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Abstract

Background

Nasogastric tube (NGT) feeding is the preferred method of delivering nutrients to children who cannot tolerate oral feeding and medication. However, there are various risks associated with NGT misplacement.

Objective

To evaluate the impact of a structured educational program on pediatric nurses’ knowledge and practice in NGT placement.

Methods

This quasi-experimental study was conducted among 130 nurses in two hospitals in Saudi Arabia. Pretest and posttest data were collected using a questionnaire and an observational checklist. The educational program included theoretical and practical sessions on the recommended best practices for NGT placement and location verification in pediatric patients.

Results

Prior to the intervention, more than half (53.1%) had unsatisfactory knowledge, and 59.5% exhibited incompetent practice regarding NGT placement. Significant improvements were observed following the educational program. Postintervention, 90% of the nurses demonstrated satisfactory knowledge, and 88.5% exhibited competent practice (p < 0.01). A strong positive correlation was found between knowledge and practice levels both before and after the intervention (p < 0.01).

Conclusion

The educational program on NGT placement significantly improved pediatric nurses’ knowledge and promoted best practices, thereby increasing patient safety. It is recommended that structured training and simulation-based refreshers be incorporated into continuing nursing education to sustain safe and effective NGT practice.

Keywords

educational program nasogastric tubes pediatric nurses knowledge practice impact

Introduction

Ensuring proper nutrition is a fundamental aspect of pediatric healthcare, particularly for children who are unable to feed orally due to prematurity, neurological impairments, or critical illness. Nasogastric tube (NGT) placement is one of the most commonly performed procedures in pediatric care, providing a safe and effective method for enteral feeding when oral intake is not possible (Northington et al., 2022). However, despite being a routine intervention, incorrect NGT placement poses serious risks, including aspiration pneumonia, feeding intolerance, and, in severe cases, life-threatening misplacement into the respiratory tract. These complications underscore the critical need for ensuring that pediatric nurses have the proper knowledge and skills to perform NGT placement safely and accurately.

Verification of correct tube placement remains a major challenge in clinical practice. Studies have highlighted inconsistencies in the use of verification methods, with some nurses relying on outdated techniques such as auscultation, which lacks accuracy and reliability (Ellett et al., 2012). International guidelines, including those from The British Association for Parenteral and Enteral Nutrition (BAPEN) and The American Society for Parenteral and Enteral Nutrition (ASPEN), advocate for standardized protocols to reduce the risk of misplacement and complications (BAPEN, 2016). However, adherence to these guidelines varies across healthcare settings, leading to ongoing concerns about patient safety.

While previous research has explored the role of education and competency-based training in improving NGT management, there remains a gap in structured training programs specifically designed for pediatric nurses. Many available interventions are general or tailored to adult care, leaving a lack of targeted educational frameworks that address the unique challenges of pediatric NGT placement and verification (Powers et al., 2021). Given the complexity and risks associated with NGT management, developing a structured, evidence-based training program for pediatric nurses is essential to ensure safe and effective care.

This study aims to evaluate the effectiveness of an educational program in improving pediatric nurses’ knowledge and practices regarding NGT placement. By implementing a targeted educational intervention, this research seeks to address existing knowledge gaps, improve procedural accuracy, and contribute to safer enteral feeding practices for pediatric patients.

Review of Literature

The Importance of NGT Feeding in Pediatric Care

Nasogastric tube feeding is widely regarded as a lifeline for pediatric patients with conditions preventing oral intake. Enteral feeding offers numerous benefits, including supporting gut integrity, improving immune function, and reducing the risk of infections associated with parenteral nutrition (Preiser et al., 2015; Singer et al., 2011). Despite these advantages, safe and effective NGT placement remains a significant challenge in pediatric healthcare, with studies reporting variations in clinical practices that can lead to serious complications such as aspiration and feeding intolerance (Northington et al., 2022).

Challenges in NGT Placement and Verification Techniques

Proper verification of tube placement is critical for patient safety, yet current practices remain inconsistent. Traditional verification methods such as auscultation are unreliable and no longer recommended, as they fail to distinguish between gastric and respiratory placement (Ellett et al., 2012). pH testing, while more accurate, is affected by factors such as recent feeding and acid suppression therapy, making it impractical in some cases (Fan et al., 2017).

The BAPEN recommends a multimodal approach to verifying NGT placement, including pH testing, capnography, auscultation, and radiographic confirmation. While radiographic confirmation remains the gold standard, it is not always feasible in pediatric settings due to radiation exposure risks and practical constraints. Capnography has emerged as a promising alternative, providing real-time assessment of tube placement by detecting exhaled carbon dioxide (BAPEN, 2016).

More recent advancements in verification techniques include capnography and bedside ultrasound, which have demonstrated higher accuracy in confirming correct tube placement (American Association of Critical Care Nurses, 2016; Claiborne et al., 2021). However, accessibility and training limitations prevent widespread adoption in many clinical settings. These findings highlight the urgent need for improved education and training to ensure nurses are proficient in the safest, most effective verification techniques available.

The Role of Education in Enhancing NGT Competency

Several studies have demonstrated that structured educational programs significantly improve nurses’ competency in NGT management. Competency-based training, simulation exercises, and refresher courses enhance procedural skills, decision-making, and adherence to safety protocols (Kaltenmeier et al., 2022). Research shows that nurses who undergo formal training are more confident, make fewer errors, and are more likely to follow recommended verification methods (Powers et al., 2021).

Motta et al. (2021) found that hospitals implementing structured NGT training programs reported a 30% reduction in misplacement-related incidents, underscoring the importance of education in improving patient safety outcomes.

University Education and Its Role in NGT Training

A strong academic foundation is essential in developing nurses’ critical thinking and clinical decision-making skills related to NGT placement. Studies show that nurses who receive formal NGT education during university training perform significantly better in clinical practice than those who rely on workplace training alone (Perry et al., 2022). The integration of simulation-based learning in nursing curricula has been shown to enhance knowledge retention, procedural accuracy, and confidence in handling enteral feeding challenges (Zeb et al., 2022).

Advanced Practice Nurses and Clinical Nurse Specialists in NGT Management

Advanced Practice Nurses (APNs) and Clinical Nurse Specialists (CNSs) are vital in leading nursing education and ensuring adherence to best practices in enteral nutrition. Research highlights that hospitals with APN-led training programs report higher compliance with NGT guidelines, improving overall patient safety (Hussien & Sayed, 2021).

Identified Gaps and Rationale for This Study

While existing studies highlight the benefits of education in NGT management, most research focuses on adult care, leaving a gap in pediatric-specific training. Furthermore, long-term evaluations on knowledge retention and clinical outcomes following NGT training remain limited. This study seeks to fill these gaps by evaluating a structured NGT educational program tailored specifically for pediatric nurses.

Methods

Design

In addition to efficiency in time, effort, and resource utilization, the quasi-experimental design used in this study allowed the researchers to evaluate the impact of the educational program on pediatric nurses’ knowledge and practices regarding NGT placement. Using a pretest–posttest approach, the researchers collected data before and after the implementation of the educational program. This design enabled them to compare changes in participants’ knowledge and practices, providing valuable insights into the effectiveness of the intervention.

Moreover, the quasi-experimental design allowed the study to be conducted in real-world clinical settings, reflecting the actual conditions and practices of pediatric nurses in the Asser Region, Saudi Arabia. This increases the external validity of the findings to similar healthcare settings.

This study adheres to the EQUATOR network guidelines for observational studies, with the STROBE checklist included in Appendix I to ensure transparency and reproducibility of reporting.

Data Collection

Meetings were arranged with eligible participants at their convenience to provide a clear explanation of the study's purpose and obtain informed consent from those willing to participate. The educational program consisted of a 6-h training divided into theoretical (3 h) and practical (3 h) components. The theoretical segment focused on indications, contraindications, and recommended verification techniques for NGT placement, based on evidence-based guidelines such as those from the ASPEN, while the practical component of the training involved hands-on skill sessions conducted in a simulated clinical skills lab using pediatric manikins. Nurses were directly observed by trained raters who used standardized observational checklists to assess each participant's performance. These sessions utilized low-fidelity simulation scenarios and structured written case studies to replicate common complications associated with NGT placement. This approach enabled participants to practice procedural skills and clinical decision-making in a realistic yet controlled environment. Importantly, no self-reported assessments were used to evaluate practice. A detailed breakdown of the training structure is included in Appendix II. The data collection process involved the administration of a structured questionnaire and direct observation using a checklist to assess participants’ baseline knowledge and practices regarding NGT placement. Each participant took approximately 10 min to complete the questionnaire and 15 min to complete the observational checklist. Following the pretest, all participants were randomly assigned to subgroups and scheduled for the educational program according to their availability without disrupting their work commitments.

The educational program consisted of two parts. The first part focused on theory, providing participants with scientific and theoretical information on NGT placement. This section involved interactive sessions, group discussions, and PowerPoint presentations. The second part of the program was dedicated to practice. It commenced with a video demonstration of the recommended best practices for NGT placement and location verification in pediatric patients, as approved by ASPEN Board of Directors (ASPEN, 2016). The participants then engaged in hands-on practice sessions in the clinical skills lab using pediatric manikins. Nurses practiced and redemonstrated key procedures and engaged in scenario-based learning to manage simulated complications using low-fidelity models and case-based examples. After completing both program parts, the participants underwent a posttest assessment using the same questionnaire and the same observational checklist applied by trained raters. This evaluation aimed to measure the improvements in the participants’ knowledge and practice following the implementation of the educational program. Data collection was conducted between November 2022 and March 2023.

Sample

A purposive sampling technique was used to select a sample of 130 nurses working in maternity and pediatric hospitals located in the cities of Bisha, Khamis Mushait, and Abha, Saudi Arabia. The inclusion criteria for the study required nurses to have a minimum work experience of six months and a willingness to participate. Head nurse supervisors, educators, and nurses not directly involved in patient care were excluded to ensure research validity. The sample size was determined based on Zeb et al. (2022). Using an effect size estimate of 0.42, a mean of 15.42 ± 4.11 in the preintervention group and 17.82 ± 3.90 in the postintervention group, a statistical power of 95%, a confidence level (1-Alpha Error) of 95%, an alpha of 0.05, and a beta of 0.1, the sample size was calculated by comparing the two means using Kane's SP. The calculated sample size for each group was 118 nurses with a 10% attrition rate (12 nurses), resulting in a final sample size of 130 nurses. The sample size was calculated using a Sample Size Calculator developed by Kane and referenced on the ClinCalc platform by Rosner (2011).

Ethical approval was granted by the UBCOM Research Committee [Approval No: UBCOM/ H-06-BH-087 (0202.23)], ensuring compliance with the ethical principles outlined in the Declaration of Helsinki. All participants provided informed consent, and confidentiality was strictly maintained throughout the study.

Data Collection Tool

The questionnaire was developed from literature review and validated by a panel of experts. The questionnaire comprised the following sections:

(1) Sociodemographic background questions: These questions gathered information on pediatric nurses’ sociodemographic data, including their age, position, education, and years of experience.

(2) Knowledge-related questions: This section focused on assessing nurses’ knowledge of NGT placement and verification. After conducting a literature review, a total of 14 knowledge-related questions were designed based on the literature. Among these, 12 were multiple-choice questions and two were open-ended questions. The questions covered eight domains: indications for NGT placement, nutritional needs of pediatric patients, verification of tube position, tube placement techniques, warning signs during insertion, and assessment of gastric content, caring of NGT, and estimating the length of NGT. The scoring system involved checking the nurses’ answers against the model key answers. Each correct response was given a score of 1, while incorrect answers were scored as 0. The scores were then summed and converted into percentages. Nurses’ knowledge was categorized as “satisfactory” if the score was ≥70% or “unsatisfactory” if the score was <70%.

Knowledge scores ≥70% were considered satisfactory based on prior research establishing this threshold as indicative of adequate theoretical understanding for safe NGT management (Greer, 2001; Perry et al., 2022).

(3) Observation checklists: The observation checklists were adapted from Greer (2021) and Perry et al. (2022) with an inter-rater reliability of Cohen's kappa = 0.85 ensuring consistency and were used to assess nurses’ practices related to NGT placement and verification. The checklists included items covering various steps involved in the process such as tube preparation, tube placement, checking tube placement, feeding the pediatric patient, and postfeeding care. Each item was evaluated as “done” (scored as 1) or “not done” (scored as 0). The scores were then summed and converted into percentages. Nurses’ practices were classified as “competent” if the score was ≥90% or “incompetent” if the score was <90%.

A ≥90% competence threshold was used for practice assessments to ensure a high standard of procedural accuracy and safety, aligning with established competency frameworks (Powers et al., 2021).

A validation process was conducted to ensure the validity of the research tool. Five nursing faculty professors reviewed the tool for clarity, comprehensiveness, applicability, and ease of implementation. Based on their feedback, minor modifications were made to enhance the tool's quality.

The reliability of the tool was assessed through a test–retest process using a pilot study sample. The tool was administered at the same location but on different occasions, and no modifications were made based on the results of this test–retest process.

Statistical Analysis

Data collected from the study sample were carefully reviewed, coded, and entered into a personal computer for further analysis. Computerized data entry and statistical analyses were conducted using Statistical Package for the Social Sciences (SPSS) version 22. Descriptive statistics were used to present the data and provide a clear understanding of the distribution and characteristics of the study variables, including frequencies, percentages, means, and standard deviations. To determine whether there was a significant association between the categorical variables, the chi-square test was used. Furthermore, Pearson correlation coefficients were calculated to measure the strength and direction of the statistical relationships between two variables. The significance of the results was evaluated based on p values. P values of less than 0.01 and 0.05 were considered highly significant and significant, respectively.

Results

Table 1 provides an overview of the nurses’ characteristics. The mean age of the nurses was 34.70 ± 5.86 years. Most participants (80%) were female, and more than half (60.7%) held a bachelor's degree in nursing. The mean years of work experience among the nurses was 6.63 ± 2.19 years. Only 13.8% of nurses attended training courses, and the majority (55.4%) were permanent employees. Additionally, a significant portion of the nurses (70.8%) worked rotating shifts, and more than one-third (36.9%) worked in the pediatric intensive care unit or neonatal intensive care unit (NICU).

Table 1.

Demographic Characteristics of Pediatric Nurses Participating in the Study.

Studied nurses’ characteristics	N	%
Age
20–30	34	26.2
31–40	75	57.7
41–50	21	16.1
Mean (S.D) 34.70 ± 5.86
Gender
Male	26	20
Female	104	80
Educational qualification
Doctorate	2	1.5
Master	6	4.6
Pediatric nursing specialist	43	33.2
Expert	5	3.8
Bachelor's degree of nursing	74	56.9
Years of experience
1–5	68	52.3
6–10	28	21.5
11–15	23	17.7
>15	11	8.5
Mean (S.D) 6.63 ± 2.19
Attended training courses
Yes	18	13.8
No	112	86.2
Type of employment
Permanent	72	55.4
Temporary	58	44.6
Work shift
Morning	38	29.2
Rotating	92	70.8
Work unit
Inpatient pediatric ward	23	17.7
PICU and NICU	48	36.9
Pediatric emergency department	40	30.8
Neonatal ward	19	14.6

Table 2 displays the nurses’ knowledge levels before and after the intervention. Preintervention, 54.6%, 63.1%, and 64.6% of the nurses had unsatisfactory knowledge regarding the indications for NGT placement, the nutritional needs of the infant, and warning signs during insertion, respectively. Postintervention, the knowledge levels significantly improved, with 96.9%, 97.7%, and 98.5% of the nurses demonstrating satisfactory knowledge about checking tube placement, NGT care, and estimating the length of the NGT, respectively. There were highly significant differences in all knowledge domains pre- and postintervention (p < 0.01). Moreover, more than half (53.1%) of the nurses had unsatisfactory knowledge about gavage feeding preintervention, whereas the majority (90%) had satisfactory knowledge postintervention (p < 0.01).

Table 2.

Knowledge Levels of Pediatric Nurses Pre- and Postintervention Across Different Domains.

Domains of knowledge	Pretest		Posttest		Chi-square p value
Domains of knowledge	N	%	N	%	Chi-square p value
Indications of nasogastric tube
Satisfactory	59	45.4	121	93.1	7.897
Unsatisfactory	71	54.6	9	6.9	<.01
Nutritional needs of the pediatric patient:
Satisfactory	48	36.9	117	90	9.002
Unsatisfactory	82	63.1	13	10	<.01
Verifying position of oro/nasogastric tubes:
Satisfactory	75	57.7	122	93.8	8.446
Unsatisfactory	55	42.3	8	6.2	<.01
Check the placement of the tube:
Satisfactory	78	60	126	96.9	8.601
Unsatisfactory	52	40	4	3.1	<.01
Warning signs during insertion:
Satisfactory	46	35.4	119	91.5	7.994
Unsatisfactory	84	64.6	11	8.5	<.01
Nasogastric tube care:
Satisfactory	66	50.8	127	97.7	8.162
Unsatisfactory	64	49.2	3	2.3	<.01
Assessment of gastric content:
Satisfactory	52	40	120	92.3	7.661
Unsatisfactory	78	60	10	7.7	<.01
Estimate the length of nasogastric tube:
Satisfactory	81	62.3	128	98.5	8.250
Unsatisfactory	49	37.7	2	1.5	<.01
Total knowledge:
Satisfactory	61	46.9	117	90	15.688
Unsatisfactory	69	53.1	13	10	<.01

Table 3 presents nurses’ practice levels before and after the intervention. Preintervention, 65.4%, 54.6%, and 56.2% of the nurses demonstrated incompetent practices in preparing to place the tube, placing the tube, and postfeeding, respectively. Postintervention, the practice levels significantly improved, with 96.2%, 94.6%, and 93.8% of the nurses’ demonstrating competency in placing, preparing for, and checking the placement of the tube, respectively. There were highly significant differences in all practice domains pre- and postintervention (p < 0.01). Additionally, more than half (59.5%) of the nurses had incompetent gavage feeding practices preintervention, while the majority (88.5%) had competent practices postintervention (p < 0.01).

Table 3.

Practical Competence of Pediatric Nurses in Nasogastric Tube Management Pre- and Postintervention.

Practice level	Pretest		Posttest		Chi-square p value
Practice level	N	%	N	%	Chi-square p value
Preparing to place the tube:
Competent	45	34.6	123	94.6	10.245
Incompetent	85	65.4	7	5.4	<.01
Placing the tube:
Competent	59	45.4	125	96.2	9.716
Incompetent	71	54.6	5	3.8	<.01
Check the placement of the tube:
Competent	60	46.2	122	93.8	8.562
Incompetent	70	53.8	8	6.2	<.01
Feeding the pediatric patient:
Competent	64	49.2	119	91.5	10.112
Incompetent	66	50.8	11	8.5	<.01
Post feeding:
Competent	57	43.8	120	92.3	9.500
Incompetent	73	56.2	10	7.7	<.01
Preparing to place the tube:
Competent	45	34.6	123	94.6	10.245
Incompetent	85	65.4	7	5.4	<.01
Placing the tube:
Competent	59	45.4	125	96.2	9.716
Incompetent	71	54.6	5	3.8	<.01
Check the placement of the tube:
Competent	60	46.2	122	93.8	8.562
Incompetent	70	53.8	8	6.2	<.01
Total practice:
Competent	54	41.5	115	88.5	13.872
Incompetent	76	58.5	15	11.5	<.01

Table 4 highlights the positive correlation between the knowledge and practice levels of the nurses both pre- and postintervention, which was highly significant (p < 0.01). The educational program significantly improved nurses’ knowledge and practices, which may contribute to safer NGT placement practices. While the study did not directly measure patient safety outcomes, these improvements align with established best practices that support safer care delivery.

Table 4.

Correlation Between Knowledge and Practice Levels of Pediatric Nurses Before and After the Educational Program.

Total knowledge and total practice pre intervention
	R	.764
	p	.000
Total knowledge and total practice post intervention
	R	.603
	p	.000

Statistically significant at p < 0.01. R = Pearson correlation.

Discussion

Clinical nutrition plays a pivotal role in the safe and effective management of NGT placement in pediatric patients. According to the BAPEN, enteral nutrition is preferred over parenteral feeding due to its positive impact on gastrointestinal function, immunity enhancement, and cost-effectiveness (BAPEN, 2016). Adequate nurse training ensures adherence to these guidelines, thereby promoting accurate placement verification and reducing the risk of complications (Irving et al., 2018).

Adequate nutritional support is essential for pediatric patients requiring NGT placement, ensuring optimal growth and recovery. Clinical nutrition guidelines emphasize the need for individualized feeding regimens tailored to metabolic demands, reinforcing the importance of nurse competency in enteral feeding practices (BAPEN, 2016; Northington et al., 2022).

Formal university education serves as the cornerstone of nursing competency, providing a structured foundation that integrates theoretical knowledge with clinical practice. Nurses who receive specialized training in pediatric care, including enteral nutrition and NGT management, often demonstrate higher proficiency and confidence in performing these procedures compared to those who rely solely on workplace training (Greer, 2001; Zeb et al., 2022). A strong academic foundation not only enhances technical skills but also fosters critical thinking, enabling nurses to make informed, evidence-based decisions in clinical settings. Moreover, university education plays a key role in shaping professional attitudes toward patient safety, reinforcing the importance of accurate verification techniques and adherence to best practices. As nursing curricula continue to evolve, integrating simulation-based learning and hands-on training in enteral feeding could further enhance nurses’ readiness for real-world clinical challenges. These findings are consistent with those of Mohamed et al. (2021), who demonstrated enhanced nursing performance toward enteral feeding in pediatric critical care units following structured education.

The results of this study show that there was a significant improvement in nurses’ knowledge levels regarding indications of the NGT, nutritional needs of the infant, warning signs during insertion, placement checking of the tube, NGT care, and estimation of the length of the NGT. These improvements can be attributed to the effectiveness of the training program, which was tailored to address the specific needs and knowledge gaps identified during the preintervention assessment. These findings align with previous research conducted by El-Morsy et al. (2020) which showed a notable enhancement in nurses’ understanding of the nutritional needs of low-birthweight infants following the implementation of a guideline protocol.

While the findings of this study align with El Morsy et al. (2020) in demonstrating improvements in NGT knowledge, key methodological differences exist. El Morsy et al. utilized a longer intervention period (8 weeks vs. our 6-h program) and included direct patient outcome tracking, whereas our study focused primarily on competency assessment. Future research should explore whether extended training durations yield more sustained improvements in clinical practice.

Furthermore, according to Hussien & Sayed (2021), the positive impact observed on nurses’ knowledge after participating in a training program focused on critically ill children's nutrition emphasizes the relevance and effectiveness of targeted educational interventions. Additionally, Márquez et al. (2018) showed that educational interventions effectively increased nurses’ knowledge of pediatric nasogastric intubation, further supporting the importance of tailored training in specific areas of nursing practice. Moreover, as revealed by Mohammed et al. (2018), the positive effect of an educational program on enhancing nurses’ knowledge of NGT feeding in NICUs highlights the potential benefits of improving care outcomes in NICUs. Zeb et al. (2022) found that using informative pamphlets as teaching tools significantly improved nurses’ knowledge of NGT feeding. Improved knowledge can lead to more accurate tube placement, better identification of warning signs, and enhanced overall care for children requiring NGTs.

The significant improvement in pediatric nurses’ NGT practices post intervention underscores the importance of tailored training programs. Before the intervention, a considerable proportion of the nurses demonstrated incompetent practices. However, most participants exhibited competent practices after the intervention, highlighting the effectiveness of the training program in addressing the identified practice gaps and the use of different illustrative methods for training and redemonstration. These findings align with research conducted by Jabbar and Hattab (2022) which emphasized the positive impact of an interventional program on nurses’ practice of enteral feeding tube insertion and continuous feeding initiation in premature neonates. In their research, the study group's nurses showed a notable increase in their level of practice as a direct result of the training sessions provided within the interventional program. Similarly, Kaltenmeier et al. (2022) emphasized the effectiveness of structured educational interventions tailored to nurses’ clinical needs and guided by evidence-based protocols. Their study demonstrated significant improvements across all aspects of NGT management—ranging from insertion and placement verification to feeding and medication administration—following the implementation of a targeted training program. The intervention incorporated practical training tools, including checklists and standardized assessment methods, which contributed to enhanced clinical performance. These findings support our own, in which a brief yet focused educational program significantly improved pediatric nurses’ knowledge and procedural competence. Together, these results highlight the value of context-specific training programs that integrate both theoretical instruction and hands-on practice, particularly in high-risk areas such as pediatric enteral feeding.

The educational background of nurses significantly influences their NGT practices. Our findings indicate that nurses with formal training in pediatric care demonstrated higher competence levels compared to those without such training. This aligns with prior research highlighting the importance of specialized education in enhancing clinical practice and ensuring the safe administration of enteral nutrition (Hussien & Sayed, 2021; Irving et al., 2018). In line with our findings, Carrasco et al. (2023) demonstrated that simulation-based training significantly improved pediatric nurses’ skills in NGT placement. Their study used scenario-based simulations and debriefing sessions, which allowed nurses to practice critical steps in a risk-free environment while receiving real-time feedback. As a result, participants showed substantial gains in both confidence and procedural accuracy. These outcomes reinforce the importance of incorporating simulation into pediatric nursing education, particularly for high-stakes procedures such as NGT placement, where precision and safety are vital. Our program, though brief, shared similar hands-on components and yielded comparable improvements, suggesting that even short-format simulations can produce meaningful learning outcomes when well-designed. Mohammed et al. (2021) found that the provision of nursing guidelines was effective in improving nurses’ performance regarding complications associated with NTG procedures. The availability of clear guidelines and protocols helps nurses navigate potential challenges and ensures safe and appropriate care of patients with NGTs. Similarly, Elsayed et al. (2021) noted statistically significant differences in the total mean scores of nurses’ performance in NGT feeding before and after an educational intervention. This finding suggests that educational interventions play a vital role in enhancing nurses’ skills and competence in the proper management of NGTs. Moreover, Powers et al. (2021) emphasized the importance of establishing the placement and verification of feeding tubes as a clinical standard of care. While techniques for placing feeding tubes may not be inherently difficult, the authors emphasize that proper training and measures of competency are crucial for avoiding significant harm to patients. The authors stressed the need for a systematic approach to tube placement to ensure patient safety and optimal health outcomes. Collectively, these studies highlight the significance of educational interventions, nursing guidelines, and standardized practices in improving nurses’ knowledge, skills, and performance in NGT care. By implementing educational programs, providing clear guidelines, and establishing standardized procedures, healthcare institutions can enhance the quality of care provided to patients requiring NGT feeding while minimizing potential complications and ensuring patient safety.

Advanced Practice Nurses and CNSs play a critical role in the continuous professional development of nursing staff. Their expertise in evidence-based practice, mentorship, and hands-on training sessions is crucial for maintaining high standards of NGT management. Incorporating APNs and CNSs into training programs can bridge knowledge gaps and foster a culture of continuous improvement in pediatric care (Carrasco et al., 2023; Kaltenmeier et al., 2022).

Furthermore, the positive correlation observed between nurses’ knowledge and practice levels underscores the importance of knowledge acquisition in influencing their practical skills and performance. These findings are in line with those of previous studies, such as the research conducted by Jeesh et al. (2021) which found a positive correlation between nurses’ NGT knowledge and practice levels in critical care units. In addition, Abo Elezz et al. (2020) stated that there is a positive correlation between nurses’ knowledge and practice levels regarding enteral feeding in pediatric critical care units. Moreover, Alhassan et al. (2019) found a strong positive correlation between nurses’ knowledge and training, and their competence in inserting and managing NGTs. These consistent findings emphasize the significance of enhancing pediatric nurses’ knowledge to promote better clinical practices and ultimately improve patient outcomes in the context of NGT care.

Strengths and Limitations

This study demonstrated the effectiveness of a short, structured educational program in improving pediatric nurses’ knowledge and practice in NGT placement. The strengths include a practical component with objective assessments and a high response rate. However, the study's generalizability is limited by its relatively small sample size, a lack of control group, and no follow-up evaluation to assess long-term retention of knowledge and skills.

Implications for Practice

Findings from this study suggest that structured, hands-on training can significantly improve pediatric nurses’ competence in performing high-risk procedures like NGT placement. Nurse educators and administrators should incorporate such programs into continuing education and onboarding protocols to reduce complications and promote patient safety. The strong correlation between knowledge and practice further supports ongoing competency assessment in clinical settings.

Conclusion

This study concludes that the educational program significantly improved pediatric nurses’ knowledge and practices on NGT placement, with potential implications for clinical care. It is recommended that such educational programs be routinely implemented as part of clinical orientation and continuing education for pediatric nurses. Additionally, periodic evaluation and hands-on simulation should be integrated to sustain improvements in competence and patient safety.

Footnotes

Acknowledgements

The authors extend their appreciation to the Deanship of Scientific Research at University of Bisha for funding this research through the general research project under grant number (UB-GRP −57-1444).

ORCID iD

Shimmaa Mansour Moustafa Mohammed

Ethical Considerations

Ethical Considerationshis study was approved by the UBCOM Research Committee of the University of Bisha UBCOM/ H-06-BH-087 (0202.23), ensuring adherence to the organization's research approval protocol. This step is crucial for maintaining ethical standards and ensuring the protection of the participants’ rights and welfare. In addition, all participants provided written informed consent.

Author Contributions

All authors have participated sufficiently in the work to take public responsibility for appropriate portions of the paper and approve of the final version of the manuscript. Shimmaa Moustafa: Made substantial contributions to conception and design, data collection, analysis and interpretation, drafting, and final approval of the manuscript. Gihan Mohamed: Involved in drafting the manuscript, revising it critically for important intellectual content, and final approval of the manuscript. Raghad Almushawah: Involved in drafting the manuscript and final approval of the manuscript. All authors agreed to the final approval of the version to be published and to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors extend their appreciation to the Deanship of Scientific Research at University of Bisha for funding this research through the general research project. The funding source has not been involved in the collection, analysis, and interpretation of data; in the writing of the paper; and in the decision to submit the article for publication.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Recommendations

Periodic evaluation of training programs is of utmost importance in the field of healthcare, specifically for healthcare professionals and educators involved in designing and implementing educational initiatives. This evaluation process allows them to assess the effectiveness of their programs, identify areas that may require further improvement, and ensure that healthcare organizations stay up-to-date with best practices. Such evaluations play a crucial role in gauging the impact of educational interventions on the competence and knowledge of healthcare professionals, particularly in specialized procedures such as nasogastric tube placement in pediatric care. By identifying strengths and weaknesses in the training programs, healthcare professionals and educators can fine-tune their educational approaches to optimize healthcare delivery and patient outcomes. To comprehensively understand the long-term impact of educational programs on nasogastric tube placement and the overall quality of pediatric patient care, longitudinal studies are essential. This is especially crucial for researchers and healthcare policymakers seeking evidence-based practices to enhance patient safety and healthcare outcomes. Longitudinal studies follow participants over an extended period, allowing researchers to observe and measure the sustained effects of the educational interventions. These studies provide valuable insights into how knowledge and practices acquired through the training programs evolve over time and whether they translate into improved patient care outcomes. By conducting such longitudinal studies, researchers and healthcare policymakers can gain valuable evidence to inform policy decisions, support evidence-based practices, and continually improve the quality of pediatric care.

Appendix (I): STROBE Checklist for Reporting Observational Studies

Title and Abstract:

Provide an informative and balanced summary of the study design, results, and conclusions.

Introduction:

Background/Rationale: Explain the scientific background and rationale for the study.

Objectives: State specific objectives, including any prespecified hypotheses.

Methods:

Study Design: Present key elements of the study design.

Setting: Describe the setting, locations, and relevant dates.

Participants: Describe eligibility criteria and the selection process.

Variables: Define outcomes, exposures, predictors, and confounders.

Data Sources: Explain how data were collected and measured.

Bias: Describe efforts to address potential biases.

Study Size: Explain how sample size was determined.

Quantitative Variables: Explain how quantitative variables were handled.

Statistical Methods: Describe statistical methods, including adjustments.

Results:

Participants: Report participant numbers at each stage.

Descriptive Data: Provide characteristics of the study population.

Outcome Data: Present outcome data for each group.

Main Results: Give unadjusted estimates and effect sizes.

Discussion:

Key Results: Summarize key results with reference to study objectives.

Limitations: Discuss study limitations.

Interpretation: Interpret results considering objectives, limitations, and generalizability.

Generalizability: Discuss the external validity of the study.

Other Information:

Funding: Describe funding sources and conflicts of interest.

Appendix (II): Training Program Flowchart for Nasogastric Tube Placement Educational Program

Step 1: Pretraining Assessment

Administer a knowledge questionnaire (14 questions) covering NGT placement, verification techniques, and associated risks.

Conduct an observational checklist evaluation to assess current practice standards.

Identify knowledge and skill gaps to tailor the educational content.

Step 2: Theoretical Training (3 h)

Interactive lectures on NGT indications, anatomy, and physiology relevant to pediatric care.

Overview of guidelines from ASPEN and BAPEN.

Discuss alternative verification techniques (e.g., pH testing, auscultation, and radiography).

Group discussions and Q&A sessions to enhance understanding.

Step 3: Practical Training (3 h)

Demonstration of correct NGT insertion and verification using pediatric training manikins.

Hands-on practice sessions with structured, individualized feedback.

Simulated scenarios utilizing low-fidelity simulation and case-based written exercises to develop skills in identifying and managing common complications.

Training on documentation standards and adherence to safety protocols.

Step 4: Posttraining Assessment

Re-administer the knowledge questionnaire and observational checklist.

Analyze improvements and identify any persistent knowledge or skill gaps.

Step 5: Program Evaluation and Follow-Up

Distribute evaluation forms to gather participant feedback.

Schedule follow-up refresher sessions as needed.

Develop a report on training outcomes for hospital administration.

References

Abo Elezz

N. F.

Ibrahim

R. A.

Osman

N. E.

(2020). Nurses’ knowledge and practice regarding enteral feeding in pediatric intensive care units. Journal of Nursing and Health Science, 9(4), 33–41.

Alhassan

R. K.

Tsikata

Tizaawaw

R. N.

Tannor

P. A.

Quaw

P. P.

Awortwi

C. A. A.

Ayanore

M. A.

Afaya

Salia

S. M.

Milipaak

Mwini-Nyaledzigbor

P. P.

(2019). Adherence to standard nursing protocols on nasogastric tube feeding in a secondary referral hospital in Ghana: Comparing self-ratings by professional and auxiliary nurses. BMC Health Services Research, 19(1), 119. https://doi.org/10.1186/s12913-019-3931-6

American Association of Critical Care Nurses. (2016). AACN practice alert: Initial and ongoing verification of feeding tube placement in adults. https://www.aacn.org/clinicalresources/practice-alerts/initial-and-ongoing-verification-of-feeding-tube-placement-in-adults

American Society for Parenteral and Enteral Nutrition (ASPEN). (2016). Verification of enteral tube placement: ASPEN Board of Directors guideline. https://www.nutritioncare.org

BAPEN. (2016). Guidelines on enteral feeding in pediatric care. https://www.bapen.org.uk

Carrasco-Guirao, J. J., Leal-Costa, C., Castaño-Molina, M. d. l. Á., Conesa-Ferrer, M. B., Molina-Rodríguez, A., Díaz-Agea, J. L., & Adánez-Martínez, M. G. (2024). Exploring how evidence-based practice, communication, and clinical simulation outcomes interact in nursing education: A cross-sectional study. Nursing Reports, 14(1), 616–626. https://doi.org/10.3390/nursrep14010047

Claiborne

M. K.

Gross

McGreevy

Riemann

Temkit

Augenstein

(2021). Point-of-care ultrasound for confirmation of nasogastric and orogastric tube placement in pediatric patients. Pediatric Emergency Care, 37(12), e1611–e1615. https://doi.org/10.1097/PEC.0000000000002134

El-Morsy

H. A. S.

El-Sayed

R. E. S. H.

Abd El Aziz

M. A.

(2020). The effect of implementing a guideline protocol on nurses’ knowledge about the nutritional requirements of low birth-weight infants. American Journal of Nursing Research, 8(1), 9–17.

Ellett

M. L. C.

Perkin

S. M.

Croffie

J. M. B.

Lane

K. A.

Austin

J. K.

(2012). Comparing methods of determining insertion length for placing gastric tubes in children 1 month to 17 years of age. Journal for Specialists in Pediatric Nursing, 17(1), 19–32. https://doi.org/10.1111/j.1744-6155.2011.00302.x

10.

Elsayed, I. F., Reyad, A. R., Mahmoud, M. M., Abdelrahman, H. A., & Kandeel, N. A. (2021). The effect of nasogastric tube feeding educational interventions on critical care nurses' knowledge and performance. Mansoura Nursing Journal, 8(3), 11–26. https://doi.org/10.21608/mnj.2021.213155

11.

Fan

E. M. P.

Tan

S. B.

Ang

S. Y.

(2017). Nasogastric tube placement confirmation: Where we are and where we should be heading. Proceedings of Singapore Healthcare, 26(3), 189–195. https://doi.org/10.1177/2010105817705141

12.

Greer

F. R.

(2001). Feeding the premature infant in the 20th century. The Journal of Nutrition, 131(2), 426S–430S. https://doi.org/10.1093/jn/131.2.426S

13.

Hussien

A. A.

Sayed

E. H.

(2021). Effect of training program on nurses’ knowledge and practice about total parenteral nutrition of critically ill child. Assiut Scientific Nursing Journal, 9(27), 199–209. https://doi.org/10.21608/asnj.2022.132600.1356

14.

Irving

S. Y.

Rempel

Lyman

Sevilla

W. M. A.

Guenter

(2018). Enteral nutrition practices in critically ill children: A national survey of pediatric intensive care physicians. Journal of Parenteral and Enteral Nutrition, 42(3), 515–523. https://doi.org/10.1002/jpen.1009

15.

Jabbar

H. A.

Hattab

K. M.

(2022). Effectiveness of the interventional program on nurses’ practices about enteral feeding tube for premature neonates in the neonatal intensive care unit. Pakistan Journal of Medical & Health Sciences, 16(5), 544–549. https://doi.org/10.53350/pjmhs22165544

16.

Jeesh

Y. A. A.

Khalid

E. F. E. M.

Elbashier

I. M. A.

(2021). The effect of an educational program on nurses’ practices regarding the implementation of patient care and safety measures during nasogastric tube feeding in the critical care units in Syria. European Scientific Journal, 17(29), 59.

17.

Kaltenmeier

Littleton

Carozza

Kosko

Althans

Lawrence

Hamad

(2022). Efficacy of a nasogastric tube educational intervention for nursing staff. The American Surgeon, 88(1), 93–97. https://doi.org/10.1177/0003134820976080

18.

Márquez

G. G.

Serrano

A. M.

Juárez

M. G.

Garcia Lozano

Mayordomo Casado

Torrijos Rodriguez

M. I.

Verges Pernia

Fernandez Morales

Sanchez

Medina Duran

Miguez Navarro

M. C.

(2018). Effectiveness of an educational intervention to improve nurses’ knowledge on pediatric nasogastric intubation. Archivos Argentinos de Pediatría, 116(6), 402–408. https://doi.org/10.5546/aap.2018.eng.e402

19.

Mohamed

A. E.

Mohamed

A. R.

Tantawi

R. H.

(2021). Assessment of nursing performance toward enteral feeding at pediatric critical care units. Egyptian Journal of Healthcare, 12(4), 1159–1178. https://doi.org/10.21608/ejhc.2021.206587

20.

Mohammed

A. A.

Abdel Fattah

S. A.

Mahmoud

M. A. E.-F.

(2018). The effect of educational program on nurses’ knowledge and practices about nasogastric tube feeding at neonatal intensive care units. Journal of Nursing Education and Practice, 8(8), 21–27. https://doi.org/10.5430/jnep.v8n8p21

21.

Mohammed

A. F.

Hamed

M. M.

Mahmoud

A. E.

(2021). Effect of implementing nursing guidelines on nurses’ performance regarding complications of nasogastric tube among critically ill patients. Journal of Nursing Science Benha University, 2(2), 586–600. https://doi.org/10.21608/jnsbu.2021.194609

22.

Motta

A. P. G.

Rigobello

M. C. G.

Silveira

R. C. C. P.

Gimenes

F. R. E.

(2021). Nasogastric/nasoenteric tube-related adverse events: An integrative review. Revista Latino-Americana de Enfermagem, 29, e3400. https://doi.org/10.1590/1518-8345.3355.3400

23.

Northington

Kemper

Rempel

Lyman

Pauley

Visscher

Moore

Guenter

(2022). Evaluation of methods used to verify nasogastric feeding tube placement in hospitalized infants and children: A follow-up study. Journal of Pediatric Nursing, 63, 72–77. https://doi.org/10.1016/j.pedn.2021.10.018

24.

Perry

S. E.

Hockenberry

M. J.

Cashion

M. C.

Alden

K. R.

Olshansky

Lowdermilk

D. L.

(2022). Maternal child nursing care (E-book). Elsevier Health Sciences.

25.

Powers

Brown

Lyman

Escuro

A. A.

Linford

Gorsuch

Mogensen

K. M.

Engelbrecht

Chaney

McGinnis

Quatrara

B. A.

Leonard

Guenter

(2021). Development of a competency model for placement and verification of nasogastric and nasoenteric feeding tubes for adult hospitalized patients. Nutrition in Clinical Practice, 36(3), 517–533. https://doi.org/10.1002/ncp.10671

26.

Preiser

J. C.

Van Zanten

A. R.

Berger

M. M.

Biolo

Casaer

M. P.

Doig

G. S.

Griffiths

R. D.

Heyland

D. K.

Hiesmayr

Iapichino

Laviano

Pichard

Singer

Van den Berghe

Wernerman

Wischmeyer

Vincent

J.-L.

(2015). Metabolic and nutritional support of critically ill patients: Consensus and controversies. Critical Care, 19(1), 35. https://doi.org/10.1186/s13054-015-0737-8

27.

Rosner

(2011). Fundamentals of biostatistics (7th ed.). Brooks/Cole.

28.

Singer

Berger

M. M.

Van den Berghe

Biolo

Calder

Forbes

Griffiths

Kreyman

Leverve

Pichard

(2011). ESPEN Guidelines on parenteral nutrition: Neonatal intensive care. Clinical Nutrition, 28, 387–400. https://doi.org/10.1016/j.clnu.2009.04.024

29.

Zeb

Karim

Idrees

Bibi

Rehman

Ali

(2022). Pamphlet as a teaching tool for improving nurses’ knowledge regarding nasogastric tube feeding. Journal of Farkhanda Institute of Nursing and Public Health, 2(1), 21–25. https://doi.org/10.37762/jfinph.30

A Quasi-Experimental Study on the Impact of a Nasogastric Tube Placement Educational Program on Pediatric Nurses’ Knowledge and Practices

Abstract

Background

Objective

Methods

Results

Conclusion

Keywords

Introduction

Review of Literature

The Importance of NGT Feeding in Pediatric Care

Challenges in NGT Placement and Verification Techniques

The Role of Education in Enhancing NGT Competency

University Education and Its Role in NGT Training

Advanced Practice Nurses and Clinical Nurse Specialists in NGT Management

Identified Gaps and Rationale for This Study

Methods

Design

Data Collection

Sample

Data Collection Tool

Statistical Analysis

Results

Discussion

Strengths and Limitations

Implications for Practice

Conclusion

Footnotes

Acknowledgements

ORCID iD

Ethical Considerations

Author Contributions

Funding

Declaration of Conflicting Interests

Recommendations

Appendix (I): STROBE Checklist for Reporting Observational Studies

Appendix (II): Training Program Flowchart for Nasogastric Tube Placement Educational Program

References