Healthcare professionals’ views on barriers to implementing evidence-based enteral nutrition management in ICU patients receiving prone position ventilation: a qualitative descriptive study

Abstract

Aim

To explore healthcare professionals’ views on barriers to implementing evidence-based enteral nutrition management specifically in ICU patients receiving prone position ventilation, with particular focus on prone positioning-induced challenges distinct from general ICU enteral nutrition care.

Design

A qualitative descriptive study.

Setting

The study was conducted in a general ICU of a tertiary comprehensive hospital in a city in Sichuan Province, China.

Methods

In 2025, semi-structured interviews were conducted with 15 participants, including 12 nurses and 3 physicians, all of whom had worked in the ICU for more than one year and had experience in providing enteral nutrition care for patients undergoing prone positioning ventilation. Participants were recruited using purposive sampling until data saturation was achieved. Interview questions specifically targeted prone positioning-related challenges rather than general enteral nutrition barriers. All interview data were analyzed using thematic analysis.

Findings

Four main themes emerged that were uniquely shaped by prone positioning context: (1) prone positioning-specific care prioritization conflicts (airway management during prone position competing with feeding schedules), (2) prone positioning-specific resource demands (specialized positioning equipment, temperature monitoring during restricted patient access), (3) lack of prone positioning-specific training protocols, and (4) communication barriers regarding prone positioning timing and feeding coordination.

Conclusion

This study identifies four key barriers that are uniquely amplified or created by the prone positioning context: the conflict between prone positioning-specific airway management and feeding schedules, increased resource demands for specialized positioning care, absence of prone positioning-specific training curricula, and coordination challenges between positioning schedules and enteral nutrition timing.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-05026-8.

Introduction

Critically ill patients are at high risk of malnutrition due to underlying diseases and acute organ dysfunction [1–3]. Malnutrition-related adverse outcomes include muscle wasting, pressure injuries, increased incidence of infections, prolonged length of hospital stay, and increased mortality [4, 5]. Early enteral nutrition has been associated with reduced infectious complications and mortality in critically ill patients [6, 7]. Therefore, current clinical guidelines recommend initiating enteral nutrition support within 24–48 h of ICU admission [1, 8, 9].

Prone positioning ventilation is an essential therapeutic strategy for patients with severe respiratory failure, particularly those with acute respiratory distress syndrome (ARDS). This intervention has been shown to improve oxygenation and lung compliance and to reduce mortality [10, 11]. However, compared with the supine position, prone positioning is associated with a more complex care process, restricted patient positioning, and increased abdominal pressure, which may increase the risk of enteral nutrition-related complications, such as vomiting, elevated gastric residual volumes, and ventilator-associated pneumonia [12, 13].

Although evidence-based guidelines provide clear recommendations for enteral nutrition management, specific operational guidance tailored to the prone positioning context remains limited. As a result, substantial challenges persist in the implementation of these recommendations in real-world clinical settings. A meta-analysis comprising five studies with a total sample size of 319 patients reported that, compared with the supine position, enteral nutrition delivered during prone positioning was associated with lower energy target achievement and higher rates of enteral nutrition interruption [12]. A multicenter survey conducted in Jordan identified inadequate resources, safety concerns, and workload as major barriers perceived by ICU nurses in the implementation of enteral nutrition [14]. Additionally, a study involving ICU physicians and nurses demonstrated that incomplete knowledge of guideline recommendations and negative attitudes toward nutritional support constituted significant barriers to effective enteral nutrition delivery in critical care settings [15].

While previous studies have examined barriers to enteral nutrition in general ICU populations, the unique challenges posed by prone positioning ventilation remain underexplored [14, 16]. Critically, prone positioning may increase intra-abdominal pressure and alter gastric emptying dynamics, thereby increasing the risk of enteral feeding intolerance [17]. Furthermore, compared with the supine position, prone positioning has been associated with interruptions in enteral nutrition delivery as well as greater challenges in monitoring and assessing enteral nutrition-related complications [12, 13, 18]. These prone positioning-specific factors create a distinct implementation context that cannot be addressed by general enteral nutrition guidelines. Understanding these context-specific barriers is essential for developing targeted interventions to improve nutritional care quality. Therefore, this qualitative descriptive study aims to explore healthcare professionals’ views on barriers to implementing evidence-based enteral nutrition management specifically in patients undergoing prone positioning ventilation, with explicit focus on challenges that are unique to or amplified by the prone positioning context.

Method

This study employed a qualitative descriptive design as proposed by Sandelowski [19], with the aim of inductively exploring healthcare professionals’ views on barriers to implementing evidence-based enteral nutrition management in ICU patients receiving prone position ventilation. This research design is particularly suited to preserving participants’ accounts in a low-inference and comprehensive manner, thereby enabling an in-depth understanding of the phenomenon under investigation. Moreover, qualitative descriptive studies generate findings that are closely grounded in participants’ experiences and are directly applicable to clinical practice [20].

Setting and sample

This qualitative descriptive study was conducted in 2025 in a general ICU of a tertiary comprehensive hospital located in a municipal city in Sichuan Province, China. The ICU has 32 beds and admitted an average of approximately 31 patients per year who underwent prone positioning over the preceding five years. Prone position ventilation was routinely implemented for patients with moderate-to-severe ARDS or acute hypoxemic respiratory failure in the absence of contraindications. Prone positioning procedures were performed in accordance with guideline-based protocols by a multidisciplinary team comprising one physician or respiratory therapist and four nurses [21, 22]. Enteral nutrition management was conducted according to guideline-recommended practices [1, 18, 23]. Nutritional prescriptions were typically initiated and adjusted by ICU physicians based on patients’ nutritional status. Bedside nurses were responsible for administering enteral nutrition, monitoring feeding tolerance, documenting nutrition-related information, and managing nutrition-related complications according to physicians’ orders.

Purposive sampling was used to recruit registered nurses and physicians who had worked in the ICU for more than one year and had experience in providing enteral nutrition care to patients undergoing prone positioning ventilation. To capture diverse perspectives, participants varied in educational background and ICU work experience, including registered nurses with and without postgraduate ICU education, as well as physicians with differing levels of clinical experience.

Data collection

The interview guide was developed using the Consolidated Framework for Implementation Research (CFIR) as the guiding framework [24]. The guide consisted of five questions designed to explore barriers and facilitators influencing the implementation of evidence-based enteral nutrition management in ICU patients undergoing prone position ventilation (see Supplementary File 1). Prior to the interviews, participants’ demographic and professional characteristics were collected, including educational background and years of experience working in the ICU. Open-ended, semi-structured interview questions were used to create an environment that encouraged participants to express their views freely [20]. All interviews were conducted in the hospital in a private room located away from participants’ clinical work areas to minimize interruptions and ensure confidentiality. Each interview was conducted and audio-recorded by a single interviewer. At the end of each interview, participants were invited to share any additional information that they considered relevant to the study topic. The interviewer was a female master’s student in nursing who had received systematic training in qualitative research methods prior to data collection. The interviewer worked in the same ICU as the participants and was therefore familiar with the clinical context; however, no direct supervisory or managerial relationship existed between the interviewer and participants. Field notes were taken during and immediately after each interview to assist in assessing data saturation. Audio recordings were transcribed verbatim by a professional transcriptionist, and the transcripts were subsequently analyzed by the research team. Data collection and analysis were conducted concurrently. Data saturation was considered to have been achieved when no new themes or views emerged from the interviews [20].

Data analysis

The interview transcripts were imported into NVivo (a qualitative data analysis software) for data management and analysis. Data were analyzed using the six-step thematic analysis approach proposed by Braun and Clarke [25]. First, the researchers independently and repeatedly read the interview transcripts to familiarize themselves with the data and generate initial codes. Relevant data extracts were then collated into potential subthemes and subsequently grouped into broader themes by identifying patterns and relationships across the dataset. The researchers reviewed all coded extracts and the entire dataset to ensure coherence within themes, clear distinctions between themes, and consistency with the dataset as a whole. Finally, the themes were refined, defined, and named to accurately represent their underlying meaning and capture the common features of the associated data.

All interviews were conducted and transcribed in Chinese. Data analysis was performed using the original Chinese transcripts. Participant quotations were translated into English and reviewed by two researchers proficient in both Chinese and English to ensure conceptual equivalence, linguistic accuracy, and preservation of participants’ intended meanings.

To ensure the rigor and reliability of the analysis, three members of the research team independently reviewed all stages of the analytical process and the identified themes. When reporting the study findings, participant quotations were identified using interview identification numbers (P1–P15) to preserve anonymity while maintaining transparency in the presentation of the findings [25].

Ethical considerations

Ethical approval for this study was obtained from the Hospital Ethics Committee prior to the commencement of the research (approval date: January 15, 2025; reference number: 2024079). Before participation, all participants were provided with clear and accessible information regarding the purpose of the study. Written and verbal informed consent was obtained from each participant prior to the interviews. All audio recordings and transcripts were accessible only to the research team. To ensure confidentiality and protect participants’ identities, pseudonyms were used in all transcribed data and subsequent reports.

Findings

A total of 15 interviews were conducted with 12 nurses and 3 physicians, with interview durations ranging from 15 to 33 min. No eligible healthcare professionals declined participation, and no participants withdrew from the study. More than two-thirds of the nurses (n = 8, 66.7%) had over five years of clinical nursing experience, with a median clinical experience of 10 years (interquartile range [IQR]: 5–14 years). More than half of the nurses (n = 7, 58.3%) had worked continuously in the ICU for more than five years. Among the nursing participants, a bachelor’s degree was the predominant educational level (n = 11, 91.7%) (see Table 1). Nurses with managerial or specialized roles included the nurse manager (NM), quality management specialists (QMS), nurse team leader (NTL), medical equipment management specialist (MEMS), and educational administration specialist (EAS), whereas bedside nurses comprised registered nurses (RN) and ICU specialist nurses (ICU - SN). The participating physicians included the director of the department, medical team leader and attending physician, who were primarily responsible for critical care decision-making, supervising junior physicians, and overseeing patient care.

Table 1.

Participants demographics characteristics

Characteristic	(N = 15) n(%)
Years of experience
< 5	3 (20.0)
5–10	5 (33.3)
> 10	7 (46.7)
Profession
Nursing	12 (80.0)
Medical	3 (20.0)
Level of nursing education
Bachelor’s degree	11 (91.7)
Master’s degree	1 (8.3)
Nursing position
NM	1 (8.3)
QMS	2 (16.7)
NTL	1 (8.3)
MEMS	1 (8.3)
EAS	1 (8.3)
RN	4 (33.3)
ICU-SN	2 (16.7)

Note: NM=Nurse manager; QMS=Quality management specialist; NTL=Nurse team leader; MEMS=Medical equipment management specialist; EAS=Educational administration specialist; RN=Registered nurse; ICU-SN = ICU specialist nurse. Categories are not mutually exclusive; therefore, percentages may not total 100%

Data analysis identified four main themes that were specifically shaped by the prone positioning context: (1) prone positioning-specific care prioritization conflicts; (2) prone positioning-specific resource demands; (3) lack of prone positioning-specific training; and (4) communication barriers related to prone positioning-feeding coordination. Importantly, these themes represent barriers that are either unique to prone positioning or significantly amplified compared to general ICU enteral nutrition care (see Table 2). Data excerpts are presented with reference to participants’ professional roles and interview identification numbers (e.g., registered nurse 11).

Table 2.

Themes and subthemes specific to prone positioning context

Theme	Subthemes	Prone Positioning-Specific Manifestation
Focus on prioritizing immediate care needs	Patient positioning; Nursing workload; Patient-related complications	Airway management during prone sessions competes with feeding schedules; positioning for secretion drainage conflicts with aspiration prevention
Insufficient resources	Equipment shortages; Insufficient staffing	Specialized temperature-control devices for restricted patient access; additional staffing for prone positioning procedures
Insufficient systematic training and knowledge of evidence-based practice	Inappropriate training approaches; Limited accessibility of knowledge	Absence of prone positioning-specific simulation training; no standardized protocols for feeding during prone sessions
Insufficient interprofessional collaboration	Communication and information transfer barriers	Unpredictable prone positioning timing disrupts feeding coordination; lack of structured handover for positioning-nutrition interface

Prone positioning-specific care prioritization conflicts

Most participants described patients receiving prone position ventilation as critically ill, clinically complex, and highly unstable, requiring frequent assessment, continuous monitoring, and advanced professional nursing care. Critically, the prone positioning context creates unique care prioritization conflicts that do not exist in supine patients: positioning strategies required for optimal secretion drainage directly conflict with aspiration prevention strategies for enteral nutrition, and the restricted patient access during prone sessions limits real-time feeding tolerance assessment. In addition, these patients were at increased risk of position-specific complications such as gastroesophageal reflux from increased intra-abdominal pressure and aspiration from altered gastric emptying dynamics. Consequently, healthcare professionals tended to prioritize immediate positioning-related care needs over enteral nutrition continuity. This theme comprised three subthemes: patient positioning conflicts, nursing workload during prone sessions, and prone positioning-related complications.

Patient positioning

Participants reported that their primary clinical focus was strongly influenced by patient positioning. For example, in patients with ARDS, prone position ventilation was perceived as beneficial for improving ventilation–perfusion matching, enhancing thoracic mechanics, and facilitating secretion drainage. As a result, many participants emphasized postural drainage as a key priority to promote secretion clearance, along with frequent oral care. One nurse explained:

For patients with severe ARDS, one major consideration is prone position ventilation. The goal is to promote lung recruitment, but… There are a lot of secretions, and oral care becomes much more difficult and time-consuming than usual. (P9)

Similarly, a physician expressed concerns regarding enteral nutrition during prone position:

For some patients with severe lung involvement, we as physicians tend to prefer prone position ventilation. But when patients are in the prone position, we also worry about many things—one of them is enteral nutrition. It becomes very difficult to administer. (P13)

Nursing workload

Most participants reported that emergency and life-saving interventions were consistently prioritized over enteral nutrition care, which was often perceived as a lower priority in daily practice. The majority indicated that they were responsible for more than two patients simultaneously, resulting in a heavy nursing workload. This burden was particularly pronounced during daytime shifts, when therapeutic interventions were most intensive. Under such circumstances, particularly when patients required prone position ventilation, certain enteral nutrition-related nursing measures were simplified, postponed, or even omitted:

…When we’re extremely busy, our main focus is on maintaining blood pressure and managing the airway. There’s simply no way to carry out all the enteral nutrition-related nursing measures, and some procedures just get overlooked. (P3)

Every time a doctor tells me that a patient needs to be placed in the prone position, there’s a long list of things I need to do. I have to stop the feeding, aspirate the gastric contents, assess the patient’s hemodynamic stability and all the tubes and lines, and organize staff to help position the patient prone. Once the positioning is completed, I need to reassess everything carefully. For patients undergoing prone position ventilation, we have to monitor and assess them more frequently, adjust the feeding rate, and in some cases even use a feeding schedule to manage the nutrition process. I’m responsible for quite a few patients. When the workload increases—especially during the day when there are so many miscellaneous tasks—it’s hard to do things at the exact scheduled time, so they often get delayed. (P8)

Managing diarrhea in patients in the prone position is not as simple as it is in the supine position. When the volume of diarrhea is large, cleaning the perineal area becomes extremely difficult. Sometimes we even have to turn the patient back to the supine position to manage the situation and then reposition them prone afterward. After going through all of that, I’m completely exhausted. (P9)

Although most participants acknowledged the importance of enteral nutrition and recognized the close association between achieving nutritional goals and patients’ clinical outcomes, many expressed feelings of guilt when enteral nutrition care was not adequately implemented. Nevertheless, a heavy workload was consistently identified by ICU staff as a prominent and pervasive barrier to the effective delivery of enteral nutrition care.

I know enteral nutrition is extremely important. If patients’ nutritional needs aren’t met, it’s definitely not good for their recovery, and it should be taken seriously. But when things get really busy, it’s honestly hard to keep up. Of course, being busy isn’t an excuse…but the reality is that there are too many patients and too much work, and some details inevitably get missed. (P12)

Patient-related complications

Most participants reported concerns regarding enteral nutrition–related complications in patients undergoing prone position, particularly the risks of gastroesophageal reflux, aspiration, and diarrhea. Several participants noted that, due to the special position, the workload associated with managing these complications would be greater once they occurred:

Sometimes, to be honest, we physicians also have some concerns…mainly about reflux and aspiration. Patients in the prone position often require relatively deep sedation and analgesia, and sometimes even neuromuscular blocking agents, which can affect gastrointestinal function. (P14)

If a patient aspirates, I need to take extra time to manage the patient and deal with the aspiration event. (P7)

Some elderly patients develop diarrhea when enteral nutrition is initiated. This can interfere with prone position ventilation, and we also need to provide perianal care and change nursing pads more frequently. (P9)

Prone positioning-specific resource demands

Most participants reported that prone positioning creates unique resource demands that exceed general ICU enteral nutrition requirements. Specifically, participants highlighted limitations in enteral nutrition warming equipment, including insufficient availability of heated feeding pumps and concerns regarding the inability of existing devices to continuously maintain and monitor formula temperature during administration. Additionally, cautious decision-making regarding nasojejunal tube placement was amplified by prone positioning constraints, as tube verification becomes more challenging when patients cannot be easily repositioned for imaging. Inadequate staffing levels were particularly problematic during prone positioning procedures, which require additional personnel for safe patient turning while simultaneously managing enteral nutrition. Within this theme, two subthemes were identified: prone positioning-specific equipment shortages and increased staffing demands during prone sessions.

Equipment shortages

Most nurses perceived that the limited availability of enteral nutrition temperature-control devices made it difficult to deliver precise and optimal care. Several participants noted that, due to the cautious use or avoidance of nasojejunal tube placement, gastric feeding was often selected, resulting in more conservative feeding rates and difficulty in achieving target nutritional volumes:

Not all patients receive tube feeding with the enteral nutrition warmed close to body temperature. Some infusion pumps in our unit can heat the solution, but we don’t have enough of them. We also have warming clamps, but we can’t guarantee that every patient can use one. (P5)

…When we use the existing warming clamps, there’s no way to monitor the actual temperature of the nutrition solution once it enters the patient’s stomach. So I think it should be continuous…like fully warming a carton of milk first, and then slowly infusing it. (P6)

Several participants further indicated that technical limitations in nasojejunal tube placement and the frequency of prone position influenced clinical decision-making, thereby restricting enteral feeding rate management:

The utilization rate in our unit is relatively low. We mainly rely on blind insertion, which has a low success rate. We have to reach the stomach first, confirm placement with X-ray, and then repeatedly adjust it… When patients are in the prone position, if gastric feeding is used, I tend to slow the feeding rate. (P1)

We usually place nasojejunal tubes for patients with gastric motility disorders or severe pancreatitis. For many patients with respiratory diseases, we don’t routinely place nasojejunal tubes. Sometimes prone position is only done once or twice, and in those cases, placing a nasojejunal tube feels like overtreatment. (P13)

Insufficient staffing

Most participants reported that high patient-to-nurse ratios and insufficient staffing levels, which prevented the implementation of a one-to-one nursing care model, constituted a major barrier to providing adequate care. Some participants further highlighted that a shortage of specialized technical personnel posed challenges to the implementation of certain clinical nursing interventions, such as ultrasound-guided procedures:

Here, each of us is usually responsible for about three to four patients. When staffing is inadequate and patients are critically ill, it means we can’t monitor patients as timely or precisely as we should. (P2)

At present, our unit can’t provide one-to-one nursing care… and enteral nutrition management is indeed quite difficult. (P4)

In particular, a lack of ultrasound-trained personnel was perceived as a significant barrier to nasojejunal tube placement:

Nasojejunal tube placement requires physicians to cooperate with ultrasound assessment, but some doctors may not be fully proficient in abdominal ultrasound evaluation. (P7)

If doctors perform the ultrasound, that might still be acceptable. But if nurses were expected to do it, it would be quite stressful, because none of us on the nursing side have received training in this area. (P6)

Lack of prone positioning-specific training

Most participants reported that while general enteral nutrition training exists, there is a critical absence of training specifically addressing the unique challenges of enteral nutrition during prone positioning. Existing training methods are fragmented and fail to address prone positioning-specific scenarios such as managing feeding during unpredictable positioning sessions, assessing feeding tolerance with restricted patient access, or coordinating feeding schedules with positioning timing. Unlike general ICU training, prone positioning-specific training requires simulation-based scenarios that replicate the physical constraints and coordination challenges unique to this patient population. Two subthemes were identified: absence of prone positioning-specific training approaches and limited accessibility of position-specific knowledge.

Inappropriate training approaches

Most participants stated that training regarding evidence-based enteral nutrition for patients receiving prone position ventilation “lacks systematic instruction,” “relies on a single training format,” and “offers limited practical opportunities,” which prevents them from linking theoretical knowledge with clinical practice:

I feel our training is quite fragmented; we only learn bits of knowledge here and there, like one topic this week and another next week… and it’s just reading from slides, which is really boring. (P5)

Maybe we were taught before, but these patients are rare, so there is little practical experience. I don’t have a systematic concept in my mind, and I forget it when actually applying it. (P8)

Training frequency is low, content is insufficient, and the effectiveness is not high. This is indeed a problem in our unit… so nurses’ understanding is inadequate, which leads to some difficulties in executing the protocols. If training were sufficient, with repeated emphasis, I believe execution would become more consistent. (P11)

Limited accessibility of knowledge

Most participants reported that enteral nutrition-related knowledge was mainly acquired during formal education or at the time of joining the unit. Although the hospital provides regular training, there is a lack of systematic education specifically targeting patients in the prone position. Physicians also mentioned some opportunities for continuing professional education:

Before joining the unit, I did have systematic theoretical training, but enteral nutrition comprised only a small portion, and training for prone positioning patients was even less. If you haven’t encountered such patients, you might not even know, so most of my knowledge relies on what I learned during graduate school. (P10)

Some provincial or municipal critical care conferences provide related training, where you can learn the latest research or guidelines. (P15)

Communication barriers related to prone positioning-feeding coordination

Insufficient interprofessional collaboration was identified as a prominent barrier, but critically, the prone positioning context amplifies these communication challenges in ways not present in general ICU care. Unlike supine patients where feeding schedules can follow predictable protocols, prone positioning introduces temporal unpredictability that requires real-time physician-nurse coordination. Most participants reported that communication regarding adjustments to enteral nutrition management plans during prone positioning was often insufficient, untimely, and inconsistent. Coordinating enteral nutrition-related practices during prone positioning, including feeding interruption and feeding rate adjustment, created communication demands that exceeded those encountered during routine ICU handovers. The constructed sub-theme was “prone positioning-feeding coordination barriers”:

For example, one hour before prone position, enteral nutrition should be paused and gastric contents aspirated. Sometimes the doctor may not have planned the patient’s prone position in advance. After rounds, they immediately inform you that the patient will be placed in the prone position. However, because the enteral feeding has already started following morning care, pausing the feeding one hour before prone position is not well implemented. (P12)

Sometimes after we start prone positioning, the feeding plan isn’t always adjusted promptly. If we don’t communicate with the doctors in time, the patient can build up a large amount of gastric residual volume and may not be able to tolerate the feeding plan. (P3)

From the doctors’ perspective, they want us to keep advancing the enteral nutrition plan for patients in the prone position, but at the same time they worry about reflux and aspiration. So they’ll tell us to slow the feeding down, but they don’t really specify what rate they want us to use. (P9)

Discussion

This study explored nurses’ and physicians’ views on barriers to implementing evidence-based enteral nutrition management specifically in ICU patients receiving prone position ventilation. Importantly, our findings reveal that while some barriers overlap with general ICU enteral nutrition challenges, the prone positioning context creates unique amplification effects and position-specific barriers that require targeted interventions.

Distinguishing prone positioning-specific barriers from general ICU challenges

Our analysis identified that barriers in prone positioning patients differ qualitatively from general ICU enteral nutrition barriers in three critical ways: (1) Temporal complexity: Unlike supine patients where feeding schedules can follow standardized protocols, prone positioning patients require dynamic feeding adjustments based on unpredictable positioning sessions, creating coordination challenges absent in general ICU care; (2) Risk amplification: While aspiration risk exists in all ICU patients, prone positioning fundamentally alters the risk profile through increased intra-abdominal pressure and head-down positioning, requiring position-specific risk mitigation strategies; (3) Access limitations: General ICU patients allow continuous feeding tolerance assessment, whereas prone positioning restricts visual and physical access to the patient, creating monitoring gaps unique to this population.

Insufficient equipment and staffing

This study indicates that insufficient equipment and staffing in the ICU context for patients receiving enteral nutrition during prone position ventilation do not merely manifest as reduced nursing efficiency. Rather, it indirectly constrains the implementation of evidence-based practice by amplifying healthcare professionals’ perceptions of enteral nutrition–related risks [26]. According to implementation science theory, the availability of resources constitutes a critical structural determinant influencing both the feasibility and fidelity of evidence-based interventions [27]. When resource support is inadequate, healthcare professionals’ execution of evidence-based guidelines may be substantially constrained, even when they fully acknowledge the importance of these recommendations.

Prone position ventilation, as a high-risk and highly complex therapeutic strategy, imposes heightened demands on the safety, precision, and interdisciplinary coordination of enteral nutrition management [28]. Previous studies have demonstrated that prone position requires additional human resources, specialized equipment, and multidisciplinary collaboration; otherwise, procedural complexity and the risk of potential complications increase significantly [29]. In this context, the inadequate availability of temperature-control devices identified in this study, the inability to continuously monitor enteral formula temperature, and limited technical and equipment support for nasoenteric tube placement collectively intensified healthcare professionals’ concerns regarding aspiration and feeding intolerance. Faced with such uncertainty, nurses tended to adopt defensive practice strategies, such as reducing feeding rates or delaying the achievement of target feeding volumes, in order to prioritize patient safety. However, these risk-averse behaviors objectively hindered the full implementation of evidence-based enteral nutrition protocols [29].

Moreover, insufficient staffing exerted a more profound and structural influence on practice implementation. Under conditions of high workload, nurses were often responsible for multiple critically ill patients simultaneously, limiting their capacity to perform timely and continuous assessments, monitoring, and adjustments of enteral nutrition [30]. Within this context, enteral nutrition management was no longer perceived as an evidence-based intervention amenable to meticulous execution, but was instead reframed as part of broader “risk management,” resulting in a lower prioritization of its implementation. This phenomenon reflects how workload shapes healthcare professionals’ risk-related decision-making patterns and, in turn, reinforces a safety-oriented clinical practice culture [31].

Notably, the shortage of specialized personnel, such as staff trained in bedside ultrasound assessment, restricted the routine application of nasoenteric tube placement techniques in patients undergoing prone position ventilation, thereby limiting the selection of more optimal feeding pathways. This finding aligns with implementation science perspectives emphasizing that resource accessibility directly influences intervention selection and implementation fidelity [32]. Collectively, these results suggest that constraints on evidence-based practice do not stem from healthcare professionals’ rejection of guideline value, but rather from structural implementation barriers arising from insufficient organizational support.

Inappropriate training approaches

In this study, “inappropriate training approaches” do not simply refer to insufficient training frequency or incomplete content coverage. Rather, the term reflects the predominant reliance on fragmented, theory-oriented training formats that lack contextualization and hands-on practice. Such approaches make it difficult for nurses to effectively bridge evidence-based enteral nutrition principles for patients receiving prone position ventilation with real-world clinical practice.

Adult learning theory emphasizes that adult learners are self-directed, bring prior experiential knowledge, and possess clear practice-oriented goals. Consequently, they are more likely to achieve deep learning through problem-centered educational approaches grounded in authentic clinical situations. In contrast, traditional didactic knowledge transmission that is detached from clinical realities often fails to translate into actual clinical behaviors [33].

Similarly, situated learning theory underscores that learning must be embedded within real work environments and social interactions; otherwise, “knowing” does not automatically translate into “doing” [34]. Consistent with this perspective, a growing body of evidence demonstrates that simulation-based or contextually embedded training enhances learners’ clinical judgment, skill performance, and behavioral adherence to evidence-based practice. By contrast, conventional classroom-based training tends to improve cognitive knowledge while exerting limited impact on practical clinical competence [34–36].

Within the intensive care context, which is characterized by high complexity, dynamic clinical conditions, and substantial demands for interprofessional collaboration, linear and theory-driven instruction alone is insufficient to facilitate the transfer of knowledge into practice, thereby creating barriers to clinical behavior change. This decontextualized training model becomes particularly problematic in the management of enteral nutrition during prone position ventilation. Even when nurses have “received training,” the lack of repeated practice and feedback in real or simulated clinical scenarios limits their confidence in applying knowledge to rapidly evolving clinical judgments and multidisciplinary coordination, ultimately impeding the implementation of evidence-based practices [37].

Barriers in interprofessional information exchange and communication

This study demonstrates that barriers in interprofessional information exchange and communication exert a substantial influence on the implementation of evidence-based enteral nutrition practices in patients receiving prone position ventilation. Although participants generally acknowledged the importance of enteral nutrition management, communication between physicians and nurses regarding prone position plans, timing arrangements, and related nursing measures was often incomplete and inconsistent in practice.

Within the intensive care setting, physicians typically assume primary responsibility for treatment decision-making, whereas nurses are chiefly responsible for care implementation and risk management [38]. In the specific context of prone position ventilation, the risks associated with enteral nutrition management, such as aspiration and gastric residuals, are predominantly perceived and managed by nurses; however, related decisions do not always reflect a shared understanding within the interprofessional team. When prone position plans are insufficiently communicated in advance or subject to frequent modification, nurses are often required to respond passively within predefined constraints. This increases uncertainty in care delivery and encourages the adoption of more conservative strategies to mitigate potential risks. Such asymmetry between decision-making authority and execution responsibility hinders the stable integration of evidence-based enteral nutrition management into routine nursing practice [39].

These findings are highly consistent with previous research on interprofessional collaboration in intensive care units. Existing studies have identified incomplete information transfer, fragmented communication, and blurred professional role boundaries as major barriers to collaboration between nurses and physicians and to the implementation of evidence-based practices [38]. When nurses experience limited involvement in treatment decision-making processes and reduced information transparency, their confidence in the safety and feasibility of evidence-based interventions is significantly diminished, thereby adversely affecting consistency and quality of implementation. Furthermore, research on patient safety culture emphasizes that effective interprofessional communication is a critical prerequisite for maintaining safety in high-risk care practices [39, 40]. Conversely, communication breakdowns may indirectly undermine the uptake of evidence-based practices by altering risk perception and priority-setting.

Notably, this study further reveals that within the highly complex care context of enteral nutrition management during prone position ventilation, the negative impact of interprofessional communication barriers may be amplified. Given that both prone position procedures and enteral nutrition management require precise temporal coordination and multidisciplinary collaboration, insufficient information sharing within the healthcare team may lead to enteral nutrition being perceived as an “additional risk” rather than a standard component of care, thereby marginalizing it within clinical priority-setting.

Implications for practice and future interventional research

Based on the facilitators identified in this study, a multilevel implementation framework was developed to improve evidence-based enteral nutrition management for patients receiving prone positioning.

Organizational level strategies

Ensure adequate temperature-control devices for enteral nutrition delivery (target: one device per prone positioning patient) - Develop clear protocols for nasojejunal tube placement timing relative to prone positioning schedules - Implement flexible staffing models that allow temporary one-to-one nursing during prone positioning periods - Establish bedside ultrasound training programs for nursing staff to support tube placement verification.

Professional level strategies

Replace didactic training with simulation-based scenarios that replicate prone positioning challenges - Develop competency checklists specific to enteral nutrition management during prone positioning - Create quick-reference decision aids for feeding rate adjustments based on patient positioning status - Implement regular case-based learning sessions focusing on prone positioning nutrition complications.

Team level strategies

Establish structured handover protocols that include planned prone positioning times and corresponding enteral nutrition adjustments - Implement daily interprofessional nutrition rounds for prone positioning patients - Create standardized communication templates for physician-nurse coordination regarding positioning schedules - Define clear role responsibilities for enteral nutrition monitoring during prone positioning periods.

Future research should focus on developing and testing these implementation strategies using hybrid effectiveness-implementation designs to simultaneously evaluate clinical outcomes and implementation fidelity.

Conclusion

This study identified four interconnected barriers to implementing evidence-based enteral nutrition management that are uniquely amplified or created by the prone positioning context. Unlike general ICU enteral nutrition barriers, prone positioning introduces: (1) position-specific care prioritization conflicts where airway management during prone sessions directly competes with feeding continuity; (2) specialized resource demands including positioning equipment and temperature monitoring systems adapted for restricted patient access; (3) absence of prone positioning-specific training curricula that address the distinct physiological and practical challenges; and (4) coordination barriers between positioning schedules and enteral nutrition timing that do not exist in supine care.

Limitations

This study has several limitations. Although participants were encouraged to discuss any factors influencing enteral nutrition management during prone position ventilation, several interview questions focused on implementation challenges. As a result, barriers have been explored in greater detail than facilitators in some interviews. Although maximum variation sampling, researcher reflexivity, and team discussions were employed to enhance informational richness and data credibility, the transferability of the findings may be influenced by organizational culture, social desirability, and recall bias. In addition, the study was conducted in a single ICU within a specific Chinese healthcare setting. Variations in healthcare systems, organizational structures, and clinical practices across settings may influence how the findings are interpreted and applied in other contexts.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ARDS

Acute respiratory distress syndrome

EAS

Educational administration specialist

ICU

Intensive care unit

ICU-SN

ICU specialist nurse

IQR

Interquartile range

MEMS

Medical equipment management specialist

NM

Nurse manager

NTL

Nurse team leader

QMS

Quality management specialist

RN

Registered nurse

Author contributions

Zhenxiu Yu and Xiaomei Chang contributed to the methodology and writing—original draft. Xueqin Li and Wenfeng Lu performed data acquisition. Shenglin Hu and Guorong Li contributed to the analysis and interpretation of data.

Funding

This research was supported by the Key Laboratory of Gastroenterology Tumor and Microenvironment at Chengdu Medical College of Sichuan Province (Grant No. 24LHXHZW1-02).

Data availability

The datasets generated and analysed during the current study are not publicly available due to the inclusion of qualitative interview data and the potential risk of participant identification, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Ya’an People’s Hospital (approval date: January 15, 2025; reference number: 2024079). Written and verbal informed consent was obtained from each participant prior to the interviews.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.