Knowledge, Attitudes and Practices Regarding Enteral Nutrition Management Among ICU Nurses

ABSTRACT

Background

Intensive care unit (ICU) patients frequently experience disruptions in their nutritional needs, and ICU nurses play a critical role in managing enteral nutrition.

Aim

This study aimed to evaluate ICU nurses' knowledge, attitudes and practices (KAP) regarding enteral nutrition.

Study Design

A multicentre cross‐sectional study was conducted from September to December 2024 across 15 hospitals in China. A self‐developed questionnaire was used to collect socio‐demographic data and assess KAP scores. The KAP levels were dichotomised using a threshold value of 80% of the maximum possible score. Differences in KAP scores based on demographic factors were analysed, and the relationships between KAP dimensions were explored using correlation analysis and structural equation modelling (SEM).

Results

A total of 420 valid questionnaires were analysed, with 80.0% of participants being female. The mean KAP scores were 17.87 ± 2.49 (range: 0–46), 48.74 ± 4.65 (range: 11–55) and 65.39 ± 7.36 (range: 15–75), respectively. Positive correlations were found between KAP scores (r = 0.243–0.450, all p < 0.001). Female gender (OR = 0.542, 95% CI: 0.324–0.907, p = 0.020), holding administrative positions (OR = 1.931, 95% CI: 1.014–3.681, p = 0.045), and attending enteral nutrition lectures (OR = 1.721, 95% CI: 1.096–2.702, p = 0.018) were independent factors associated with adequate knowledge. SEM revealed direct effects between knowledge and attitude (β = 0.275, p < 0.001) as well as between attitude and practice (β = 0.462, p < 0.001). Additionally, knowledge demonstrated both direct effect (β = 0.198, p < 0.001) and indirect effect (β = 0.127, p < 0.001) on practice.

Conclusion

ICU nurses generally exhibited inadequate knowledge but demonstrated positive attitudes and proactive practices regarding enteral nutrition. Attitude showed a partial mediating effect between knowledge and practice. Educational interventions are necessary to enhance knowledge, which may further improve attitudes and practices.

Relevance to Clinical Practice

ICU nurses need better knowledge of enteral nutrition to enhance patient care and outcomes. Educational interventions are essential.

Impact Statements.

• What is known about the topic

  • ○
    ICU patients often face nutritional disruptions, and enteral nutrition (EN) is a critical aspect of their care.
  • ○
    Nurses play a pivotal role in managing EN, but gaps in knowledge, attitudes and practices (KAP) may affect patient outcomes.
  • ○
    Previous studies suggest variability in nurses' KAP regarding EN, with knowledge often being the weakest area.
• What this paper adds

  • ○
    This multicentre study quantifies ICU nurses' KAP levels in China, revealing inadequate knowledge but positive attitudes and proactive practices towards EN.
  • ○
    Identifies key factors influencing knowledge, including gender, administrative roles and prior EN training.
  • ○
    Demonstrates significant relationships between KAP dimensions, with knowledge indirectly improving practice through attitude (using structural equation modelling).
  • ○
    Highlights the need for targeted educational interventions to enhance ICU nurses' EN knowledge, which may further improve clinical practice and patient outcomes.

1. Introduction

Intensive care unit (ICU) patients often exhibit a range of acute and complex health problems that involve multi‐organ dysfunction, severe metabolic disturbances and profound alterations in nutritional requirements [1]. The stress response to illness leads to reduced splanchnic blood flow, altered gut motility and intestinal permeability, which often makes it difficult to administer nutrition via conventional oral or enteral routes [2]. Enteral nutrition facilitates the direct delivery of nutrients into the gastrointestinal tract through feeding tubes, such as nasogastric, nasojejunal or gastrostomy tubes [3]. Early initiation of enteral nutrition has been linked with a reduction in the incidence of infections, as it helps to maintain gut integrity and the gut‐associated immune system [4]. Besides, the treatment supports the synthesis of proteins and enzymes that are essential for cellular repair and immune function [5]. Population‐based evidence highlighted the effects of rapid EN advancement on the reduction in in‐hospital mortality and a significant decrease in hospital stay duration [6]. Despite these established benefits, the effective implementation of EN in ICUs confronts multifaceted challenges including physiological barriers, protocol adherence gaps and interprofessional coordination complexities. Research has shown that the actual amount of nutrition delivered via EN in the ICU is often less than 50% of the prescribed goal, even among the most malnourished patients [7]. In China, only 32.7% of critically ill patients received EN feeding within 48 h of ICU admission, highlighting the gaps in EN practice [8].

Nurses play a central role in the management of enteral nutrition in ICU patients. They are responsible for the day‐to‐day monitoring of nutritional status, ensuring the proper administration of enteral feeding and managing complications related to tube feeding [9]. In the context of enteral nutrition, nurses should be familiar with the different types of enteral feeding formulas, and their specific applications depending on the patient's condition, such as high‐protein formulas for those at risk of muscle wasting [10]. Nurses' attitudes towards enteral nutrition are shaped by their experiences, training, institutional protocols and perceptions of the importance of nutrition in critical care. In some cases, nurses may fail to assess the patient's baseline nutritional status adequately [11]. However, despite the importance of nutrition in critically ill patients, there is a growing concern that ICU nurses may have varying levels of awareness and practices regarding nutrition management and enteral nutrition [12, 13, 14], which may lead to inconsistent application of protocols and poorer clinical outcomes.

Knowledge, attitudes and practices (KAP) studies are designed to assess the understandings, attitudes and behaviours of specific groups in relation to a health intervention [12]. This approach has been widely used in healthcare research to examine how the understanding and perceptions of healthcare providers influence their clinical practices [12]. Several KAP studies have been done regarding enteral nutrition among nurses, suggesting the insufficiency in clinical implementation [13, 15]. A study in South Africa found that military nurses held positive attitudes towards the importance and administration of enteral nutrition but lacked sufficient knowledge [13]. Similarly, research from Ethiopia indicated that over half of ICU nurses demonstrated inadequate knowledge and poor practices related to enteral nutrition [15]. A recent systematic review indicated that nurses generally hold favourable attitudes towards enteral feeding, though gaps persist in their knowledge and clinical practice [16]. However, limited evidence exists regarding the KAP of Chinese ICU nurses in enteral nutrition. For example, nurses in burn intensive care units (BICUs) demonstrated suboptimal understanding of enteral nutrition protocols, requiring updated training and standardised practices [17]. Further research is thus needed to develop targeted educational interventions that enhance their nutritional management proficiency.

1.1. Aim and Hypothesis

This study aimed to comprehensively evaluate Chinese ICU nurses' KAP regarding enteral nutrition and identify associated influencing factors. The following hypotheses were tested: (1) ICU nurses' knowledge positively influences their attitudes towards enteral nutrition; (2) knowledge directly enhances their clinical administration of enteral nutrition; and (3) positive attitudes contribute to improved practice adherence.

2. Methods

2.1. Study Design and Participants

This multicentre cross‐sectional study was conducted between September and December 2024, involving ICU nurses from 15 hospitals across diverse regions in China. The study protocol received ethical approval from the author's Hospital. Prior to participation, informed consent was obtained from all enrolled nurses following a comprehensive explanation of the study objectives and procedures. The inclusion criteria were as follows: (1) registered nurses working full‐time in ICU settings and (2) aged ≥ 18 years. The exclusion criteria included: (1) questionnaire completion time < 90 s, indicating potential inattention; (2) implausible responses (e.g., reported age > 100 years); (3) incorrect answers to quality control items; and (4) inconsistent or logically contradictory response patterns.

2.2. Questionnaire Design

The questionnaire design was informed by relevant literature [13, 15] and guidelines [18, 19, 20], including the Expert Panel on Enteral Nutrition in Emergency Critical Patients in China, the Clinical practice guidelines for nutritional assessment and monitoring of adult ICU patients in China, and the Expert consensus on prevention and management of enteral nutrition therapy complications for critically ill patients in China (2021 edition). Following the initial draft, an expert in ICU nursing conducted a review, and subsequent revisions were made in response to the feedback received, thereby enhancing the content validity of the questionnaire. A preliminary investigation involving 24 participants tested the reliability and face validity of the instrument. The overall Cronbach's α coefficient was 0.862, with 0.718 for the knowledge section, 0.925 for the attitude section and 0.808 for the practice section, indicating strong internal consistency. During the pilot study, participants were encouraged to share feedback on any items they found confusing or unclear. Since no items were reported as such, this confirmed the face validity of the study.

The final questionnaire, in Chinese, consisted of four sections: demographic information, knowledge, attitudes and practices. Demographic data collected included age, gender, education level, years of work experience, professional title, hospital classification level, ICU capacity (number of beds), academic engagement (teaching and research activities), administrative roles, frequency of providing enteral nutrition in the past year and participation in enteral nutrition‐related training. The knowledge section contained 23 items, scored 1 point for correct answers and 0 for incorrect or unclear responses (score range: 0–23). The knowledge section assessed ICU nurses' understanding of EN, including its definition and clinical application (items 1–3), nutritional risk screening (items 4–5), timing of EN initiation (item 6), prevention and management of EN‐related complications (items 7–16), formulation selection (items 17–19) and special precautions (items 20–23). The attitude section incorporated 11 statements measured on a 5‐point Likert‐type scale, ranging from ‘strongly agree’ (5 points) to ‘strongly disagree’ (1 point), resulting in a potential score range of 11–55 points. The attitude section evaluated nurses' perspectives on early initiation of EN (items 1–2), confidence in EN management (items 3–5), perceptions of EN safety (items 6–8), as well as views on interdisciplinary collaboration and patient education (items 9–11). Similarly, the practice section contained 15 items assessed using an identical 5‐point Likert scale, with a total possible score range of 15–75 points. The practice section focused on EN‐related behaviours, including nutritional risk screening (item 1), adherence to standard operating procedures (items 2–4), prevention of adverse reactions (items 5–6), patient education practices (item 7), continued professional training (item 8) and assessment of nutritional intake (item 9). According to the modified Bloom's cut‐off point, a threshold of ≥ 80% of the maximum possible score was considered adequate knowledge, positive attitudes and proactive practices [21].

2.3. Questionnaire Distribution and Quality Control

Data were collected using an online questionnaire created via the Questionnaire Star platform, with a unique link provided for participants. Snowball sampling was employed for recruitment. A research team composed entirely of ICU nurses from our hospital received standardised training covering study objectives, ethical guidelines, privacy protection, questionnaire design and communication skills. In the field, initial participants were invited directly by research team members and were then asked to refer other eligible colleagues to participate, gradually expanding the sample size. After data collection, responses were exported from the Questionnaire Star platform. A designated team member was responsible for data quality control, which was conducted according to the exclusion criteria for the questionnaire. An additional general knowledge trap question, ‘Among China's 56 ethnic groups, the Han ethnic group has the smallest population’, was included to identify and exclude invalid questionnaires from participants who failed to review the questions before answering.

2.4. Sample Size Calculation

The sample size calculation followed a commonly used formula in KAP studies, which is suitable for cross‐sectional surveys [22]:

$$n={\left(\frac{Z_{1-\frac{\alpha }{2}}}{\delta }\right)}^2\times p\times \left(1-p\right)$$

where n denoted the sample size, and p was assumed to be 0.5 to ensure the maximum sample size. α, also known as the type I error, was set to 0.05. In this case, $Z_{1-\frac{\alpha }{2}}=1.96$, and δ represents the effect sizes between groups, which was determined as 0.06. The minimum theoretical sample size was 384. Assuming an effective questionnaire recovery rate of 80%, the final target was to collect at least 480 completed questionnaires.

2.5. Statistical Methods

Statistical analyses were performed using SPSS 26.0 and AMOS 24.0 (IBM, Armonk, NY, USA). The Kolmogorov–Smirnov test was conducted to examine the normality distribution of scores. Data following a normal distribution were reported as mean ± standard deviation (SD), while non‐normally distributed data were presented as medians (interquartile range, IQR). The categorical variables were described as n (%). For continuous variables with normal distribution, comparisons between two groups were made using the Student's t‐test. For non‐normally distributed continuous variables, the Mann–Whitney test was applied. For comparisons across three or more groups, ANOVA was used for normally distributed data with equal variances, and the Kruskal–Wallis test was applied for non‐normally distributed data. Correlations between dimension scores were assessed using Spearman's correlation. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with knowledge. Knowledge scores were dichotomised based on the threshold of ≥ 80% of the maximum possible score. Variables with p values < 0.05 in univariate analysis were selected for inclusion in multivariate analysis. Using the KAP theoretical framework [12], structural equation modelling (SEM) assessed whether attitudes mediate the relationship between knowledge and practices [23]. Direct and indirect effect sizes were calculated and compared. Model fit indices were evaluated with threshold criteria: root mean square error of approximation (RMSEA) < 0.08, standardised root mean square residual (SRMR) < 0.08, Tucker–Lewis index (TLI) > 0.80 and comparative fit index (CFI) > 0.80. A two‐tailed p value < 0.05 was considered statistically significant.

3. Results

3.1. Baseline Information of Participants

A total of 508 questionnaires were initially collected, and the exclusion included 4 cases without informed consent, 3 cases with response times under 90 s and 81 cases with incorrect responses to quality control questions. Ultimately, 420 valid responses were retained for analysis, resulting in a valid response rate of 82.6%. Among the participants, 39.5% were aged 30–34 years, and 80.0% were female. The majority held a bachelor's degree (78.8%) and had 3–10 years of experience (55.7%). Most worked in tertiary hospitals (81.7%) and had been working in the ICU for 2–5 years (35.7%). Additionally, 67.6% had no teaching responsibilities, 82.9% had no research responsibilities, and 88.1% held no administrative positions. Moreover, 41.7% frequently provided enteral nutrition support (daily or nearly every day), and 73.3% had attended lectures on enteral nutrition (Table 1).

TABLE 1.

Baseline characteristics and KAP scores of nurses.

N = 420	N (%)	Knowledge	Effect, p	Attitudes	Effect, p	Practices	Effect, p
		mean ± SD		mean ± SD		mean ± SD
Total score	420 (100.0)	17.87 ± 2.49		48.74 ± 4.65		65.39 ± 7.36
Gender a			10797.5, 0.001		10 436, < 0.001		9981, < 0.001
Male	84 (20.0)	18.80 ± 2.39		50.40 ± 4.06		68.23 ± 6.33
Female	336 (80.0)	17.64 ± 2.46		48.33 ± 4.70		64.68 ± 7.44
Age (year) b			1.379, 0.502		1.051, 0.591		3.819, 0.148
18–29	106 (25.2)	17.90 ± 2.22		49.24 ± 4.26		65.89 ± 7.45
30–34	166 (39.5)	18.05 ± 2.46		48.47 ± 4.85		65.72 ± 7.81
35 and more	148 (35.2)	17.66 ± 2.68		48.70 ± 4.69		64.66 ± 6.75
Education level b			4.108, 0.128		2.618, 0.270		4.752, 0.093
Associate degree	38 (9.0)	17.90 ± 2.41		49.89 ± 4.61		66.58 ± 8.37
Bachelor's degree	331 (78.8)	17.78 ± 2.49		48.63 ± 4.56		65.04 ± 7.32
Master's degree/doctoral degree	51 (12.1)	18.45 ± 2.49		48.65 ± 5.19		66.73 ± 6.71
Working duration b			0.775, 0.855		7.504, 0.057		3.597, 0.308
2 years	26 (6.2)	17.73 ± 2.38		48.92 ± 4.79		66.81 ± 8.47
3–10 years	234 (55.7)	17.87 ± 2.46		48.29 ± 4.46		65.09 ± 7.41
11–20 years	124 (29.5)	17.96 ± 2.50		49.36 ± 4.74		65.88 ± 7.08
≥ 21 years	36 (8.6)	17.72 ± 2.74		49.44 ± 5.23		64.58 ± 7.24
Professional title a			21 872, 0.957		23 558, 0.190		21 043, 0.470
Junior title or below	225 (53.6)	17.96 ± 2.32		48.53 ± 4.54		65.61 ± 7.54
Intermediate title or above	195 (46.4)	17.78 ± 2.67		48.99 ± 4.77		65.12 ± 7.17
Level of your hospital a			11 031, 0.022		12 949, 0.789		12 371, 0.385
Tertiary hospital	343 (81.7)	17.74 ± 2.36		48.67 ± 4.77		65.33 ± 7.12
Other hospital	77 (18.3)	18.46 ± 2.95		49.08 ± 4.07		65.65 ± 8.42
Number of ICU beds at your hospital b			2.623, 0.269		4.948, 0.084		17.805, < 0.001
Less than 10 beds	72 (17.1)	18.42 ± 2.24		49.82 ± 4.66		67.42 ± 7.08
11–20 beds	213 (50.7)	17.80 ± 2.46		48.43 ± 4.95		65.85 ± 7.22
Greater than 20 beds	135 (32.1)	17.71 ± 2.62		48.67 ± 4.06		63.56 ± 7.39
Working duration in ICU b			1.173, 0.759		7.617, 0.055		0.813, 0.846
Less than 1 year	45 (10.7)	18.27 ± 2.43		48.64 ± 5.54		65.67 ± 8.67
2–5 years	150 (35.7)	17.90 ± 2.40		48.13 ± 4.23		65.52 ± 7.13
6–10 years	147 (35.0)	17.77 ± 2.34		49.14 ± 4.52		65.31 ± 7.45
More than 10 years	78 (18.6)	17.78 ± 2.92		49.22 ± 5.03		65.12 ± 6.95
Teaching responsibilities a			19 060, 0.826		24 872, < 0.001		19 713, 0.730
No	284 (67.6)	17.91 ± 2.51		48.04 ± 4.69		65.27 ± 7.45
Yes	136 (32.4)	17.80 ± 2.45		50.21 ± 4.20		65.62 ± 7.20
Research responsibilities a			13 846, 0.153		16 526, < 0.001		12 836, 0.742
No	348 (82.9)	17.83 ± 2.39		48.34 ± 4.57		65.27 ± 7.54
Yes	72 (17.1)	18.07 ± 2.91		50.68 ± 4.57		65.96 ± 6.47
Administrative position a			10 670, 0.073		11 794, 0.002		10 532, 0.111
No	370 (88.1)	17.82 ± 2.41		48.49 ± 4.65		65.24 ± 7.22
Yes	50 (11.9)	18.26 ± 2.99		50.64 ± 4.22		66.46 ± 8.34
Frequency of providing enteral nutrition support b			1.649, 0.800		15.927, 0.003		6.907, 0.141
Never	17 (4.0)	18.12 ± 2.96		49.06 ± 5.92		62.00 ± 11.77
Occasionally (less than once a month)	49 (11.7)	17.84 ± 3.23		48.35 ± 4.94		63.96 ± 9.67
Sometimes (at least 1–4 times per month)	92 (21.9)	18.02 ± 2.55		47.82 ± 5.01		64.64 ± 6.51
Frequently (at least 2–3 times per week)	87 (20.7)	17.77 ± 2.77		47.90 ± 4.30		66.98 ± 6.05
Very frequently (every day or almost every day)	175 (41.7)	17.83 ± 2.00		49.73 ± 4.23		65.71 ± 6.96
Participation in lectures on enteral nutrition a			20 714, 0.001		20 310, 0.005		21 744, < 0.001
No	112 (26.7)	17.31 ± 2.51		47.42 ± 5.52		62.63 ± 8.42
Yes	308 (73.3)	18.08 ± 2.45		49.22 ± 4.19		66.39 ± 6.68

^a Student's t‐test.

^b Analysis of variance.

3.2. Knowledge Dimension

The mean knowledge score was 17.87 ± 2.49. Significant variations in knowledge scores were observed by gender (t = 10797.5, p = 0.001), hospital level (t = 11 031, p = 0.022) and participation in enteral nutrition lectures (t = 20 714, p = 0.001) (Table 1). Correctness rates for knowledge items ranged from 46.19% to 98.57%. The highest correctness (98.57%) was with the difference between enteral and parenteral nutrition (K1) and the use of nasogastric and gastrostomy/jejunostomy tubes (K10). The lowest correctness (46.19%) was with the recommendation to flush feeding tubes with warm water every 24 h when enteral nutrition is administered via a pump (K11). Furthermore, only 51.43% recognised that enteral nutrition can be provided to patients with lower gastrointestinal bleeding, except when colonoscopy preparation is required (K20) (Table S1).

3.3. Attitude Dimension

In the attitude section, the mean score was 48.74 ± 4.65. Significant differences in attitude scores were observed by gender (t = 10 436, p < 0.001), teaching responsibilities (t = 24 872, p < 0.001), research responsibilities (t = 16 526, p < 0.001), administrative position (t = 11 794, p = 0.002), frequency of providing enteral nutrition support (F = 15.927, p = 0.003) and participation in lectures on enteral nutrition (t = 20 310, p = 0.005) (Table 1). Positive responses (‘Strongly agree’ and ‘Agree’) to attitude items ranged from 38.29% to 98.33%. The highest agreement (98.33%) was with the statement that it is crucial to assess enteral nutrition, including gastrointestinal tolerance, aspiration risk and swallowing function (A8). The lowest agreement (38.29%) was with the statement that enteral nutrition is underused in the ICU due to a lack of training and resources (A4) (Table S2).

3.4. Practice Dimension

In the practice section, the mean score was 65.39 ± 7.36. Significant differences were observed based on gender (t = 9981, p < 0.001), the number of ICU beds (F = 17.805, p < 0.001) and participation in enteral nutrition lectures (t = 21 744, p < 0.001) (Table 1). Adherence rates (‘Always’ and ‘Often’) to practice items ranged from 59.29% to 96.43%. The highest adherence (96.43%) was for aseptic techniques in clinical practice (P3.1), while the lowest (59.29%) was for measuring intra‐abdominal pressure (P4.3). Additionally, 60.00% of participants reported regularly assessing caloric and protein intake (P9) (Table S3).

3.5. Multivariate Logistic Regression Analysis

Multivariate analysis indicated that being female (OR = 0.542, 95% CI: 0.324–0.907, p = 0.020), holding an administrative position (OR = 1.931, 95% CI: 1.014–3.681, p = 0.045) and participation in enteral nutrition lectures (OR = 1.721, 95% CI: 1.096–2.702, p = 0.018) were independently associated with adequate knowledge (Table 2).

TABLE 2.

Univariate and multivariate logistic regression analysis of knowledge.

Knowledge	Univariate logistic analysis		Multivariate logistic analysis
	OR (95% CI)	p	OR (95% CI)	p
Gender
Male	1.000 (Reference)		1.000 (Reference)
Female	0.554 (0.338, 0.898)	0.018	0.542 (0.324, 0.907)	0.020
Age (year)
18–29	1.000 (Reference)		1.000 (Reference)
30–34	1.605 (0.984, 2.634)	0.059	1.586 (0.956, 2.630)	0.074
35 and more	1.250 (0.757, 2.071)	0.384	1.265 (0.734, 2.179)	0.398
Education level
Associate degree	1.000 (Reference)
Bachelor's degree	1.003 (0.511, 1.979)	0.994
Master's degree/doctoral degree	1.722 (0.739, 4.069)	0.210
Working duration
2 years	1.000 (Reference)
3–10 years	1.341 (0.594, 3.112)	0.483
11–20 years	1.455 (0.623, 3.489)	0.390
≥ 21 years	0.974 (0.350, 2.735)	0.960
Professional title
Junior title or below	1.000 (Reference)
Intermediate title or above	1.053 (0.718, 1.547)	0.791
Level of your hospital
Tertiary hospital	1.000 (Reference)
Other hospital	1.490 (0.907, 2.467)	0.117
Number of ICU beds at your hospital
Less than 10 beds	1.000 (Reference)
11–20 beds	0.708 (0.412, 1.209)	0.208
Greater than 20 beds	0.765 (0.429, 1.357)	0.361
Working duration in ICU
Less than 1 year	1.000 (Reference)
2–5 years	1.046 (0.536, 2.044)	0.896
6–10 years	0.900 (0.460, 1.762)	0.757
More than 10 years	1.159 (0.555, 2.424)	0.695
Teaching responsibilities
No	1.000 (Reference)
Yes	0.970 (0.644, 1.460)	0.883
Research responsibilities
No	1.000 (Reference)
Yes	1.467 (0.882, 2.462)	0.142
Administrative position
No	1.000 (Reference)		1.000 (Reference)
Yes	2.003 (1.097, 3.760)	0.026	1.931 (1.014, 3.681)	0.045
Frequency of providing enteral nutrition support
Never	1.000 (Reference)
Occasionally (less than once a month)	1.164 (0.383, 3.681)	0.790
Sometimes (at least 1–4 times per month)	1.628 (0.575, 4.836)	0.363
Frequently (at least 2–3 times per week)	1.531 (0.539, 4.565)	0.428
Very frequently (every day or almost every day)	1.289 (0.473, 3.695)	0.623
Participation in lectures on enteral nutrition
No	1.000 (Reference)		1.000 (Reference)
Yes	1.898 (1.223, 2.973)	0.005	1.721 (1.096, 2.702)	0.018

3.6. Correlation Analysis and SEM Analysis

Spearman correlation analysis revealed positive relationships between knowledge and attitude (r = 0.243, p < 0.001), knowledge and practice (r = 0.319, p < 0.001) and attitude and practice (r = 0.450, p < 0.001) (Table S4). The SEM analysis showed a moderate model fit (RMSEA = 0.073, SRMR = 0.057, TLI = 0.748, CFI = 0.762) (Table S5). To assess the explanatory power of the SEM, we reported R² values for all latent constructs and selected observed variables (Table S6). Direct effects were found between knowledge and attitude (β = 0.275, 95% CI: 0.165–0.384, p < 0.001), knowledge and practice (β = 0.198, 95% CI: 0.088–0.307, p < 0.001), as well as attitude and practice (β = 0.462, 95% CI: 0.372–0.553, p < 0.001). Knowledge also had an indirect effect on practice (β = 0.127, 95% CI: 0.072–0.182, p < 0.001) (Figure 1 and Table 3).

FIGURE 1.

SEM analysis. The direction of causality is indicated by single‐headed arrows, and the double‐headed arrow indicates a correlation among variables. The standardised path coefficients are presented alongside the arrows.

TABLE 3.

Results of direct and indirect effects analysis in the SEM model.

Model paths	Total effects		Direct Effect		Indirect effect
	β (95% CI)	p	β (95% CI)	p	β (95% CI)	p
Knowledge → Attitude	0.275 (0.165, 0.384)	< 0.001	0.275 (0.165, 0.384)	< 0.001
Knowledge → Practice	0.325 (0.214, 0.435)	< 0.001	0.198 (0.088, 0.307)	< 0.001	0.127 (0.072, 0.182)	< 0.001
Attitude → Practice	0.462 (0.372, 0.553)	< 0.001	0.462 (0.372, 0.553)	< 0.001

4. Discussion

In this study, ICU nurses generally held insufficient knowledge but positive attitudes and proactive practices concerning enteral nutrition. Positive and direct associations were observed across KAP scores, and knowledge was indirectly associated with practice. Gender, administrative position and participation in enteral nutrition lectures emerged as key influencing factors for adequate knowledge. These findings underscore the need for implementing targeted educational interventions to bridge knowledge gaps, thereby optimising attitudes and enhancing clinical practices in enteral nutrition management.

Aligning with our results, military nurses in South Africa shared positive attitudes towards enteral nutrition; however, they lacked sufficient knowledge on best practices, contraindications and indications in critically ill patients [13]. This suggests that while ICU nurses may understand the broad importance of enteral nutrition, there remains a need for knowledge enhancement to bridge the gap between their attitudes and actual clinical competence. Another study from Kenya reported conflicting results, which revealed that approximately 65.9% of critical care nurses had an adequate level of knowledge regarding enteral nutrition. In Kenya, efforts may have been made to enhance nurse education, possibly through more structured training programs or more frequent workshops on enteral nutrition [24]. Notably, a recent study among Chinese nurses in burn ICUs similarly reported insufficient EN knowledge and emphasised the need for updated training and standardised protocols [17]. Together, these findings highlighted a pervasive gap in EN education among ICU nurses in China.

ICU nurses demonstrated sufficient knowledge on basic aspects of enteral nutrition, such as the difference between enteral and parenteral nutrition, as well as the use of nasogastric tubes and gastrostomy/jejunostomy tubes. These findings suggest that ICU nurses held a solid understanding of fundamental concepts of enteral nutrition, which are essential for the safe administration of nutrition in critically ill patients. However, significant gaps emerged in more clinically nuanced areas. For instance, only 46.19% correctly recognised the recommendations about feeding tube flushing. The practice of tube flushing is essential to prevent tube occlusion, ensure adequate nutritional delivery and reduce the risk of infection [25]. Research has shown that tube occlusion remains a significant complication in patients receiving enteral nutrition, leading to interruptions in feeding and potential delays in nutritional recovery [26]. Another noteworthy finding was the limited responses to enteral nutrition in patients with lower gastrointestinal bleeding. Although still debated, recent evidence supports the benefits of enteral nutrition in this population, including prevention of gastric overdistension and provision of balanced nutrient delivery to facilitate mucosal healing [27]. Also, the treatment helps preserve the integrity of the gut mucosal barrier and enhances overall recovery of these patients [28]. Educational modules should include not only theoretical knowledge but also practical demonstrations and case studies that allow nurses to engage with real‐world scenarios. This approach can enhance nurses' ability to apply their knowledge in clinical practice, ensuring that they are adequately prepared to handle complex situations.

Most participants held positive attitudes towards assessing enteral nutrition, including gastrointestinal tolerance, aspiration risk and swallowing function. The positive attitude may stem from nurses' recognition of the need to prevent complications such as aspiration pneumonia, tube displacement and gastrointestinal discomfort [29]. However, only 38.29% agreed with the underuse of enteral nutrition due to a lack of training and resources. Reportedly, ICU nurses underwent insufficient enteral nutrition training and related quality management in China [30]. The relatively low agreement in our study may indicate an underestimation of the systemic barriers in enteral nutrition. This disconnect between perceived and actual barriers to the implementation of enteral nutrition warrants further investigation. It may also suggest that nurses are not fully aware of the role that organisational and educational deficiencies play in the underutilisation of enteral nutrition.

The highest level of adherence was observed for aseptic technique, which is essential to minimising the risk of infections, such as catheter‐related bloodstream infections (CRBSIs) and ventilator‐associated pneumonia (VAP) [31]. As aseptic practices are routine and frequently emphasised in nursing education, ongoing education is needed to maintain high standards. In contrast, the practice with the lowest adherence was the measurement of intra‐abdominal pressure. The finding was concerning, as elevated intra‐abdominal pressure is a known risk factor for several complications in critically ill patients, including abdominal compartment syndrome, organ dysfunction and mortality [32]. Several factors could contribute to this low adherence. First, intra‐abdominal pressure measurement is not as commonly emphasised in routine ICU practice compared to other monitoring tasks, such as monitoring vital signs or laboratory values. Additionally, the measurement can be technically challenging and may require additional training to ensure accurate results [33]. Another concerning area was the assessment of caloric and protein intake. Critically ill patients receiving enteral nutrition require tailored caloric and protein support to optimise recovery and reduce complications [34]. Reasons for the limited adherence could include the complexity of calculating caloric and protein requirements, inadequate staffing and competing priorities in the ICU. By addressing these gaps through enhanced education, streamlined protocols and institutional support, the quality of enteral nutrition management in ICU settings may be improved.

Consistent with the theory of planned behaviour, positive and direct correlations were observed among KAP scores [35]. ICU nurses who possess adequate understandings of enteral nutrition are more likely to appreciate the importance of administration and feel confident in applying appropriate practices. The SEM further supported the mediating role of attitude, suggesting that knowledge may influence attitudes and subsequently shape practices. Aligning with our results, ICU nurses in Iran with higher knowledge levels exhibited more positive attitudes towards nutritional care, which in turn correlated with improved practices [36]. Similarly, a systematic review emphasised that enhancing nurses' knowledge and attitudes through targeted educational interventions leads to better enteral feeding practices (16). Multivariate analysis further identified the impacts of demographic and professional factors. First, female nurses may face greater barriers to career advancement or educational opportunities, potentially limiting their access to training in enteral nutrition [37]. Second, nurses holding an administrative position may be more involved in policy development and staff training, leading to sufficient knowledge. Third, regular training sessions can improve nurses' knowledge, highlighting the critical role of continuing education.

4.1. Implications for Practice

The findings highlight an urgent need to strengthen enteral nutrition education among ICU nurses. Substantial gaps in advanced knowledge and clinical application remained, particularly in tube flushing, intra‐abdominal pressure measurement and assessment of caloric and protein requirements. These deficiencies underscored the importance of structured, evidence‐based training that integrates theoretical instruction with practical demonstrations and case‐based learning. Institutional support through standardised protocols, quality management and adequate resources is equally critical to overcome systemic barriers and ensure consistency in practice. Attitudes were shown to mediate the association between knowledge and practice, suggesting that enhancing knowledge can indirectly improve clinical behaviours. Future research should explore interventions that address both educational needs and organisational constraints, while longitudinal studies are warranted to evaluate their long‐term effectiveness. Strengthening competencies in enteral nutrition management will ultimately contribute to improved outcomes for critically ill patients.

4.2. Study Limitations

Several limitations should be acknowledged. The cross‐sectional design limited causality inference of relationships between KAP and factors such as administrative position or participation in training. Longitudinal research would be valuable for evaluating the long‐term impact of educational interventions and institutional support on KAP in ICU nurses. Additionally, our sample, drawn from hospitals across China, may not fully represent other countries or healthcare settings with different educational systems and resources. Furthermore, the self‐reported data may introduce social desirability bias, potentially inflating KAP scores [38].

5. Conclusion

In conclusion, while Chinese ICU nurses demonstrated positive attitudes and proactive practices towards enteral nutrition, significant knowledge deficiencies persisted. The positive correlations among KAP suggested that attitude may mediate the knowledge‐practice relationship, positioning attitude enhancement as a focus for improving clinical implementation. Targeted educational interventions—including modular e‐learning for knowledge gaps, mentorship programs to reinforce attitudes and simulation‐based training for skill development—should prioritise female nurses, non‐administrative staff and those with limited training participation to effectively address these disparities.

Author Contributions

Changli Song, Wei Zhang, Lijuan Zhu, Teng Ge and Cao Min conducted the studies, participated in data collection and participated in its design. Changli Song performed the statistical analysis and participated in the acquisition, analysis or interpretation of data. Changli Song and HaiHong Xu drafted the manuscript. All authors read and approved the final manuscript.

Ethics Statement

The study was approved by the Medical Ethics Committee of Fu Xing Hospital, Capital Medical University, ethical approval date: 9/19/2024 (2024FXHEC‐KSP067). All participants were informed about the study protocol and provided written informed consent to participate in the study.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: Knowledge dimension distribution.

Table S2: Attitude dimension distribution.

Table S3: Practice dimension distribution.

Table S4: Spearman correlation analysis of KAP scores.

Table S5: Model fit indices of structural equation model.

Table S6: The R ² values in the SEM.

Song C., Zhang W., Zhu L., Ge T., Cao M., and Xu H., “Knowledge, Attitudes and Practices Regarding Enteral Nutrition Management Among ICU Nurses,” Nursing in Critical Care 31, no. 1 (2026): e70260, 10.1111/nicc.70260.

Data Availability Statement

All data generated or analysed during this study are included in this published article.