Original Communication

Journal of Parenteral and Enteral

Nutrition
Home Gastrostomy Feeding Education Program: Volume 00 Number 0
xxx 2019 1–9
Effects on the Caregiving Burden, Knowledge, and Anxiety 
C 2019 American Society for

Parenteral and Enteral Nutrition

Level of Mothers DOI: 10.1002/jpen.1747
wileyonlinelibrary.com

Hatice Pars, PhD, RN1 ; and Tutku Soyer, Prof, MD2

Abstract
Background: It is highly important for healthcare professionals to give discharge education to families to increase their knowledge
of gastrostomy care and complications and to inform them about the correct behaviors. The purpose of the present descriptive
pretraining and posttraining evaluation study was to investigate the effects of a standardized, evidence-based discharge education
program prepared for children with gastrostomy tubes on the caregivers’ knowledge, anxiety levels, and caregiving burden. Methods:
The primary caregivers of children with a gastrostomy tube (n = 30) were interviewed on the first day of the education program
and the first week and third month after the program, and a pretest/posttest, the Zarit Caregiver Burden Scale and the State-
Trait Anxiety Inventory were applied. Complications were determined by assessing the number of unplanned clinic visits and
complications in the study group compared with the historical control group (historical comparison; n = 30). Results: The study
revealed that the knowledge levels of mothers increased in the first week and third month after training, and their caregiving burden
and state-trait anxiety levels significantly decreased. Although some complications arising from the enteral nutrition process were
observed, it was found that the complications were fewer, and the difference was statistically significant compared with the group that
did not receive the standardized, evidence-based discharge education program. Conclusion: The standardized education program
should be recommended because caregivers managed the home care process more successfully, and the stress, anxiety, and difficulties
experienced during homecare decreased. (JPEN J Parenter Enteral Nutr. 2019;00:1–9)

Keywords
caregiver; children; education; enteral nutrition; gastrostomy

Clinical Relevancy Statement fibrosis, metabolic problems, chronic infections such as

Findings of this study imply that standardized, evidence-
based discharge training programs increase the knowledge
level of mothers while decreasing the burden of care, level
of anxiety, and complications observed during home care.
We believe that the results of this study highlight the
importance of discharge education with a multidisciplinary
team approach and may assist nursing staff and other health
professionals in aligning nutrition care plans with the goal
to ultimately improve patient outcomes during and after a
hospital stay.
Introduction
Gastrostomy tubes (G-tubes) are 1 of the methods
commonly used to facilitate the nutrition, hydration, and
administration of medication in children.1 The general
indications of G-tubes are chronic inadequate oral intake
(eg, dysphagia and neurological disorders), chronic medical
conditions impairing nutrition status, oncologic problems
associated with malnutrition, and other clinical conditions
leading to malnutrition (eg, chronic renal failure, cystic
HIV, cardiac diseases, short bowel syndrome, and Crohn’s
disease).1-3 Although G-tube placement is a safe procedure
used frequently among children, the complications are
reported at different frequencies.2,4-7 Different studies have
reported that home care plays a significant role in the
occurrence of common, minor, preventable complications
From the 1 Faculty of Nursing, Pediatric Nursing Department,
Hacettepe University, Ankara, Turkey; and 2 Faculty of Medicine,
Department of Pediatric Surgery, Hacettepe University, Ankara,
Turkey.
Financial disclosure: None declared.
Conflicts of interest: None declared.
Received for publication June 7, 2019; accepted for publication
November 1, 2019.
This article originally appeared online on xxxx 0, 2019.
Corresponding Author:
Hatice Pars, Assistant Professor, PhD, RN, Faculty of Nursing,
Pediatric Nursing Department, Hacettepe University, 06100,
Samanpazari, Ankara, Turkey.
Email: hatice.saglam.hs@gmail.com
2 Journal of Parenteral and Enteral Nutrition 00(0)
such as tube blockage, infection, and overgranulation tissue
in children with a gastrostomy tube.1-3 Because of com-
plications, families may experience problems in home care
because of a lack of knowledge and adequate discharge
support by health professionals. Families have reported
that they have not been adequately informed by healthcare
professionals during discharge, and thus they had problems
providing the correct care and disease management.1,7,8
The major problems observed in home care are the feeling
of guilt experienced by families because of the need for
tube-feeding, the difficulty in the daily care of the child
because of the development of tube-related complications,
and the fear of development of complications due to enteral
nutrition.1,7,9-11 The fact that enteral feeding with G-tubes
is a long process increases the burden of care.12-14 In the
literature, it has been reported that the burden of care
is closely related to the quality of care, and as a result
of the difficulties related to long-term care, individuals
undertaking the caregiver responsibility may experience
feelings such as helplessness, anger, fear, anxiety, depression,
burnout, deterioration in physical health, family conflict,
and economic hardship.12,13,15 To minimize the burden
of care and anxiety levels of families, it is important to
ensure that children receive care at home and their families
successfully manage the process.
The American Society for Parenteral and Enteral Nutri-
tion (ASPEN) has emphasized that patients with a chronic
illness and certain nutrition problems and their families
should be provided discharge education and that home
nutrition should be maintained safely.16 The implementa-
tion of a standardized, evidence-based discharge educa-
tion protocol is expected to result in improved treatment
outcomes, increased level of knowledge among caregivers,
and a decrease in care burden and anxiety levels. Thus, the
present study aims to investigate the effect of a standard-
ized, evidence-based discharge education program designed
for children with G-tubes on the caregivers’ knowledge,
anxiety levels, and caregiving burden. The present study
also aims to investigate the effect of discharge education on
the complications that may be observed because of enteral
nutrition and gastrostomy care.
Methods
Study Aim
The aim of the present study was to describe the effective-
ness of the discharge education program for children with
G-tubes on caregiving burden, knowledge, and anxiety level
of the mothers.
Study Design and Participants
This quasi-experimental study was conducted between
November 2017 and November 2018. The present study
employed a pretraining and posttraining descriptive eval-
uation and consisted of primary caregivers of children
who were hospitalized for gastrostomy placement in a
pediatric surgery service of a university hospital in Ankara
(capital city), Turkey. The study’s inclusion criteria included
primary caregivers of <1- to 18-year-old children with a
newly inserted G-tube. The study was conducted in a single
service and included children who had just opened a G-
tube during the study interval. To evaluate the effects of
education on the patient, the enteral nutrition and G-tube
complications and unplanned clinic visits during the process
were followed in clinical interviews. The patient outcomes
were determined by assessing the number of and reason for
the unplanned clinic visits and complications in the study
group when compared with the historical comparison (HC)
control group. The study was completed with 30 caregivers,
who voluntarily agreed to participate in the study. Flow
of participants can be found in Figure S1. The HC group
included 30 children, who underwent G-tube placement
between November 2016 and November 2017 and did not
receive discharge training. This time frame preceded initial
implementation of the discharge education program in
November 2017. In the HC group, children’s G-tubes were
inserted and monitored by the same team and in the same
service medium.
Measures
Training Guide. In designing the training protocol, we first
examined various databases, including PubMed, Cumu-
laitve Index of Nursing and Allied Health, Mosby’s Nursing
Suite, Cochrane Library, ASPEN, and European Society
for Clinical Nutrition and Metabolism guides. Then, we
developed an evidence-based training guide and a checklist
drawing based on case reports, system reviews, randomized
control studies, observation studies, and clinical protocols.
The training material was then reviewed by 20 experts con-
sisting of specialist nurses, doctors, and faculty members,
who are all experienced in the field of enteral nutrition.
The experts were given the sample training material and
a material evaluation form. They were asked to complete
the form based on their evaluation. The opinions of experts
were tested using the Predictive Analytics Software 18 pro-
gram, and the content validity was found to be statistically
significant according to Kendall coefficient of correlation
test (P < .001). It was also determined that the expert
opinions were compatible with each other, and the scope of
the training material was accepted as valid.
On the first day after the procedure, the education
guide was explained to the primary caregivers through a
demonstration. The training lasted about 1.5 hours. All
mothers were given a single training by the same person
using the same educational content. The training included
both theoretical and practical components. The steps in the
Pars et al
education guide were explained to the primary caregivers
through demonstration. After the training, the guide was
delivered to all caregivers. The training was given to the
caregivers by 1 of the researchers. The researcher previously
worked as an enteral nutrition training nurse.
Pretest-Posttest Questionnaires
The items on the form for the pretest and posttest were
prepared by the researchers and then reviewed by enteral
nutrition nurses, 10 academicians, and 2 instructors who are
specialized in assessment and evaluation; and the final form
of the questionnaire was given (supplementary material).
The pretest and posttest questionnaires and the scales were
applied by a volunteer interviewer in order not to cause bias
during the research process. This person was the chief nurse
in the surgical clinic where the study was conducted.
Zarit Caregiver Burden Scale
The items in the scale are generally about social and emo-
tional effects, and a high score indicates that the caregiver
experiences serious problems. The scores are evaluated
based on the following categorization: 0–20, little/no bur-
den; 21–40, mild/moderate burden; 41–60, moderate/high
level of burden; and 61–88, overloaded.17
State-Trait Anxiety Inventory
State anxiety is defined as how a person feels at a certain
moment, whereas trait anxiety is defined as how a person
feels regardless of the conditions he or she is under. The
inventory consists of 2 subscales (state anxiety and trait
anxiety), each of which contains 20 items. The lowest score
(for both scales) is 20, and the highest score is 80. High
scores indicate high state and trait anxiety levels.18
Procedure
The patients for whom the G-tube placement was planned
and their primary caregivers were involved in the study by
the researchers. One day after tube placement, the primary
caregivers of children with a G-tube were interviewed. Then,
a pretest, the Zarit Caregiver Burden Scale (ZCBS), and
State Anxiety and Trait Anxiety (STAI) were applied. After
these tests, training was provided. The primary caregivers
were reinterviewed during the first week and third month
after training, and the posttests, ZCBS, and STAI were reap-
plied. The average hospitalization period of the patients was
1 week. Therefore, in the third month, the caregivers were
invited to the polyclinic by telephone, and the posttest was
performed in the polyclinic. During the research process, a
multidisciplinary team made phone calls to follow up on
patients who were discharged from the clinic. The problems
related to the enteral nutrition process, the complications,
the compliance with treatment, and the applications of
3
the caregivers were reexamined through phone calls, and
the questions asked by the parents were answered. The
study group was asked about complications that occurred
during the first day, first week, and third month following
the education program. The problems experienced within
3 months after G-tube placement and the unplanned clinic
visits were retrospectively analyzed for HC group.
Interdisciplinary cooperation was ensured during the
whole process, from G-tube placement to discharge and
from discharge to the follow-up at home. This multidisci-
plinary team consisted of a pediatric surgeon (researcher),
a faculty member specializing in child health (researcher),
a nutrition nurse, a nutrition team, a gastroenterologist, a
head nurse in the clinic, and clinical nurses.
Ethical Considerations
Prior to the study, the official permission was obtained
from the hospital, and ethical approval was obtained from
The Non-Interventional Clinical Research of Ethical Com-
mittee of Hacettepe University (ethical approval number:
GO17/543). Voluntary and anonymous participation was
guaranteed. Informed consent forms were given and re-
ceived from each of the participants. The HC group was
informed that only questions about complications would be
asked, and their consents were obtained.
Data Analysis
The Kendall’s coefficient of concordance test was used to
evaluate the training guide. Descriptive statistics (mean,
SD, median, min-max values, percentage, and frequency)
were used to evaluate the sociodemographic data. In further
analyses, Cochran Q and post hoc Dunn tests were con-
ducted. Repeated-measures analysis of variance (ANOVA)
test and Bonferroni adjustment were performed in pair
comparisons. In the evaluation of the relationships be-
tween scales and demographic data, the repeated-measures
ANOVA with 1 fix factor was applied, and in the subgroups,
Bonferroni adjustment was used. Data analysis was per-
formed using IBM SPSS (version23.0, IBM Corporation,
Armonk, NY, USA). The significance was fixed at the
value .05.
Results
In the present study, all the primary caregivers were mothers.
Most of the children (60%) were diagnosed with cerebral
palsy. All the children were fully dependent. Maternal
demographics (n = 30) are displayed in Table 1. When the
relationship among the mean scores over time, the sociode-
mographic data of the mothers, and the variables within the
group were examined, it was found that the mean scores
of all the variables decreased after the education program
4 Journal of Parenteral and Enteral Nutrition 00(0)

Table 1. The Distribution of Scale Scores Across the Sociodemographic Characteristics of the Caregivers.

Trait Anxiety Mean State Anxiety Mean Caregiving Burden Mean

First First Third First First Third First First Third

Characteristics n (%) Day Week Month Day Week Month Day Week Month Fa Pa

Age of the child, y

0–1 12 (40) 48.5 39.5 37.8 41.5 36.8 34 39 32.8 29.1
1–3 8 (26.7) 46.2 40.1 35.7 45.5 37.8 35.7 41 35.3 35 33.816 .000
3–6 7(23.3) 49.8 39.5 36 46 37.8 35.7 45.1 35.1 32 36.270
6–12 3(10) 41 39.3 35.3 36 34.6 31.3 27 29.6 28 10.809
Fb p 1.147 .000 1.221 .321 10.809. .000
Educational level
Elementary and 11 (36.7) 52.4 40.2 36.2 49 39 36.5 49.9 36.7 35.8 70.206 .000
high school
Undergraduate 19 (63.3) 44.5 39.3 36.5 39.6 36 33.3 34.2 32 28.6 77.639
and
postgraduate
Fb p 8.288 .003 1.221 .321 1.613 .162 30.787
Employment
Yes 9 (30) 45.8 37.1 35.3 41.2 34.6 32 38.6 30.5 27.7 41.108 .000
No 21 (70) 48.1 40.7 37.1 43.8 38.1 35.6 40.5 35 32.7 43.488
18.477
Fb p .352 .650 .160 .853 .547 .532
Income level
Less 10 (33.3) 52.6 41.6 38 48.2 39.2 36.6 49.9 37.9 36.5 38.247 .000
Balanced 16 (53.3) 45.8 39.3 36.8 41.5 36.9 34.2 36.8 32.3 29.2 37.562
High 4 (13.4) 41.2 36.9 32 36.2 32.7 30.5 27.7 29.2 26.2 18.802
Fb p 1.767 .176 2.381 .100 3.314 .030
Any other dependent
Yes 13 (43.3) 50.8 41.3 37.3 48.3 40 37.3 49.2 38 35 54.028 .000
No 17 (56.7) 44.8 38.3 36 39 34.8 32.7 32.9 30.4 28.3 59.984
Fb p 2.193 .040 4.444 .038 27.593 .000 27.593
Receiving help for care
Yes 15 (50) 50. 2 40.5 37.4 45.2 38.6 36.4 43.8 36.2 32.5 51.613 .000
No 15 (50) 44.7 38.8 35.7 40.8 35.6 32.6 36.2 31.2 30 49.693
Fb p 1.190 .030 1.350 .043 1.564 .040 19.746
Effect on responsibilities
Yes 28 (93.3) 55.5 47.5 43 43.2 37.2 34.5 42.5 35.5 34 54.028 .000
No 2 (6.7) 46.5 39.1 36.1 40 35.5 34 39.8 33.6 30.9 59.984
Fb p .088 .916 .299 .615 .106 .824 27.593
Total 47 ± 8.8/39 ± 5.6/36± 5 43 ± 8.2/37± 5.1/36± 5 50 ± 11.6/33.7 ±
10.1/31.26 ± 8.8
c
P1–2 = .05; P2–3 = .01; P1–2 = .05; P2–3 ࣘ .01; P1–2 ࣘ .05; P2–3 ࣘ .01;
P1–3 = .01 P1–3 < .01 P1–3 < .01

Difference resulted according to Bonferroni test (Tukey honest significant difference), statistical test: one-way analysis of variance and P-value.
a Measurement differences (intergroup differences).
b Intragroup differences.
c P1 compares preprocedure (first day/before education) with postprocedure (first week); P2 compares posttraining (first week) with 3 months

postprocedure; and P3 compares preprocedure (first day/before education) with 3 months postprocedure.

(P < .05). A significant relationship was found between the
scale scores and the demographic variables, such as mother’s
educational status, presence of other children the mother
has to take care of, and the state of receiving help about
care (P < .05) (Table 1).
The mean scores of the ZCBS and the STAI were sig-
nificantly lower in mothers with high school and university
education (P = .00; P = .000; and P = .003). On the other
hand, the ZCBS and the STAI scores were found to be
significantly higher in mothers who had other children to
take care of (P = .002; P = .038; and P = .004). The
ZCBS and STAI mean scores of the mothers receiving
support about care were calculated to be significantly lower
(P = .040; P = .04; P = .003). Examining the total score
averages of the scales, it was found that the mean scores
decreased in the third month after the education program.
Pars et al 5

Table 2. Correct Responses for Caregiver Mastery of Information Questionnaire Items.

Preprocedure Postprocedure Postprocedure

First Day First Week Third Month

Questions n % n % n % P-Valuea

Q1 11 36.7 30 100 30 100 P1 < .01; P2 = NS; P3 < .01

Q2 12 40 30 100 30 100 P1 < .01; P2 = NS; P3 <.001
Q3 2 6.7 30 100 30 100 P1 < .01; P2 = NS; P3 < .01
Q4 7 23.3 30 100 30 100 P1 < .01; P2 = NS; P3 < .01
Q5 0 0 30 100 30 100 P1 < .01; P2 = NS; P3 < .01
Q6 1 3.3 25 83.3 30 100 P1 < .01; P2 = NS; P3 < .01
Q7 2 6.7 27 90 30 100 P1 < .01; P2 = NS; P3 < .01
Q8 10 66.7 30 100 30 100 P1 < .01; P2 = NS; P3 < .01
Q9 0 0 30 100 30 100 P1 < .01; P2 = NS; P3 < .01
Q10 15 50 30 100 30 100 P1 < .01; P2 = NS; P3 < .01
Q11 10 66.7 30 100 30 100 P1 < .01; P2 = NS; P3 < .01
Q12 5 16.7 30 100 30 100 P1 < .01; P2 = NS; P3 < .01
Q13 4 13.3 30 100 30 100 P1 < .01; P2 = NS; P3 < .01
How do you find your knowledge level on enteral nutrition?
Fully 0 0 5 16.7 20 66.7 P1 < .01; P2 = NS; P3 < .01
Sufficiently 0 0 25 83.3 10 33.3
Partially 20 66.7 0 0 0 0
Not at al 10 33.3 0 0 0 0

NS, not significant.

a Adjusted P-value (Bonferroni method) from χ 2 tests to compare the proportion of correct and incorrect responses at each time point. P1

compares preprocedure (first day/before education) with postprocedure (first week); P2 compares posttraining (first week) with 3 months
postprocedure; and P3 compares preprocedure (first day/before education) with 3 months postprocedure.

A statistically significant difference was observed between
the preeducation scores and the scores in the first week
and the third month after the program as well as between
the first-week scores and the third-month scores after the
program (P < .05) (Table 1).
Table 2 shows the correct response rates of mothers
to the pretest and posttest questions. Although there was
no statistically significant difference between the correct
response rates in the first week and third month after the
program, it was found that there was a statistically signif-
icant difference between the pretraining and the first-week
and third-month scores after the program (P <.01). When
the mothers were asked about their level of knowledge
about enteral feeding before the training, 66.7% stated that
their knowledge was insufficient (partially), whereas 33.3%
emphasized that they had no knowledge. However, after the
training, in the first week, 16.7% of mothers reported that
their knowledge was extensive (fully), whereas 83.3% stated
that their knowledge was at a good level (sufficiently). On
the other hand, 3 months after the training, the mothers
reported their knowledge levels as extensive (fully) and good
(sufficiently) at the rates of 66.4% and 33.4%, respectively
(Table 2).
When we examine the enteral feeding practices that the
mothers can perform on their own, it is observed that
the number of applications increased after the training
(Table 3). It was determined that the number of mothers
who could perform the pretraining applications on their
own increased significantly in the first week and 3 months
after the training (P < .005). When the mothers were asked
about difficulties they experienced while feeding with the
G-tube, all the mothers reported before the training that
they had difficulty. However, 40% (in the first week after the
training) and 6.7% (in the third month after the training) of
the mothers stated that they had difficulty. The difficulties
experienced were a lack of knowledge and self-confidence
and fear of the inability to manage the complications. How-
ever, in the first week after the program, 12 mothers reported
experiencing diarrhea and reflux problems in their children;
and in the third month, 2 mothers reported experiencing a
reflux problem in their children.
In Table 4, the results about how competent mothers felt
about enteral feeding applications are presented. Although
no mother reported feeling competent before the training,
it was determined that the number of mothers feeling
partially competent or competent increased 1 week after the
training, and all mothers considered themselves competent
in applications in the third month after the training (P <
.005).
In Table 5, the complications experienced during the
enteral feeding process is presented. A statistically signifi-
cant difference was found between the group that received
6 Journal of Parenteral and Enteral Nutrition 00(0)

Table 3. Enteral Nutrition Practices of Caregivers (n = 30).

Preprocedure Postprocedure Postprocedure

First Day First Week Third Months

Mastery Items n % n % n % P-Valuea

Enteral nutrition via pump 1 3.3 8 26.7 10 33. 0 P1 < .05; P2 = NS; P3 < .05
Enteral nutrition via injector 5 16.7 20 66.7 22 77. 3 P1 < .05; P2 = NS; P3 < .05
Drug administration 5 16.7 20 66.7 30 100 P1 < .01; P2 = NS; P3 < .01
Flushing 9 30 29 96.7 30 100 P1 < .01; P2 = NS; P3 < .01
Checking nutrition plan 0 0 15 50 15 50 P1 < .01; P2 = NS; P3 < .05
Checking gastric residual volume 0 0 30 100 30 100 P1 < .01; P2 = NS; P3 < .01
Stoma care 0 0 30 100 30 100 P1 < .01; P2 = NS; P3 < .01
Rotating buttons 0 0 15 50 15 50 P1 < .01; P2 = NS; P3 < .01
Providing mouth care everyday 5 16.7 20 66.7 30 100 P1 < .05; P2 = NS; P3 < .01
Fixing PEG tubes 0 0 22 73.3 30 100 P1 < .01; P2 = NS; P3 < .01

NS, not significant; PEG percutaneous endoscopic gastrostomy, .

a Adjusted P-value (Bonferroni method) from χ 2 tests to compare the proportion of correct and incorrect responses at each time point. P1

compares preprocedure (first day/before education) with postprocedure (first week); P2 compares posttraining (first week) with 3 months
postprocedure; and P3 compares preprocedure (first day/before education) with 3 months postprocedure.

the standardized, evidence-based discharge training and the
group that received no training (P < .005).
Finally, a statistically significant, positive correlation was
found between the scores of the ZCBS and the STAI (r =
.690, P = .000; r = .782, P = .000).
Discussion
The present results suggest that the care burden and anxiety
levels of mothers receiving the discharge education program
decreased and their knowledge level increased. When the
complications observed within 3 months after the operation
were examined, it was observed that the children of families
receiving no standardized, evidence-based discharge educa-
tion program experienced significantly more complications.
The previous studies reported that mothers undertake
the daily care responsibilities of children with chronic
diseases.19-21 Chronic disease treatment leads to recurrent
and long-term hospitalization and emotional, social, and
economic losses for the children and families. For families,
providing care for their children may cause various prob-
lems, such as difficulties in social life and daily activities,
family and marital relationships, and economic status, as
well as not spending enough time with other family mem-
bers. It leads to psychological problems and a decrease in
quality of life (QoL) of caregivers, besides the physiological
problems.19-21 In the present study, all the primary caregivers
were mothers, and their mean burden of care before the
training was 50 ± 11.6. It suggests that the burden of care
was at moderate levels. After the training, the score was
found to gradually decrease during the first week and third
month. The score was found to be 31.26 ± 8.8 in the final
measurement. The last score indicates that the care burden
was low or none.
The STAI scores were also high before the education (43
± 8.2; 50 ± 8.8); however, in the first week and third month
after training, the scores were found to decrease. Although
anxiety was at moderate levels before the training, the score
was calculated to be 36 ± 5 at the final measurement, indi-
cating no/low level of anxiety. Similarly, in a study carried
out on 160 children with a chronic disease, the mean care
burden of the parents was 45.74 ± 11.03, the State Anxiety
Scale score was 41.59 ± 6.15, and the Trait Anxiety Scale
score was 46.12 ± 6.73.22 In other studies on the caregivers
of children with chronic diseases, the caregiver burden
and anxiety level averages were found to be similar to the
values found before the training.21,23-26 After the training,
a decrease was observed in the mean scale scores, and the
knowledge level of mothers and their perception of self-
competence in implementations also increased as a result of
the training provided. This result proves the effectiveness of
discharge education programs. In literature, various studies
reported that the training given to caregivers increased their
knowledge levels and improved their practices.27-30 It is
thought that caregiving burden and anxiety levels decreased
because of the mothers’ level of knowledge, which increased
after the training, and the increased level of self-competence
in practice.28,31
As the mother’s educational status and financial status
increased, the burden of care and the state of anxiety
decreased. As previous studies have reported, level of ed-
ucation and financial status affects the caregiving burden
and anxiety level of the mother.9,12,32-34 It is thought that
the increase in educational status positively influences health
perception and management, develops conscious coping
mechanisms, improves the family’s financial situation, and
decreases the burden of care and level of anxiety, which lead
to a better QoL.
Pars et al 7

Table 4. The Competence Level of Caregivers in Terms of Enteral Nutrition.

3 Months
Preprocedure Postprocedure Postprocedure

NE PE E NE PE E NE PE E
n n n n n n n n n
Ability To % % % % % % % % % P-Valuea

Check the correctness of tube 27 3 0 0 15 15 0 0 30 P1 < .05; P2 < .01; P3 <.01

location 90 0 10 0 50 50 0 0 30
Use the pump, injector, and enteral 20 10 0 0 0 30 0 0 30 P1 < .01; P2 = NS; P3 < .01
product sets 66.7 33.3 0 0 0 30 0 0 30
Give formula and flushing 18 12 0 0 0 30 0 0 30 P1 < .01; P2 = NS; P3 < .01
60 40 0 0 0 30 0 0 30
Stoma care 19 11 0 0 22 8 0 0 30 P1 < .01; P2 = NS; P3 < .01
63.3 36.7 0 0 73.3 26.7 0 0 30
Store the enteral products under 27 3 0 0 53.3 46.7 0 0 30 P1 < .01; P2 = NS; P3 < .01
appropriate conditions 90 10 0 0 16 14 0 0 30
Know the amount of water and 23 7 0 0 9 21 0 0 30 P1 < .01; P2 = NS; P3 < .01
formula that should be given daily 76.7 23 0 0 30 70 0 0 30
Manage mechanical complications (eg, 23 7 0 0 19 11 0 0 30 P1 < .01; P2 = NS; P3 <. 01
tube blockage and tube dislocation) 76.7 23.3 0 0 63.3 36.7 0 0 30
Manage pulmonary complications (eg, 27 3 0 0 16 14 0 0 30 P1 < .01; P2 = NS; P3 <.01
aspiration) 90 10 0 0 53.3 46.7 0 0 30
Manage gastrointestinal complication 26 4 0 0 19 11 0 0 30 P1 < .01; P2 = NS; P3 < .01
(eg, diarrhea,constipation, nausea,
and vomiting) 56.7 13.3 0 0 63.3 36.7 0 0 30
Manage infection complications (eg, 23 7 0 0 19 11 0 0 30 P1 < .01; P2 = NS; P3 < .01
overgranulation tissue, bleeding,
secretion, peristomal infections) 76.7 23.3 0 0 63.3 36.7 0 0 30

E, enough; NE, not enough; NS, not significant; PE, partially enough.
a P1 compares preprocedure (first day/before education) with postprocedure (first week); P2 compares posttraining (first week) with 3 months

postprocedure; and P3 compares preprocedure (first day/before education) with 3 months postprocedure.

Table 5. The Distribution of Complications and Unplanned The present study revealed a positive relationship be-
Clinic Visits During the Enteral Nutrition Process. tween the ZCBS and STAI levels, as supported by previous
studies.22,35 The child’s current disease affects the whole
Study Group Historical X2 (df)
(n = 30)(%) Group (n = 30) P-Value family, both psychosocially and economically. As the du-
ration of disease prolongs, the results also become more
Unplanned clinic 4(13.3) 10(33.3) 7.18(2), remarkable, the burden of care increases, and the disease
visits P< .05 turns into a traumatic experience causing anxiety for child
Reason for complication and parent.23,36 Thus, a chronic disease requiring long-term
Vomiting 1 (3.3) 6(20) 4.57(2), care increases the burden of care. As the burden increases,
Diarrhea 2 (6.6) 4(13.3) P< .05
Constipation 1 (3.3) 2(6.6)
the level of anxiety also increases.
Blockage 0(0) 4(13.3) In the present study, although some complications were
Tube 0(0) 1(3.3) observed to arise from the enteral nutrition process, the
dislodgement complications and unnecessary visits to the clinic were
Leakage 2 (6.6) 8(26.6) at statistically, significantly lower frequency in the group
Overgranulation 2 (6.6) 10(33.3) receiving no standardized, evidence-based discharge educa-
tissue tion program. Similarly, a study carried out in the United
Bleeding (around 1 (3.3) 5(16.6)
stoma)
Kingdom reported that, after gastrostomy insertion, there
Infection 0(0) 7(23.3) were fewer complications in the training group.37 It suggests
that the education program and its continuity are important
in preventing gastrostomy complications. In a retrospective
cohort study on 1340 children with G-tubes, the number
of unnecessary visits was compared between trained and
8 Journal of Parenteral and Enteral Nutrition 00(0)
untrained cohorts. They found that 59% of patients had an
unscheduled, gastrostomy-related clinic visit within 1 year
of placement, and gastrostomy education independently de-
creased 1-year gastrostomy-related healthcare utilization.38
In a preintervention/postintervention single-group study
design used in evaluating the effect of standardized G-tube
education protocol with 26 subjects on caregivers and chil-
dren, the education protocol improved the patient outcomes
and increased the caregiver knowledge and confidence.
Regarding the location of complication, the study group
had significantly more phone calls than did the historical
group (P < .05).21
The strengths of the present study are that is was carried
out in a single service, provided training by a specialist for
the families, and had questionnaires carried out by another
researcher having no information about the purpose of the
present study. The present study can be repeated in a clinic
(where no multidisciplinary discharge training is planned)
by including control group cases.
Conclusion
The present study demonstrated that the standardized,
evidence-based discharge training and a multidisciplinary
team approach increases the knowledge level of mothers
while decreasing the burden of care, level of anxiety, and
complications observed during home care. Informing the
family during the process of feeding with a G-tube signifi-
cantly affects the adaptation to the treatment and the course
of the disease. It also ensures the active participation of
families in the treatment. During the treatment process, as
the mother takes part in the applications, her knowledge
about the care to be given increases; she knows what to
expect during the course of the illness; and her perceived
stress and burden of care will be reduced as her sense of
control improves. Discharge education is an important part
of this approach.
Acknowledgments
We are very grateful to the mothers who volunteered to
participate in this study.
Statement of Authoriship
H. Pars and T. Soyer contributed to the conception and design
of the research; H. Pars contributed to analysis of the data; H.
Pars and T. Soyer contributed to interpretation of the data; H.
Pars and T. Soyer drafted the manuscript. All authors critically
revised the manuscript, agree to be accountable for the accuracy
and integrity of the data, and read and approved the final
version of this manuscript.
Supplementary Information
Additional supporting information may be found online in the
Supporting Information section at the end of the article.
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