This quasi-experimental study was carried out with experimental and control groups by observing 240 cases of executing drug and food orders. The sample consisted of 60 nurses (30 in each group) in Ilam, Iran. This study was conducted from April 2015 to October 2015. The behaviour of each nurse in provision of food and drugs through NGT was observed four times (two times before intervention and two times after intervention) and during different shifts (morning, afternoon, and evening). The inclusion criterion was having a bachelor’s or master’s degree, and exclusion criteria were having experience in pharmaceutical and nutrition executive management training courses through NGT in the last six months and desire to withdraw from the study.

Data gathering tools consisted of a questionnaire related to demographic characteristics of participants including age, gender, work shift, employment status, and a second part consisted of the NGT checklist [Appendix-1]. The checklist consisted of 18 questions, and each question was given a score based on responses of Yes (one) or No (zero); the maximum score was 18, and the minimum was zero.

For evaluation, the performance of nurses was divided into three categories: excellent (13-18), medium (7-12), and weak (0-6). These items measure the process of medication and food administration by nurses from beginning to end. This checklist was created by the researchers and prepared using library information such as reference books and checklists related to nursing services of the Nursing Organisation of Iran. The content validity of the checklist was determined using opinions of 10 nursing professors with the Content Validity Index (CVI 0.98), and its reliability was determined using test-retest among 10 nurses by observing their drug provision process (r=0.94). These 10 nurses were included in the other 60 nurses.

The researchers observed the performance of nurses in all shifts (morning, afternoon, and evening) during the week. Before observations, it was explained to the nurses that their performance would be analysed in total and that the researchers would avoid disclosing their names, wards, or hospitals. Observing the performance of a nurse required 10 to 60 minutes depending on the type of drug, food, and intended ward. The researchers would only record any mistake made by nurses in feeding tube method, and no intervention was carried out at the time of feeding through NGT. Before intervention sessions, researchers attempted to reduce the sensitivity of nurses to their presence by being present in the ward in the preceding days.

Nurses were divided into experimental and control groups after observations. Then, the experimental group was divided into three small groups containing 10 individuals, and training was provided in 4 sessions for each group in a total of 12 sessions; the sessions were held weekly. The control group did not receive any training. Training sessions lasted between half an hour and one hour. During the session, the nurses presented their beliefs and experiences while listening to and thinking about the subject. A researcher played the role of team leader while providing the training and presented his opinions. Contents were summarised at the end of each session, and the title of the next session was determined. Training about recognition of a variety of pharmaceutical forms, preparation of drugs for gavage, washing feeding tubes in case of necessity, and common interactions between foods and medicine were provided in the training sessions [14].

The checklist was completed again by researchers through observation after one month, and the behaviour of each nurse in provision of food and drugs through the NGT was observed twice by two researchers.

Data were analysed using SPSS version 21.0 and descriptive (mean and standard deviation) and analytical (independent t-test) statistical tests.

Data were subjected to statistical analysis using mean, standard error and Student t-test etc., p-value <0.05 was accepted as significant.

The behaviour of 60 nurses in two groups: control (n=30) and experiment (n=30) were observed a total of 240 times (120 times before intervention and 120 times after). Findings showed that there was no statistically significant difference between demographic characteristics of experimental and control groups [Table/Fig-1].

According to the checklist scoring, nurses’ performance scores were considered excellent (13-18), medium (7-12), and weak (0-6). The [Table/Fig-2] shows, scores of nurses’ performance in experimental (10.05±1.47) and control (10.60±1.35) groups were medium before intervention. After intervention, scores of nurse’s performance in the control group (10.71±1.20) remained medium, but they reached the excellent level in the experimental group (13.40±1.94). There was no statistically significant difference between performance scores of experimental and control groups before intervention (p=0.86), but those of the experimental group significantly increased after the intervention (p=0.01).

The findings of this study showed that performance scores of nurses in the field of nutrition through NGT was at a medium level. The reasons for this can be lack of involvement of pharmacists in clinical rounds [19,20], inadequate knowledge of nurses in the field of nutrition using NGTs [3], workload of nurses, high rate of patients under care [21,22], lack of interaction and collaboration between physicians and nurses [14].

In both control and experimental groups, nurses’ performance was moderate. Poor knowledge, need for retraining, or weak skills can affect nurses’ performance. A study by Marshall AP and West SH, revealed that nurses play a major role in appropriate management of NGT, but there were different nursing skills, and knowledge was insufficient in relation to the type of feeding [12]. In a study by Zhu LL et al., 60% of the nurses did not have enough knowledge about dosage forms; 30% did not have enough knowledge about the possibility of crushing or opening the drugs, and 80% got all prescription drugs to patients via NGT at the same time with the same syringe [13]. Hazrati-Marangloo A et al., showed that nurses’ knowledge about nasogastric feeding was poor and that most nurses did not have appropriate performance [14]. Dashti-Khavidaki S et al., showed that more than 50% of the nurses did not have enough knowledge about oral dosage forms and implementation of drug orders regarding feeding tubes [7].

In the present study, training intervention improved the performance of nurses in the experimental group from moderate to excellent, this result is consistent with those of previous studies. In the study of Hazrati-Marangloo A et al., knowledge and performance of the intervention group changed optimally after education so that 97.1% of the nurses were promoted to a good level [14]. The study of Van den Bemt P et al., examined the impact of a multidisciplinary program on reducing errors in medication orders by using NGT. Educational intervention included setting up a database for oral dosage forms, the precise job training for nurses, day visit by pharmacy technician, and labelling drugs with a "Don’t crush" image. The results of this study showed that the educational program led to a significant reduction in tube feeding obstruction, and medication errors as reported by each nurse [6]. In the study by Dashti-Khavidaki S et al., implementing an educational program increased nurse’s knowledge about food and drug orders and interactions [7].

Results of the present study indicated that the training intervention improved nursing performance but cannot resolve all errors in medication orders for food and drugs. In the study by Hazrati-Marangloo A et al., some checklist items did not change before and after the training program. One of the causes that can be mentioned is the prescription of solid drugs in medical orders. Nurses are not involved with the prescription of drugs; it is the primary responsibility of the physician [14].

The sample size was small and recruited from a hospital in a small city; hence, the findings could not be generalised to all treatment centers.

Training intervention could improve nurses’ performance regarding NGT feeding. Thus, it can be appropriate and useful in improving the quality of care for the patients. It is recommended to consider training interventions as effective, convenient, and cheap in all nursing care.