk score (3–5 days or every 7 days). Only one participant declared that follow-up must be conducted 1 day after the tube-feeding initiation. In contrast, a homogeneous pattern was noticed in the monitoring aspects, as most agreed that patients’ laboratory results, weight, and feeding tolerance are the main monitoring aspects during the EN intervention.

The transitional process from EN to oral nutrition and assessing the oral intake adequacy during the transitional process were highlighted during discussions, with four emerging subthemes (Table 2). Most participants reported the lack of clear protocols that guide the EN/oral feeding transitional process; usually the physician or family decides with no clear role for the RD. In contrast, some participants reported using a clear transitional protocol, and the transitional process is usually based on the RD’s recommendations. Regarding food intake adequacy, most participants agreed that RDs might use calorie counting or other related tools; however, it is not mandatory, and sometimes it is not even completed. Only a few participants declared that calorie counting for 3 days is mandatory during the transitional process and must be documented and shared with the multidisciplinary team.

A homogeneous pattern was noticed in the discharge plan of care/education practices. The majority of participants reported the availability of a clear protocol that guides the patient-discharge plan of care and patients’ education, which is mainly available because it is a part of the hospitals’ accreditation requirements. In contrast, only a few participants reported the lack of clear discharge-related protocols; instead, the discharge process is usually based on personal diligence (Table 2).

Technical and logistic aspects of EN were highlighted during the practice discussions, in which three subthemes were defined (Table 2). Some participants reported the availability of an assigned formula room with applied safety precautions to prepare EN formulas, besides applying a clear labeling system. In contrast, some participants reported the lack of a specialized formula room/formula labeling system. Only one of the participants reported the availability of a specialized formula room but without any applied safety precautions or labeling systems.

Four obstacle-related themes and four need-related themes were defined (Table 3), and each obstacle-related theme is presented with its associated need-related theme.

Some participants viewed the lack of clear internal/national protocols to guide the RD’s practices as an obstacle to optimum EN delivery, and two subthemes emerged (Table 3). Additionally, participants mostly agreed that the EN process for non-critically ill patients is more challenging compared to critically ill patients due to the lack of attention from multidisciplinary team and limited scientific evidence.

Almost all participants agreed that national guidelines and protocols designed based on the Saudi population’s characteristics are highly needed. Additionally, to reduce the gap between academic/clinical expertise and to develop practical guidelines, it was suggested that a national multidisciplinary expert panel from different institutions should be assigned to develop the needed guidelines. One of the participants stated, “The involvement of a multidisciplinary team (dietitians, nurses, and physicians) with representatives from different hospitals and universities (academic part) is necessary to develop a practical EN national guideline. As known, there is a huge gap between academics and practitioners and between what we learned in university and our practice.” Moreover, using the local primary research and international guidelines to formulate the newly developed national guidelines was also proposed. However, most of the participants highlighted that the need for a unified national guideline does not conflict with the necessity of personalized plans and clinical judgment; both should be used together to reach the best individualized evidence-based practices. One participant described guidelines/protocols as “a road map to start with” and then added, “Guidelines and experience are used together to pull out a specific plan. No one can apply guidelines without experience.”

The role of RD and communication channels was thoroughly discussed during the obstacles discussions, and four subthemes emerged (Table 3). More than half of the participants considered the poor communication, low awareness of the RD’s role in EN (EN’s eligible patients/feeding sites), and the lack of ordering privileges as obstacles that may delay and negatively affect the EN process and feeding delivery. For example, one participant stated, “Sometimes, other members of the medical team overstep my role. Moreover, there is a delay in the communication channel between the multidisciplinary team, which may affect the feeding delivery.”

Some participants highlighted the need to delegate the ordering privileges to RDs in order to improve feeding delivery and accuracy. Moreover, some participants highlighted the need to clarify/document the role and responsibilities of each discipline within the multidisciplinary team.

A few participants reported the challenges of following EN discharge plans at home, and some of them linked it to poor family compliance. In addition, one participant was concerned about the EN care continuity for patients transferred between hospitals, as feeding plans are sometimes not documented in the discharge reports.

Few participants highlighted the value of multidisciplinary team efforts to facilitate care continuity after patients’ discharge. Additionally, the necessity of nutritional follow-up after patients’ discharge was highlighted.

Some participants reported the lack of a specialized formula room equipped with tools/trained personnel and formula shortage as the primary technical and logistics obstacles for delivering EN accurately and safely. In addition, some participants were concerned about the safety of preparing formulas at the patient’s bedside by other health staff, such as nurses.

Some participants suggested that having a specialized formula room equipped with tools/trained personnel, besides maintaining a sufficient formula supply, is highly needed for safe and accurate EN delivery.

Group discussions focused mainly on the EN practices for non-critically ill patients among RDs, besides highlighting the obstacles faced during EN delivery and relevant needs. Our study showed some variations in EN practices among the interviewed participants. The reported variations may be explained by the lack of national guidelines and protocols among Saudi hospitals, which highlighted the need for unified EN national guidelines/protocols to improve the quality of care for this population. This is in line with the international standards and recommendations for developing health-related guidelines and protocols. Practically, the need to develop clinical guidelines increases when there is a wide regional variation in managing a specific condition [16]. Additionally, the Institute of Medicine (IOM) as well recognizes care variations along with disease burden, topic controversy, and potential impact as essential criteria that assist organizations in identifying high-priority topics while formulating clinical guidelines [17]. On the institutional level, the ASPEN standards of practice also recommend that each health institution strive to provide the best nutritional support services by developing internal EN-related policies and protocols [14].

Another focus group concern was the heterogeneity of the nutritional screening process among RDs, besides using invalidated screening tools. Generally, using invalidated screening tools or overlooking the screening step is against the established international practices, which view nutritional screening by using a validated tool as an essential element in the nutritional care process [7, 11, 18]. For instance, the US Joint Commission mandates nutritional screening for all patients within 24 h of hospital admission [19]. In addition, a previous investigation suggested that screened patients at admission had more than two-fold chances of being assessed by an RD compared to non-screened patients [20], which highlighted the important role of nutritional screening in the nutritional care process.

Challenges in calculating nutritional requirements and the suitability of international reference values to the Saudi population were highlighted during discussions. Scientifically, some similarities exist in the individuals’ physiological/pathological characteristics and responses. However, genetic and environmental variations between races and populations are still present [21, 22]. Therefore, nutrient requirements and nutritional needs may differ between individuals [22], which should be considered while applying international nutrient reference values and predictive equations to the Saudi population.

Insufficient protocols that regulate the transitional process from EN to oral nutrition and the role of RD in the transitional process were pointed out during discussions. In literature, minimum guidelines exist to guide the transition from EN to oral nutrition [10]. However, typically, if the patient is able to consume 60–75% of the estimated nutritional requirements, the multidisciplinary team should consider discontinuing EN and removing the feeding device [3, 10]. In addition, ASPEN standards of practice recommend that oral intake adequacy must be monitored and documented in the medical file before discontinuing EN [14]. Generally, monitoring the nutritional status and oral intake sufficiency is performed by the RD as part of the multidisciplinary team [3], which highlights the role of the RD during the EN/oral transitional process.

In our study, participants viewed the low awareness level of RD’s role, overstepping the RD’s role, and poor communication between the multidisciplinary team members as barriers to deliver the optimum EN. These practices are against the generally established international and national standards. In hospital settings, EN intervention must be implemented under a multidisciplinary team’s supervision, in which RD is the key [3, 7, 11, 14]. Nationally, according to the CBAHI standards, medical interventions should be conducted in a multidisciplinary manner, and a qualified RD must provide all dietary services [23]. Moreover, the Saudi Standards Classification of Educational Specialties and Occupation includes the EN therapy as well under the RD’s scope of services and responsibilities [24].

Concerns were raised about the EN ordering privileges and the role of other multidisciplinary members in the EN process. The necessity of a physician’s approval before implementing the RD’s recommendations seems to be a barrier to timely intervention. On a national level, CBAHI standards highlighted that it is a physician’s responsibility to prescribe therapeutic nutrition support along with consulting the RD [23]. However, the dilemma of ordering privileges and its correlated consequences were frequently reported in the literature. Numerous studies showed that RD’s recommendations that require a physician’s approval are frequently not implemented, which negatively affects and delays the nutritional support [25‒27]. In contrast, several articles highlighted that giving RDs the ordering privileges was associated with a significant improvement in the quality of care and patients’ safety [27, 28]. However, giving RDs the ordering privileges must be accompanied by national regulations that assure competency and proficiency [28], besides providing sufficient EN training and education during the academic period [29].

The EN technical and logistic aspects in terms of EN’s formula preparations and labeling systems were reported through the obstacles and needs discussions. Some participants seemed to be concerned about the lack of an assigned formula room to prepare EN formulas and the safety of preparing formula at the patient’s bedside. ASPEN guidelines highlighted the importance of EN’s formula preparation and labeling systems [10, 14]. ASPEN standards emphasize that the open-system EN’s formula must be prepared accurately by trained personnel and stored according to the manufacturer’s safety recommendations [10, 14]. Furthermore, the formula should not be prepared at the patient’s bedside for safety reasons [14]. Additionally, the EN’s formula must be labeled with the formula contents and two patient identifiers (name, medical record number, and date of birth), with a clear statement, indicating that this product is intended for enteral administration only and not for intravenous (IV) administration [10, 14].

To the best of the researcher’s knowledge, this is the first study highlighting the EN practices for non-critically ill patients among RDs in Riyadh city compared to the international guidelines, besides identifying the related gaps and local needs by using a qualitative approach. A qualitative approach was used to obtain a comprehensive and detailed understanding of the participants’ insights and opinions. However, the generalizability of the study’s results is limited, and further studies employing a quantitative approach with a larger sample size are required to strengthen the current findings.

Our study highlighted the need to develop unified EN national guidelines and regulatory protocols for non-critically ill patients by the relevant national authorities. The national guidelines should cover all the EN-associated aspects, including nutritional screening, nutritional assessment, EN indication/access site, initiation process and delivery routes, nutritional requirements, transition processes, monitoring/care continuity, and EN technical/logistic aspects, along with defining the scope of practice for health practitioners, including RDs.

On the institutional level, it is recommended that each healthcare facility should develop internal regulatory protocols to regulate the EN process, besides establishing an internal quality monitoring procedure and training programs. Additionally, the local primary research should be encouraged to act as a base for building national evidence-based guidelines. Finally, having a national evidence-based guideline will help the decision-makers standardize EN protocols among Saudi hospitals, which will benefit the national accrediting agencies in the quality monitoring processes.

The Research Ethics Committee at King Khalid University Hospital (KKUH) approved this study (NO. E-20-5314). In addition, a signed consent form was obtained from participants before the beginning of focus group sessions.

The authors have no conflicts to declare.

Funding was not received for this research.

Fatimah Alsoqeah: conception and design, data collection, formulating the interview questions, transcripts’ formulation, and article drafting. Rabaa Alyumni: conception and design, data collection, formulating the interview questions, and transcripts’ formulation. Nawaf Alruwaili: conception and design, data collection, formulating the interview questions, coding analysis and inter-rater agreement, critical revision of the article, and article drafting. Khalid Aldubayan: formulating the interview questions, coding analysis and inter-rater agreement, and critical revision of the article.

The audio-recorded data that support the findings of this study are not publicly available since it is containing information that could compromise the privacy and identity of research participants. However, other needed data and information are available upon request from the corresponding author.