Ticn article

Top Clin Nutr
Vol. 26, No. 4, pp. 335–345
Copyright c 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

DIETETIC PRACTICE PROJECTS
Medical Residents and
Nutrition Support in
Critical Care
A Survey of Knowledge, Attitudes,
and Practice
Sandi Westfal, MS, RD, CNSC, CDN;
Jerrilynn D. Burrowes, PhD, RD, CDN;
Barbara Shorter, EdD, RD, CDN;
Josephine Wright, MS, RD, CDN

This study surveyed medical residents about their perceived attitudes, knowledge, and practice in
the delivery of enteral nutrition (EN) in the critical care setting. An e-mail survey was sent to 693
medical residents; 56 completed the survey for a response rate of 8.7%. Descriptive statistics were
used to compare survey responses. Medical residents reported inadequacies in their knowledge of
EN despite the fact that 98% agreed that nutrition support in critical care is important. Data analysis
also revealed discrepancies between attitude, knowledge, and practice in prescribing EN therapy
in the critical care setting. In addition, almost all residents (95%) agreed that a standardized EN
feeding protocol should be used. Key words: critical care, enteral nutrition, medical residents,
nutrition attitudes, nutrition knowledge

T REATMENT of critically ill patients in the
intensive care unit (ICU) is multifaceted
and requires extensive education and train-
not placed on the prescription and delivery
of enteral nutrition (EN) demonstrated by a
survey conducted by the National Academy
ing. Nutrition is an integral component of this of Sciences, which found that an average of
treatment; however, it is often overlooked.1 21 hours of nutrition education was required
Medical residents and physicians are trained in medical schools.1 This number is less than
and educated to prescribe medication prop- the National Academy of Sciences minimum
erly. However, the same degree of training is recommendation of 25 hours. In addition, the
researchers found that the number of hours
dedicated to nutrition decreased considerably
Author Affiliations: Lutheran Medical Center, from 18.9 hours (SD = 1.2) in the first and sec-
Brooklyn, NY (Ms Westfal); and Department of ond years of medical school to 5.1 hours (SD =
Nutrition, C.W. Post Campus of Long Island 0.7) during the third and fourth years, which
University, Brookville, NY (Mss Westfal and Wright,
Drs Burrowes, and Shorter). generally are considered the clinical years of
education.1
The authors have disclosed that they have no signif-
icant relationships with, or financial interest in, any Determining the diet prescription for EN is
commercial companies pertaining to this article. complex, and several factors need to be con-
Correspondence: Sandi Westfal, MS, RD, CNSC, CDN, sidered such as timing of initiation (early feed-
Lutheran Medical Center, 150 55th St, Brooklyn, NY ing within 24-48 hours); formula selection;
11210 (swestfal@lmcmc.com). the patient’s nutrient needs, nutritional status,
DOI: 10.1097/TIN.0b013e318237932f and disease state; and assessment of gastric

335

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

336 TOPICS IN CLINICAL NUTRITION/OCTOBER–DECEMBER 2011

residuals and feeding intolerances. Medical MATERIALS AND METHODS
residents and physicians admit to being un-
Participants
dereducated and inadequately trained in EN,
and they do not feel confident in their knowl- Participants who were enrolled in a med-
edge of nutrition in critically ill patients.1-4 ical residency program either as a doctor of
Patients may not receive their estimated medicine (MD) or a doctor of osteopathy (DO)
caloric and nutrient needs in most ICUs. in the New York tristate area during the study
Underfeeding is frequently the outcome of period were included. They were required
delayed initiation of feedings, prolonged ad- to be at least 18 years of age or older. An
vancement of rates to meet feeding goals, and Internet search of major hospitals in the tris-
underprescription of the enteral formulas.5-8 tate area was conducted. Medical resident pro-
Some of the consequences of underfeeding gram directors or resident program coordina-
a critically ill patient are weight loss, muscle tors whose contact information was available,
wasting, malnutrition, increased risk and inci- including an e-mail address, were contacted
dence of infection, increased length of stay, to request the e-mail addresses of residents
respiratory distress, and increased morbidity enrolled in their program. If e-mail addresses
and mortality.7,9 could not be provided, the directors or coor-
The difficulty in overcoming inadequate dinators were asked to forward the survey to
feeding in the ICU has led to the development their medical residents.
and implementation of standardized protocols
Project design
and nutrition support teams (NSTs).10-14 Stan-
dardization allows for less decision making The design was cross sectional, using a
through the use of guidelines and/or flow Web-based survey. The medical residents re-
charts. The NSTs assist in determining the ceived an e-mail with an electronic informed
EN prescription, as well as providing oppor- consent form. By clicking on “agree,” the
tunities for education during team rounds, resident gave consent to participate and
where feeding protocols may be discussed.14 was linked to the survey conducted on
These protocols also provide improved clin- SurveyMonkey.com.15 The e-mail was either
ical outcomes in patients. Studies that have sent to the medical residents directly from
compared the provision of EN in patients the primary author or was forwarded to them
before and after the implementation of pro- from their director or coordinator with a time
tocols have shown increased caloric intake, frame of 2 weeks to complete the survey. One
decreased days of mechanical ventilation, week after the initial e-mail was sent, another
earlier initiation of EN, and decreased inci- survey was sent to the medical residents in an
dence of feedings being held for increased attempt to increase the response rate. Institu-
residuals.5,10,11 tional review board approvals were obtained
The question is whether medical residents from the C. W. Post Campus of Long Island
are properly educated and trained about the University and Lutheran Medical Center.
EN prescription. Therefore, the purpose of
this project was to evaluate medical residents’ Instruments for obtaining data
perceived attitudes, knowledge, and practices A 21-item survey was developed after a
in the delivery of EN in the critical care setting review of prior studies in EN that included
and to assess the factors used to determine surveys to physicians, medical residents, and
the EN prescription. This project sought to dietitians.16,17 The authors of these original
ascertain whether medical residents are con- articles were contacted via e-mail to obtain
fident in their knowledge about EN, what fac- permission to use all or some of the ques-
tors they consider when prescribing EN, and tions from their survey. Eight questions were
whether they are in favor of adopting feeding modified with permission. The remaining
protocols. 13 questions were developed by the primary


Medical Residents and Nutrition Support 337

author. The survey was sent to 12 registered contacted; 7 responded and agreed to par-
dietitians (RDs) and 12 medical residents and ticipate in the study, which resulted in an
physicians who worked in critical care to es- additional 395 surveys sent to medical resi-
tablish face and content validity. The survey dents. In total, 11 medical resident directors
was revised based on the recommendations and program coordinators participated in the
that were received. study (Table 1). Nine directors and coordi-
The survey consisted of 2 parts. Part I was nators forwarded the survey to their medical
a 21-item survey that used a 5-point Likert residents. The survey was sent directly to the
scale with a range of scores from 5 (strongly remaining 2 groups of residents via e-mail by
agree) to 1 (strongly disagree) to determine the primary author. In total, the survey was
perceived knowledge, attitudes, and practices sent to 643 medical residents; 56 residents
about EN in the critical care setting and to completed the survey for a response rate
assess the factors used to determine the EN of 8.7%.
prescription. The 21 items covered the 3 ar- The demographic characteristics of the re-
eas of interest: 5 questions related to attitudes; spondents are shown in Table 2. A majority
5 questions about knowledge; and the remain- of the respondents are in their ﬁrst or second
ing 11 focused on practice. Part II included year of residency (82%). Most (81.5%) hold a
demographic questions such as age, gender, doctor of medicine degree and practice inter-
year of residency, medical degree, area of nal medicine (61%).
specialty, and additional training in nutrition.
Descriptive statistics were used to compare Perceived attitudes about
survey responses. enteral nutrition
The survey responses about perceived atti-
RESULTS tudes of EN are presented in Table 3. Of the 56
respondents, 98% agreed or strongly agreed
Initially, 14 directors were contacted and that “nutrition is important in the treatment
4 hospitals agreed to participate in the study. of critically ill patients.” Most respondents
The survey was sent to a total of 248 med- also disagreed with the statement “early nu-
ical residents enrolled in the residency pro- trition support does not impact the outcome
grams. The same process was repeated, with of patient care.” In comparison, 52% agreed or
an additional 49 directors and coordinators strongly agreed that “other aspects of critical

Table 1. Participating Hospitals Where Medical Residents Were Surveyed
Number of
Residents Enrolled Number of Number of
Hospital in Program Beds Critical Care Beds

Lutheran Medical Center (NY) 115 476 22
St John’s Episcopal Hospital (NY) 68 257 16
Greenwich Hospital (CT) 22 174 10
Stony Brook University Hospital (NY) 21 571 50
Lenox Hill Hospital (NY) 95 652 12
Monteﬁore Medical Center (NY) 157 396 23
Mountainside Hospital (NJ) 25 365 16
Hoboken University Medical Center (NJ) 26 328 5
Bridgeport Hospital (CT) 44 425 38
Danbury Hospital (CT) 28 371 20
St Francis Hospital and Medical Center (CT) 20 617 39

NY, New York; NJ, New Jersey; CT, Connecticut.



Table 2. Summary of Demographic Data of Perceived knowledge about
Medical Residents (n = 56) enteral nutrition
The survey responses about perceived
Characteristic n (%) knowledge of EN are presented in Table 4.
Gendera Only 4 of the 56 respondents reported that
Male 33 (62.3) they had specialized training in nutrition sup-
Female 20 (37.7) port (Table 2). Slightly more than half of the
Year of residencyb respondents agreed or strongly agreed that
Year 1 26 (47.3) “they can function to their full potential in
Year 2 19 (34.5) regards to nutrition therapy (57%).” Of the re-
Year 3 8 (14.5) maining respondents (n = 24), 10 disagreed
Year 4 2 (3.6) that they are capable of functioning to their
>Year 4 0 (0)
full potential in providing nutrition therapy
Age, yc
and only 20% agreed that they are familiar
18–20 0 (0)
21–25 5 (9.0) with their hospital formulary. Less than half
26–30 28 (50.9) agreed that they “know how to progress the
31–35 12 (21.8) rate of feeding to goal rate” and “know how to
Medical degreed calculate the calories, protein and ﬂuid the pa-
Doctor of medicine 44 (81.5) tient receives from an EN prescription.” Most
Doctor of osteopathy 10 (18.5) residents indicated that they “would like fur-
Area of specialty ther training in EN.”
Family practice 14 (25.0)
Internal medicine 34 (60.7)
Obstetrics-gynecology 0 (0) Practices in enteral nutrition therapy
Surgery 5 (8.9) Table 5 presents the survey responses
Emergency medicine 0 (0) about practices in EN therapy. When the
Gastroenterology 0 (0) residents were asked about EN versus
Cardiology 0 (0)
parenteral nutrition (PN), most respondents
Othere 3 (5.4)
(79%) agreed or strongly agreed that “PN
Specialized training in
nutrition supportf should not be used routinely in patients
Yes 4 (7.3) with an intact GI tract” and 84% also
No 51 (92.7) agreed that, “EN should be used in pref-
erence to PN.” In practice, 69% agreed or
a Three survey responses did not indicate gender (n = 53). strongly agreed that “EN should be initiated
b One survey response did not indicate year of residency
within the ﬁrst 24 to 48 hours of admis-
(n = 55). sion.” The majority of residents (91%) agreed
c One survey response did not indicate age (n = 55).
d Two survey responses did not indicate medical degree or strongly agreed with the statement that
(n = 54). they take patient characteristics into con-
e Other: 2 responses did not specify, 1 neurology. sideration when prescribing EN. Eighty-six
f One survey response did not indicate specialized training
percent took formula characteristics into con-
(n = 55). sideration, with 73% stating that they dis-
agreed or strongly disagreed that they “use the
care take priority over nutrition therapy.” The same infusion rate regardless of the EN for-
majority disagreed or strongly disagreed that mula.” Only 66% reported that they “would
“the formula prescribed does not affect pa- change a formula based on current labora-
tient outcome.” Only 1 respondent disagreed tory values.” To determine the infusion rate,
that “a feeding protocol should be utilized in 73% agreed or strongly agreed that they “con-
the delivery of EN”; most strongly agreed or sider calorie and protein needs” and 76% dis-
agreed with this statement (Table 3). agreed or strongly disagreed that they “use



Table 3. Summary of Responses to Survey Questions Pertaining to Medical Residents’
Perceived Attitudes About Enteral Nutritiona

Strongly Neither Agree Strongly
Agree or Disagree Disagree
Question n (%) Agree n (%) n (%) Disagree n (%) n (%)

I believe nutrition 47 (83.9) 8 (14.3) 0 (0.0) 0 (0.0) 1 (1.8)
therapy is important
in critically ill patients
I think that other aspects 9 (16.1) 20 (35.7) 19 (33.9) 7 (12.5) 1 (1.8)
of patient care take
priority over nutrition
Early nutrition support 1 (1.8) 1 (1.8) 7 (12.5) 26 (46.4) 21 (37.5)
does not impact the
outcome of the
patient
The enteral nutrition 1 (1.8) 1 (1.8) 11 (20.0) 31 (56.4) 11 (20.0)
formula prescribed
does not affect the
outcome of the
patientb
An evidence-based 25 (45.5) 27 (49.1) 2 (3.6) 1 (1.8) 0 (0.0)
feeding protocol
should be considered
as a strategy to
optimize delivery of
enteral nutritionb

a Highest frequencies are in boldface.
b Responses = 55. One respondent did not answer the question.

the same rate for all patients.” Eighty-six per- results of other similar studies. Cahill et al16
cent of medical residents agreed or strongly surveyed 514 MDs and RDs to evaluate their
agreed that they “take the RD and nutrition attitudes about nutrition and the Canadian
support recommendations into consideration Critical Care Nutrition Clinical Practice Guide-
when prescribing EN.” lines. The researchers found that the majority
(91%) of those surveyed considered nutrition
DISCUSSION therapy to be very important for critically ill
patients. In another study, Behara et al2 re-
Nutrition is an important part of treat- ported that medical residents thought that nu-
ment in managing critically ill patients. The trition was important in the outcome of ICU
attitudes and beliefs of the critical care team patients, with a mean rating of 4.72 (on a
may inﬂuence the outcome of these patients. scale of 1 [not important] to 5 [very impor-
This study surveyed medical residents about tant]), which is similar to the mean score of
their perceived attitudes, knowledge, and 4.79 found in our study. Similarly, Goiburu-
practice in the delivery of EN in the criti- Bianco et al18 stated that 98% of the 60 medical
cal care setting. A group of medical residents residents and physicians who were surveyed
in the New York tristate area was surveyed; thought nutrition support were important in
98% of the medical residents agreed that nutri- critical care and had an impact on patient out-
tion is important, which is consistent with the come.



Perceived Knowledge About Enteral Nutritiona

Neither
Strongly Agree or Strongly
Agree Agree Disagree Disagree Disagree
Question n (%) n (%) n (%) n (%) n (%)

As it pertains to the 4 (7.1) 28 (50.0) 14 (25.0) 8 (14.3) 2 (3.6)
provision of nutrition
therapy, I am able to
function to my full
potential, based on my
knowledge level, skill,
competencies and scope
of practice
I would like further training 20 (35.7) 32 (57.1) 3 (5.4) 1 (1.8) 0 (0.0)
in prescribing enteral
nutrition
I am familiar with all of the 2 (3.6) 9 (16.4) 13 (23.6) 23 (41.8) 8 (14.5)
formulas used for enteral
nutrition on the hospital
formularyb
I know how to progress the 3 (5.5) 22 (40.0) 11 (20.0) 18 (32.7) 1 (1.8)
rate of feeding to goal
rateb
I know how to calculate the 3 (5.5) 20 (36.4) 10 (18.2) 20 (36.4) 1 (3.6)
calories, protein and fluid
the patient is receiving
from an enteral nutrition
prescriptionb

a Highest
frequencies are in boldface.
*Responses = 55. One respondent did not answer the question.

Despite their overwhelming statement of The majority (84%) of medical resident re-
the importance of nutrition, medical residents spondents thought that EN should be used
in this project did not perceive their nutrition in preference to PN. Behara et al2 reported
knowledge to be adequate, with more than similar findings, with 94% of the medical res-
half (57%) stating that they could provide nu- idents stating that EN is preferred over PN.
trition support at their full potential (refer- However, despite medical residents reporting
ring to their lack of knowledge in EN). In their preference for EN, only 79% agreed that
addition, almost all (93%) agreed that they PN should not be used in a patient with an in-
would like further training in nutrition, indi- tact gastrointestinal tract. This finding reflects
cating that they do not think their knowledge a similar outcome in a previous study, where
is sufficient. These findings reinforce previous 35% of physicians stated that they would pre-
surveys where medical residents, physicians, scribe PN, although no signs of gastrointesti-
and even gastroenterology fellows rated their nal dysfunction were present.20
understanding of nutrition support as insuffi- An additional discordance between at-
cient or average.2,18,19 titude and practice pertains to the early



Practices in Enteral Nutrition Therapya

Neither
Strongly Agree or Strongly
Agree Agree Disagree Disagree Disagree
Question n (%) n (%) n (%) n (%) n (%)

Parenteral nutrition should not be 27 (48.2) 17 (30.4) 6 (10.7) 5 (8.9) 1 (1.8)
used routinely in patients with
an intact gastrointestinal tract
Enteral nutrition should be used 36 (64.3) 11 (19.6) 9 (16.1) 0 (0.0) 0 (0.0)
in preference to parenteral
nutrition
Enteral nutrition should be 24 (43.6) 14 (25.5) 14 (25.5) 3 (5.5) 0 (0.0)
initiated early (24-48 hours
following admission to the
ICU)b
When determining target rate of 1 (1.8) 3 (5.4) 11 (19.6) 34 (60.7) 7 (12.5)
infusion, I use the same rate
regardless of the enteral formula
I consider patient characteristics 17 (30.9) 33 (60.0) 5 (9.1) 0 (0.0) 0 (0.0)
when choosing an enteral
nutrition formula (eg, nutrient
needs, digestive and absorptive
capacity of GI tract, and disease
state)b
I consider product characteristics 16 (29.1) 31 (56.4) 8 (14.5) 0 (0.0) 0 (0.0)
when choosing an enteral
nutrition formula (eg, form of
protein, fat content,
carbohydrate content)b
When determining rate of 1 (1.8) 4 (7.3) 8 (14.5) 29 (52.7) 13 (23.6)
infusion, I use the same rate for
all patientsb
When determining rate of 7 (12.7) 33 (60.0) 10 (18.2) 5 (9.1) 0 (0.0)
infusion, I take calorie and
protein goals into
considerationb
When prescribing enteral 33 (60.0) 20 (36.4) 1 (1.8) 0 (0.0) 1 (1.8)
nutrition, I consider the
recommendation of a registered
dietitian or the nutrition
support teamb
I will change an enteral nutrition 5 (9.1) 31 (56.4) 18 (32.7) 1 (1.8) 0 (0.0)
formula based on current
laboratory valuesb
I will always hold feedings when a 16 (29.6) 29 (53.7) 8 (14.8) 1 (1.9) 0 (0.0)
patient shows intolerances (eg,
emesis, high residuals)c

a Highestfrequencies are in boldface.
b Responses = 55. One survey respondent did not answer question.
c Responses = 54. Two survey respondents did not answer question.



initiation of EN. Although 84% of the medi- estimated nutrient needs. Although permis-
cal residents thought that early initiation of sive underfeeding is practiced with obese pa-
EN affects patient outcome, only 69% agreed tients, it is not recommended for critically
that EN should be initiated within the first 24 ill patients who are of normal weight or
to 48 hours after admission (despite evidence- malnourished.9
based guidelines stating that EN should be ini- Several studies have found that the EN pre-
tiated within this time frame).9 Initiation of scription provides an inadequate amount of
early EN in practice was not common with energy, ranging from 50% to 78% of the pa-
several studies reporting mean times of initia- tients’ needs.6-8,10,22 In addition to not meet-
tion ranging from about 40 to 76 hours after ing caloric needs, McClave et al7 also found
admission.6,8,21 Behara et al2 found that med- that only 14% of the patients reached their
ical residents reported waiting an average of goal infusion rate within 3 days, and Chapman
2.63 days before evaluating a patient’s nutri- et al5 found a mean of 6.8 days until patients
tional status in the ICU. met their goal rate. In this study, less than
Despite 76% of medical residents agreeing half (42%) of the medical residents agreed that
that formula selection impacts the outcome they knew how to calculate calories, protein,
of patient care, almost 80% stated that they and fluid delivered in an EN prescription. Only
were not familiar with their hospitals’ formu- 45% reported that they knew how to progress
lary. Most of the medical residents consid- the rate of infusion. Although no studies were
ered patient characteristics (91%) and formula found that evaluated perceived knowledge of
characteristics (86%) when determining the these aspects of the EN prescription, previ-
EN prescription. However, only 66% would ous studies have assessed actual knowledge
change the formula based on current labo- through nutrition examinations that resulted
ratory values. Therefore, it may be surmised in average test scores ranging from 48.6%
that residents considered patient and formula to 56.0%.18-20 Although actual testing and
characteristics for the initial EN prescription, perceived knowledge cannot be directly com-
but many did not reassess the prescription pared, suboptimal test scores support an accu-
once it was written. rate assessment of medical residents’ knowl-
Studies regarding formula selection were edge of nutrition. Despite their knowledge
not well represented in the literature. One deficit, 73% of residents reported that they
study, which was conducted almost 25 years considered the patients’ calorie and protein
ago, compared the practice of formula se- requirements when determining the infusion
lection among RDs and MDs and found that rate. Most choose neither the same rate (76%)
MDs were less familiar with formula availabil- nor the same formula (73%) for all patients,
ity. They placed slightly less emphasis on for- which indicates that patient and formula char-
mula characteristics compared with patient acteristics are taken into consideration.
characteristics.17 Almost all of the medical residents con-
Selecting a formula is only a part of the sider the recommendations of the dietitian
EN prescription. Knowledge about calculat- and/or the NST when prescribing EN. Behara
ing the rate of infusion, beginning with the et al2 did not find similar results in that med-
start rate and advancing the rate in incre- ical residents were not comfortable with the
ments until a goal rate is achieved, is impor- recommendations of the NST. The study by
tant to ensure that the patients’ energy, pro- Behara et al2 was conducted at a single facil-
tein, and fluid needs are met. Only 50% of ity, and the researchers credited the results
those surveyed reported that they knew how to a lack of awareness and education about
to advance the feeding rate. This is important the NST and the composition of the team. Re-
because underprescribing EN is a common sults from this study may also be skewed as
occurrence in the ICU that frequently leads there are limitations to this question. Through
to underfeeding and inadequate provision of full disclosure for informed consent, medical



residents in this study were aware that this to implement a standardized EN feeding
survey was being conducted by an RD, which protocol.
may have influenced them, consciously or This study also had several limitations.
subconsciously, to respond in a positive man- The major limitation was sample size, with
ner. Second, a differentiation should have only 8.7% responding to the Web-based sur-
been established between an RD and an NST. vey. Reliance on the directors and coordina-
Although an RD may be part of the NST, the tors to distribute the survey might have also
team may also include a registered nurse, an contributed to a low response rate, as the
MD, and/or a pharmacist. primary author did not have sole control of
Further training for medical residents survey distribution. Similar studies typically
in EN is required, which also may influ- resulted in low response rates.16 Furthermore,
ence patient outcome. Most medical resi- the low response rate indicated that there
dents surveyed believed that an evidence- were a number of nonresponders. A nonre-
based protocol should be considered to op- sponse bias check was not conducted to de-
timize the delivery of EN. Many studies have termine whether the nonresponders were dif-
shown improvements in patient outcomes ferent from the responders because the char-
after the implementation of a nutrition sup- acteristics of the former group were unknown
port protocol; however, the research does to the researchers.
not show whether there was a desire from Another limitation may be the result of
the medical residents for such protocols to be selection bias in that respondents may be indi-
developed.5,10-12 viduals with an interest in nutrition. The sur-
This project reinforced information previ- vey did not ask whether an EN protocol was al-
ously known with regard to a lack of knowl- ready in place at the residents’ facility. If a pro-
edge and inappropriate practices in the pre- tocol was in place, it might bias the residents’
scription and delivery of EN. It also provided responses. In addition, the majority of the re-
insight into the discordance between atti- spondents were internal medicine or family
tudes, knowledge, and practice. This project practice residents. Although critical care is
found that the majority of medical residents included among their rotations, exposure to
surveyed were unsure about how to calculate critically ill patients and provision of EN may
nutrients; they were unfamiliar with formu- be limited. Lastly, the residents who partici-
las prescribed in EN; and they did not always pated in the study were enrolled in programs
provide EN therapy according to established in the New York tristate area, and they were
guidelines. In addition, there is evidence of mainly in family practice or internal medicine.
the need for further education in nutrition Therefore, the results may not be general-
and a standardized protocol for EN. Future ized to other subspecialties or geographical
research should be conducted to determine locations.
where the discrepancy lies between attitudes,
knowledge, and practice. The research con- CONCLUSION
ducted should focus on where further training
should be initiated: in medical school; as part Medical residents are authorized to write
of the residency rotations; or daily education EN prescriptions; yet, most of them have min-
during rounds with a NST. imal training. The residents who participated
This study had some strengths. The use in this study reported inadequacies in their
of a Web-based survey allowed for complete knowledge despite the fact that they thought
anonymity of the responses. Standard on- that nutrition support in critical care was im-
line survey procedures were followed to in- portant. They also demonstrated discrepan-
crease the response rate. To the researchers’ cies between attitude, knowledge, and prac-
knowledge, this was the first study that tice based on their responses. In addition,
surveyed medical residents about a need residents reported that they favored the use



of a standardized feeding protocol. The cur- IMPLICATIONS FOR DIETETIC PRACTICE
rent system of nutrition education in medi-
cal school has changed little in hours devoted As part of a multidisciplinary team involved
to clinical nutrition over the past 20 years.23 in treating critically ill patients, the RD has
A transformation of the nutrition education an opportunity to bring expertise to the pro-
curriculum throughout medical school is war- vision of nutrition support. An RD can also
ranted. In the interim, approaches such as work to implement feeding protocols in their
feeding protocols and daily education through facilities or become a part of the NST. This
medical rounds, including a dietitian, may provides the opportunity to educate medical
help to train medical residents in nutrition residents in EN and nutrition therapy in criti-
support. cal care.

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