Enteral feeding tube guidelines not followed in residential settings

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Feeding problems are very common amongst people with learning difficulties. This can be due to problems with motor co-ordination, muscle tone and an increased risk of choking. Many individuals require an enteral feeding tube (EFT) in order to consume food or take medication.

Before being administered via the tube, medications need to be crushed. However, not all medications are suitable for crushing. In some cases this can lead to increased toxicity, which can irritate the stomach lining. Other difficulties include the tube becoming blocked, the mixing of multiple medications or the mixing of medications with nutrients found in foods.

To reduce these risks, guidelines on how to administer medication through an EFT have been produced. However, there is very little research into whether these guidelines are followed in residential care settings.

The current study by Joos and colleagues (2015) aimed to see if their actions of support staff were in line with the guidelines.

Little research has looked at whether guidelines on administration of medication through enteral feeding tubes are followed in residential care settings

Little research has looked at whether guidelines on administration of medication through enteral feeding tubes are followed in residential care settings


Two observers watched members of staff in six residential care settings. The observers attended each residential setting on two separate days and accompanied staff on all of the medication rounds.

Observers wrote down exactly what the staff did and compared this against international guidelines.

The authors note that guidelines did not provide a definitive guide on how to administer medications via an EFT. The authors consulted several pieces of guidance. Although had some similarities in the advice they gave, there were many inconsistencies between each source of guidance.


The observers witnessed a total of 268 occasions in which medications were administered via an EFT. In total, 862 medications were given to 48 residents, ranging from 1 to 14 medications per resident, per medication visit.

There were several deviations in the way in which medication was prepared. The most common deviation was the mixing together of multiple medications. This happened in around two thirds of cases.

Other deviations included not diluting liquid medications with the correct amount of water and not shaking emulsions before use. In addition, different members of staff used different methods for crushing tablets (e.g. pestle and mortar, two metal cups) and in around 17% of cases staff did not clean the devices used to crush medications when preparing medications for different residents. This poses a serious risk of cross-contamination.

There were also deviations in the way that medications were administered. This included not flushing the EFT with at least 15ml of water before use, not using an appropriate sized syringe, not elevating the residents’ backrest and not rinsing the residents’ medication cup.


The results of the study suggest that support staff demonstrated low levels of adherence to international guidelines on using an EFT to administer medications. In addition, the authors found a great degree of variability in the way in which staff were working, both between different settings and within the same setting.

This observational study found low levels of adherence to guidelines on using enteral feeding tubes to to administer medications

This observational study found low levels of adherence to guidelines on using enteral feeding tubes to to administer medications

Strengths and limitations

The current study by Joos and colleagues has been much needed and makes an important first step into a more rigorous assessment of the way that care is delivered in a residential setting. The authors note that prior to their study, there had been few studies of this kind.

The research was carried out in Belgium. Although this raises questions about the study’s applicability to residential settings based in the UK, it is important to think about the way in which this study can be used to inform the working practices of support staff in our own country.

In addition, the observations were carried out on weekdays between the hours of 9am and 6pm. At weekends and in the evenings, many residential settings reported that they had less staff. Therefore it is not clear if different levels of deviations would be found during these time periods.


The study suggests that support staff in Belgian residential care settings were not following international guidelines as well as they should be. However, it is important to note that the reasons for this were not examined in the current study and that future research will look into this in more detail.

The authors note that the guidelines that are available are unclear to begin with. Therefore future work could look into ways to make the guidelines clearer and more user-friendly.

As a researcher I have worked within research teams and on research projects that look at the way that research evidence is used to inform the work of healthcare professionals. However, most of this work appears to focus on NHS settings such as GP practices and hospitals. Further work focussing on other settings, such as residential care settings, is required.

In my experience as a support worker, it always strikes me that we have a very well-meaning work force that have joined the care sector with good intentions of supporting others. However, without a clearer focus on the way in which guidelines and research evidence are used in practice, it may remain the case that residential settings do not have the capacity to make use of the guidelines, information and other tools that are available to them.

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Further research is needed to look at ways to support the staff in residential settings to make use of research evidence and guidelines


Primary paper

Joos, E., Mehuys, E., Van Bocxlaer, J., Remon, J.P., Van Winckel, M., & Boussery, K., (2015). Drug administration via enteral feeding tubes in residential care facilities for individuals with intellectual disability: an observational study, Journal of Intellectual Disability Research, 59(3), 215-225 [abstract]

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Fawn Harrad

Fawn has a background in both healthcare research and front-line health and social care roles. After graduating with a BSc Psychology with Sociology degree, Fawn spent 3 years working at the University of Leicester. Based in the Department of Health Sciences, Fawn provided support to a number of research studies and evaluation projects that sought to improve local healthcare services. During this time Fawn also worked on a part-time basis as a Support Worker for adults with learning disabilities and as a Mental Health Recovery Worker. Fawn then spent 18 months working on an NHS inpatient assessment and treatment ward for people living with dementia, before returning to academic to complete a PhD. Fawn's PhD is focussed on occasions where care home residents are transferred to hospital. Alongside her PhD, Fawn is supporting other care home related research projects through her employment with the Clinical Research Network West Midlands. Here, Fawn is based in the ENRICH team (Enabling Research in Care Homes) that aims to increase the amount of research delivered in care homes.

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