Development of the Spanish Version of “Nurses’ Perceptions of Responsibility, Knowledge and Documentation Focusing on Enteral Nutrition and Nursing Practice Regarding Enteral Feeding in the Intensive Care Unit”

Abstract

Background: Adequate nutritional knowledge among intensive care nurses is essential for early identification of nutritional risk and prevention of complications in critically ill patients. The questionnaire “Nurses’ perceptions of responsibility, knowledge and documentation focusing on enteral nutrition and nursing practice regarding enteral feeding in the intensive care unit”, developed by Persenius et al., is used internationally, yet no culturally adapted Spanish version has been available. Objectives: This study aimed to translate and culturally adapt Persenius et al.’s questionnaire and evaluate its content for use among Spanish-speaking intensive care unit (ICU) nurses. Materials and methods: A multistep process was conducted, including forward–backward translation, expert review by an expert panel of ICU nurses (N = 26) with at least 2 years of critical care experience, and content validity analysis. Experts rated item relevance and comprehensibility. Item Content Validity Index (I-CVI), Scale CVI, and Aiken’s V were calculated using predefined thresholds. Linguistic clarity/comprehensibility was assessed on a 5-point Likert scale (1–5). To assess the questionnaire’s reliability, Cronbach’s alpha was also analysed in a pilot study (N = 99). Results: The Spanish version retained all 47 original items after minor linguistic adjustments. All items met the minimum content validity threshold; most showed I-CVI values > 0.78 and acceptable Aiken’s V coefficients. The mean comprehensibility score for all items exceeded 4.0, indicating high clarity. No item required significant semantic modification after expert review. Cronbach’s alpha coefficient of 0.85 reflected its reliability. Conclusions: The Spanish version of Persenius et al.’s questionnaire demonstrated adequate content and linguistic validity and internal consistency in a pilot sample of ICU nurses.

1. Introduction

The assessment of patients’ nutritional status in the Intensive Care Unit (ICU) is a fundamental aspect that directly influences their prognosis and recovery [1]. Malnutrition is a problem that, according to previous studies, can affect 40–50% of critically ill patients, with the risk of malnutrition in this population ranging from 35 to 50% [2,3]. There is strong evidence of a correlation between negative energy balance and an increase in hospital length of stay (by 5.4 to 6.6 additional days), more frequent infections, and an increase in morbidity and mortality (with a relative risk of death up to three times higher among malnourished patients) [4,5]. The potential cost of hospital malnutrition in Spain has been estimated at 1143 million euros per year [6].

Critically ill patients exhibit an inflammatory state associated with illness severity, which drives higher caloric-protein intake and, consequently, malnutrition [3,4,5]. Through adequate nutritional assessment, the use of screening tools, and early nutritional intervention, this vicious cycle could be interrupted.

It is essential to emphasize the importance of adequate training for nurses in the use of nutritional assessment tools. Nurses play a key role in the early identification of patients at nutritional risk and in implementing appropriate interventions [1,7]. Effective administration of enteral nutrition (EN) requires healthcare professionals with sufficient knowledge, as well as clearly defined competencies and responsibilities [8]. However, several studies have reported limited adherence to nutritional guidelines among intensivists, notable knowledge gaps among nursing staff regarding EN, and a tendency to prioritize nutritional care lower in the clinical workflow. These deficiencies contribute to iatrogenic malnutrition and may compromise patient outcomes [3].

Generally, nurses do not use nutritional risk screening tools to assess malnutrition in critically ill patients [5,9,10]. A recent systematic review [9] found that nurses’ knowledge of nutritional care for EN was low or inadequate. Furthermore, the scientific literature shows that nurses who had attended EN training or possessed higher levels of knowledge demonstrated better nutritional care practices [11,12].

Numerous instruments have been developed internationally to assess nurses’ nutritional knowledge, particularly in critical care settings. Among the most frequently used is the questionnaire by Persenius et al. [11], a self-administered Likert-scale tool that collects demographic information and captures nurses’ perceptions of EN across domains such as responsibility, knowledge, sources of information, and attitudes. The use of this and other instruments underscores the need for greater standardization to facilitate robust evaluation and cross-study comparison [13,14].

Although several international instruments are available, their direct application in Spain is limited by multiple factors. First, many have not been validated in Spanish, raising concerns regarding linguistic accuracy, conceptual equivalence, and measurement validity [9]. Second, cultural, organizational, and clinical practice differences, particularly in the implementation of nutritional guidelines and protocols, may influence the relevance and interpretability of specific items within the Spanish ICU context. Consequently, instruments developed in other settings may fail to capture context-specific practices and educational needs, thereby limiting the accurate identification of knowledge gaps and the design of targeted training interventions [15].

Cross-cultural adaptation is therefore essential to ensure semantic, conceptual, and experiential equivalence between the original and adapted versions [16,17,18]. In this context, adapting and validating the questionnaire developed by Persenius et al. [11] represents a feasible and methodologically sound strategy to obtain a standardized, context-sensitive measure of nurses’ knowledge regarding nutritional risk. Such an approach may support a more precise assessment of educational needs and contribute to strategies to improve the identification and management of nutritional risk in critically ill patients [19].

Despite its length, this instrument has been widely used in ICU settings to explore nurses’ EN-related perceptions and practices and to identify training needs, further supporting its selection for cross-cultural adaptation [11,19]. To the best of our knowledge, no previous cross-cultural adaptation of this questionnaire into Spanish has been published.

Multiple tools have been validated using this approach, including instruments assessing ICU nurses’ knowledge of sepsis, medication administration errors, and mechanical ventilation [20,21,22]. The increasing use of this methodology in recent years underscores the importance of having robust tools to effectively measure nurses’ knowledge [23,24].

This study aims to adapt the questionnaire to the Spanish context and to assess its content validity and internal consistency through a pilot study with a sample of Spanish registered nurses (RNs), using the Spanish version of the instrument.

2. Materials and Methods

2.1. Design

A methodological design was employed in this study that included translation and back-translation, expert review, and content validation. A cross-sectional design was used to pilot the new tool: the Spanish version of Persenius et al. instrument [11].

Several authors have developed this methodology for the cross-cultural adaptation of instruments, with slight modifications depending on the aims of their studies [16,25,26]. A methodology comprising the following phases was used to obtain the Spanish version of the instrument:

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Translation and back-translation. These two stages were carried out by professional translators and Spanish RNs with advanced English proficiency, resulting in a consensus Spanish version.

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Expert review. A panel of 26 experts in intensive care in Spain assessed the comprehensibility and relevance of each item in the Spanish version of the questionnaire, using a 5-point Likert scale (from “strongly agree” [5 points] to “strongly disagree” [1 point]). Members of the expert panel who reviewed the Spanish version of the Persenius et al. [11] questionnaire were selected from among nurses with at least two years of experience in intensive care, either working in the Spanish healthcare system or serving as university faculty teaching intensive care.

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Content validity analysis. The item Content Validity Index (I-CVI) and the overall Scale Content Validity Index (S-CVI) were calculated from the experts’ ratings; I-CVI values were also used to compute modified kappa coefficients (k); also, the experts’ scores were used to calculate Aiken’s V coefficient.

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Pilot study. A cross-sectional descriptive design was employed to evaluate the Spanish version of Persenius’ questionnaire [11], before its full implementation. The objectives were to identify potential comprehension issues and to assess internal consistency reliability using Cronbach’s alpha. Participants were also invited to report any ambiguities, misunderstandings, or difficulties encountered while completing the instrument.

The potential study population consisted of registered nurses who had worked in an ICU for more than six months, ensuring sufficient exposure to ICU practices related to enteral nutrition. The aim was to collect approximately 100 questionnaires using purposive sampling; this sample size was considered adequate for an initial statistical analysis of the items and to ensure reasonable stability of the estimators before a broader application of the instrument, in accordance with previous methodological literature [27,28].

2.2. Data Collection

• Expert evaluation. Experts received an email explaining the project and requesting their collaboration; after accepting, they were emailed a Qualtrics link containing sociodemographic data and the consensus–SV, with instructions to rate each item and add comments on wording and relevance to the ICU context.
• Pilot study. A document developed by the research team was used to collect two types of data:

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  Professional and sociodemographic data of participants (age, sex, undergraduate or postgraduate training, academic background, and specific training in nutrition in critically ill patients) and years of ICU experience.

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  The Spanish version of Persenius’ questionnaire. In addition to answering the questionnaire, participants could identify any comprehension problems with the items and provide personal comments.

Data were collected through an online survey hosted on the Qualtrics platform, which ensured careful and secure data management. An IP filter was applied to prevent multiple responses from the same participant, thereby safeguarding the integrity of the responses.

Participants in the pilot study were informed about the study objectives through an information letter accompanying the questionnaire and through direct communication with the research team during routine ICU rounds. The questionnaire was also distributed via social media platforms and professional nursing associations. Upon accessing the online survey, participants received an electronic informed consent form outlining the study’s purpose, confidentiality measures, and the voluntary nature of participation. The questionnaire was accessible only after consent was obtained.

Data from the expert panel were collected between November and December 2024, while pilot study data were collected between October and November 2025.

The original instrument developed by Persenius et al. [11] comprises 47 items, including dichotomous questions (Yes/No/Don’t know), 5-point Likert-scale items assessing perceptions of responsibility, knowledge, and documentation (ranging from “low extent” to “great extent”), as well as items addressing enteral feeding practices.

In the original study, internal consistency was evaluated for the subscales measuring responsibility, knowledge, and documentation. Cronbach’s alpha coefficients were 0.86, 0.90, and 0.86, respectively, indicating high internal consistency [11].

2.3. Instrument Translation and Cultural Adaptation

We attempted to contact the original questionnaire authors via multiple channels, but did not receive a response. Nevertheless, the original instrument was appropriately cited, and the work was limited to translation and cultural adaptation with minor linguistic adjustments, following ethical standards and ensuring data confidentiality was maintained at this stage.

The Spanish adaptation of the Persenius et al. questionnaire [11] followed standardized guidelines for the cross-cultural adaptation of self-administered instruments, as proposed by Beaton et al. [29]. Several steps were undertaken to ensure linguistic and conceptual equivalence between the original English version and the Spanish translation.

First, two independent translators, both native Spanish speakers with high proficiency in English, translated the original questionnaire into Spanish. Both translators were familiar with the subject matter and worked independently to minimize bias. The two translated versions were then compared and synthesized into a single preliminary version, with discrepancies resolved through discussion and consensus.

Next, the consensed Spanish version was back-translated into English by two different translators with certified English competence, who were blinded to the original instrument. As before, the produced versions were compared to identify any inconsistencies or errors that might have arisen during the process. The back-translated versions were systematically compared with the original instrument to ensure semantic and conceptual equivalence, in accordance with Beaton et al.’s guidelines [29].

In adapting the instrument for the Spanish-speaking population, special emphasis was placed on existing materials in Spanish ICUs, as well as on the organization and work methods specific to the Spanish healthcare setting, which may differ from those in other countries. This adaptation included a thorough review of language and wording to ensure comprehensibility.

2.4. Content Validity Analysis

During the expert evaluation process, content validity (relevance) was assessed on a scale of 1 to 5. Based on the experts’ ratings, validity indicators were calculated. Following the methodology of Polit and Beck [30], also used by other authors [23,25,26], three content validity indicators were computed for each item: Content Validity Index (CVI), modified kappa coefficient (k), and Aiken’s V, based on the experts’ evaluations, using the following formulas:

(A) Item-level Content Validity Index (I-CVI): calculated as the proportion of experts who assigned a score of 4 or 5 to the item’s relevance, relative to the total number of experts who rated that item.

CVI = number of experts who evaluated the item with 4 or 5/Total number of experts

(B) Modified kappa index (k): The criteria to determine the level of agreement among experts, calculated with the kappa coefficient, were those established by Polit: kappa ≥ 0.74 = excellent agreement; 0.60 ≤ kappa < 0.74 = good agreement; kappa < 0.59 = poor agreement [25,28].

k = (I-CVI − Pc)/(1 − Pc)

In which the I-CVI is the internal content validity coefficient, previously calculated for each item, while Pc (probability of chance agreement) is the probability of a fortuitous coincidence between observers and is calculated using the formula:

Pc = [N!/(A!(N − A)!)] × 0.5^N

where N is the number of experts who evaluated the item, and A is the number who rated it as 4 or 5.

(C) Aiken’s V coefficient: its formula, algebraically modified by Penfield and Giacobbi [31], where X is the mean score, l is the lowest possible score, and k is the scale range. For example, if the minimum score is 1 and the maximum is 5, then k = 5 − 1= 4.

V = (X − l)/k

Once Aiken’s V was calculated, confidence intervals were obtained using the scoring method [32].

The following equation was used for the lower limit of the interval:

L = [2nkV + z² − z√(4nkV(1 − V) + z²)]/[2(nk + z²)]

And for the upper limit of the interval:

U = [2nkV + z² + z√(4nkV(1 − V) + z²)]/[2(nk + z²)]

L: lower limit of the interval; U: upper limit of the interval; Z: value from the standard normal distribution; V: Aiken’s V; n: number of experts.

The CVI, modified kappa, and Aiken’s V were calculated using a database created in Excel 2013. A minimum cut-off of 0.6 was set for both I-CVI and Aiken’s V, following methodological recommendations by Polit and Beck [30].

2.5. Treatment of Missing Values

To maximize the use of expert ratings without compromising the integrity of the analysis, the I-CVI was calculated for each item using only the ratings provided for that item. This approach ensured that experts were not excluded from the analysis, thereby avoiding leaving specific items unrated.

2.6. Comprehensibility Analysis/Linguistic Validation

To assess comprehensibility, experts were asked to rate the clarity of each item using the following guiding question: “Is this item clearly and understandably formulated for ICU nurses in the Spanish context?” Responses were recorded on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). Mean scores were calculated for each item, and predefined cut-off points were used to categorize comprehensibility. Items with mean scores above 4 were considered highly comprehensible, those with scores between 3.5 and 4 were classified as moderately comprehensible, and items scoring below 3.5 were considered poorly comprehensible [23,30].

2.7. Reliability Assessment of the Questionnaire

This pilot study also enabled analysis of the questionnaire’s internal consistency by calculating Cronbach’s alpha to assess the instrument’s reliability.

A Cronbach’s alpha of 0.7 is considered the minimum acceptable value; lower values indicate low internal consistency of the instrument, although some authors suggest that, in early phases of research and exploratory studies, a value between 0.5 and 0.6 may be considered adequate [33].

2.8. Statistical Analyses

The I-CVI, Pc, kappa, and Aiken’s V indices were calculated using a database created in Excel 2013, based on the experts’ evaluations and according to their respective formulas.

Other statistical analyses (including the calculation of Cronbach’s alpha) were performed using the JAMOVI statistical package.

2.9. Ethical Considerations

The study was conducted in accordance with the principles of the Declaration of Helsinki. It was approved by the Human Research Ethics Committee of the Experimental Research Ethics Commission of the University of Valencia (reference 2024-ENFPOD-3661014). It also complied with Spanish and European data protection and information management regulations. All experts provided informed consent, ensuring confidentiality and the voluntary nature of their participation.

To ensure confidentiality and anonymity, no personally identifiable information was collected, and each document was assigned a numerical code to facilitate data management.

3. Results

3.1. Translation Process

During the translation of the questionnaire from English to Spanish, it was necessary to clarify specific items. The main issues are detailed below:

• Items 5 and 6. To translate the expression “…key persons to consult...”, the option «profesionales referentes» (“reference professionals”) was chosen to better adapt to the Spanish context, both territorial and scientific.
• Items 10–18. These items shared the phrase “To what extent do you have satisfying knowledge regarding…” and assessed nutritional knowledge of different aspects. The translators opted for «¿En qué medida posee conocimientos suficientes sobre…» (“To what extent do you have sufficient knowledge about…”) to facilitate comprehension in the Spanish healthcare context.
• Items 34 and 35. For the translation of the expression “flush tube”, discrepancies arose regarding whether to use the term «sonda nasogástrica» together with «tubo». An active debate among ICU experts led to the consensus that the term “tubo” be discarded, as it is not professionally used in Spain. Instead, the Spanish term «sonda de alimentación» (“feeding tube”) was adopted.

Table 1. Spanish and English versions of the questionnaire.

Items
1	¿Hay en su unidad guías/protocolos escritos sobre el manejo de la nutrición enteral? Are there any written guidelines regarding enteral nutrition on your ward?
2	¿Hay una enfermera responsable de la nutrición en su unidad? Is there a nurse responsible for nutrition on your ward?
3	¿Hay un equipo de nutrición en su unidad? Is there a nutritional team on your ward?
4	¿Hay un servicio de nutrición en su hospital? Is there a nutritional team at the hospital?
5	¿Hay en el hospital personas referentes para consultarles temas de nutrición? Are there other key persons to consult at the hospital?
6	¿Hay profesionales referentes externos al hospital para consultarles en temas de nutrición? Are there other key persons to consult outside the hospital?
7	¿Quién indica la cantidad de la nutrición enteral y los probióticos? Who prescribes the amount of enteral nutrition and probiotics?
8	¿Quién indica el tipo de la nutrición enteral y los probióticos? Who prescribes the type of enteral nutrition and probiotics?
9	¿Quién indica la velocidad de la nutrición enteral y los probióticos? Who prescribes the ratio of enteral nutrition and probiotics?
10	¿En qué medida ha obtenido conocimientos de: Consultar con compañeros? To which extent have you obtained knowledge from: Consulting colleagues?
11	¿En qué medida ha obtenido conocimientos de: Formación en el lugar de trabajo? To which extent have you obtained knowledge from: In-service training?
12	¿En qué medida ha obtenido conocimientos de: Congresos? To which extent have you obtained knowledge from: Lectures?
13	¿En qué medida ha obtenido conocimientos de: Formación especializada? To which extent have you obtained knowledge from: Specialist education?
14	¿En qué medida ha obtenido conocimientos de: Artículos de revistas científicas? To which extent have you obtained knowledge from: Scientific journal?
15	¿En qué medida ha obtenido conocimientos de: Otra literatura? To which extent have you obtained knowledge from: Other literatura?
16	¿En qué medida ha obtenido conocimientos de: Universidad? To which extent have you obtained knowledge from: Nursing school?
17	¿En qué medida ha obtenido conocimientos de: Cursos? To which extent have you obtained knowledge from: Courses?
18	¿En qué medida ha obtenido conocimientos de: Intranet, Internet? To which extent have you obtained knowledge from: Intranet, Internet?
19	¿En qué medida tiene responsabilidad en: evaluación del estado nutricional de sus pacientes? To what extent do you have responsibility regarding: assessment of nutritional status?
20	¿En qué medida tiene responsabilidad en la definición de objetivos sobre el estado nutricional de sus pacientes? To what extent do you have responsibility regarding: goals?
21	¿En qué medida tiene responsabilidad en la planificación e implementación de intervenciones en el estado nutricional de sus pacientes? To what extent do you have responsibility regarding: planning and implementing of interventions?
22	¿En qué medida tiene responsabilidad en la prevención de complicaciones? To what extent do you have responsibility regarding: prevention of complications?
23	¿En qué medida tiene responsabilidad en la evaluación de los resultados del tratamiento nutricional de sus pacientes? To what extent do you have responsibility regarding: evaluation
24	¿En qué medida posee conocimientos suficientes sobre la evaluación del estado nutricional? To what extent do you have satisfying knowledge regarding: assessment of nutritional status?
25	¿En qué medida posee conocimientos suficientes sobre los objetivos nutricionales establecidos? To what extent do you have satisfying knowledge regarding: goal?
26	¿En qué medida posee conocimientos suficientes sobre la planificación e implementación de intervenciones nutricionales? To what extent do you have satisfying knowledge regarding: planning and implementation of interventions?
27	¿En qué medida posee conocimientos suficientes sobre la prevención de complicaciones en nutrición? To what extent do you have satisfying knowledge regarding: prevention of complications?
28	¿En qué medida posee conocimientos suficientes sobre la evaluación de intervenciones nutricionales? To what extent do you have satisfying knowledge regarding: evaluation?
29	¿En qué medida dispone de documentos de apoyo para la evaluación del estado nutricional? To what extent do you have support from documentation regarding: assessment of nutritional status?
30	¿En qué medida dispone de documentos de apoyo para la definición de objetivos? To what extent do you have support from documentation regarding: goals?
31	¿En qué medida dispone de documentos de apoyo para la planificación e implementación de intervenciones? To what extent do you have support from documentation regarding: planning and implementation of interventions?
32	¿En qué medida dispone de documentos de apoyo para la prevención de complicaciones? To what extent do you have support from documentation regarding: prevention of complications?
33	¿En qué medida dispone de documentos de apoyo para la evaluación de intervenciones nutricionales? To what extent do you have support from documentation regarding: evaluation?
34	¿Lava la sonda de alimentación antes de la administración de nutrición o medicamentos? Flush tube before administration of nutrition or medication?
35	¿Lava la sonda de alimentación después de la administración de nutrición o medicamentos? Flush tube after administration of nutrition or medication?
36	¿Inspecciona las fosas nasales diariamente? Daily inspection of nostrils?
37	¿Se administran medicamentos que no deben triturarse en forma triturada a través de la sonda de alimentación? Clean syringe after each use?
38	¿Limpia la jeringa de alimentación enteral después de cada uso? Medications not to be crushed are administered in crushed form through feeding tube?
39	¿Se utiliza la modalidad de alimentación continua? Continuous feed?
40	¿Se utiliza la modalidad de alimentación en bolo? Bolus feed?
41	¿Verifica el residuo gástrico? Check gastric residual?
42	¿El horario de alimentación permite el descanso nocturno? Does feeding schedule allow for a night rest?
43	¿Utiliza bomba de alimentación? Use of feeding pump?
44	¿Confirma la correcta colocación de la sonda de alimentación antes de la administración de alimentación enteral? Confirm tube placement before delivery?
45	¿Cómo verifica la posición de la sonda nasogástrica de pequeño calibre después de la inserción? How to check position of the small bore tube after insertion?
46	¿Cómo averigua si un medicamento se puede triturar y administrar de manera enteral? How to find out if a medication can be crushed and given enterally?
47	¿Se coloca a los pacientes en una posición específica mientras reciben nutrición enteral? Are patients placed in a specific position while receiving enteral nutrition?

presents the items that compose the final consensual questionnaire sent to the experts, together with the original English version of the instrument.

3.2. Expert Review and Content Validity

The evaluations of 26 experts were received. All of these experts were currently working, or had previously worked, most of their professional careers within the Spanish healthcare system, specifically in different ICUs. Six of these experts combined their clinical work with part-time university teaching. The mean age of the experts was 42 years, and the mean ICU professional experience was 13.88 years. The remaining significant data are shown in

Table 2. Characteristics of the group of experts.

-	Mean ± SD	N	%
Age	42.15 ± 9.28	-	-
Sex	-	-	-
Women	-	22	84.62%
Men	-	4	15.38%
Professional experience in the ICU	13.88 ± 8.65	-	-
Academic background	-	-	-
Graduate	-	14	53.85%
Master	-	10	38.46%
Doctorate	-	2	7.69%

.

The CVI, kappa, and Aiken’s V with its confidence interval (CI) for each questionnaire item, calculated from the 26 evaluations, are presented in

Table 3. Content validity indicators and comprehensibility indicators.

Item	CVI	KAPPA	Aiken’s V	Aikens’V-CI 95%	Comprehensibility
1	0.846	0.846	0.865	(0.728–0.976)	4.65
2	0.808	0.807	0.846	(0.703–0.965)	4.65
3	0.846	0.846	0.827	(0.678–0.953)	4.38
4	0.885	0.885	0.856	(0.715–0.971)	4.54
5	0.846	0.846	0.885	(0.755–0.987)	4.73
6	0.769	0.768	0.779	(0.618–0.920)	4.62
7	0.961	0.961	0.952	(0.858–1.013)	4.73
8	0.923	0.923	0.913	(0.797–1.001)	4.65
9	0.885	0.885	0.900	(0.777–0.995)	4.62
10	0.808	0.807	0.847	(0.703–0.965)	4.46
11	0.923	0.923	0.885	(0.755–0.987)	4.42
12	0.731	0.728	0.760	(0.595–0.906)	4.38
13	0.885	0.885	0.827	(0.678–0.953)	4.38
14	0.846	0.846	0.798	(0.642–0.933)	4.31
15	0.808	0.807	0.770	(0.607–0.913)	4.27
16	0.923	0.923	0.837	(0.690–0.959)	4.31
17	0.885	0.885	0.827	(0.678–0.953)	4.38
18	0.885	0.885	0.817	(0.666–0.947)	4.31
19	0.923	0.923	0.885	(0.755–0.987)	4.65
20	0.846	0.846	0.837	(0.690–0.959)	4.58
21	0.846	0.846	0.837	(0.690–0.859)	4.58
22	0.961	0.961	0.913	(0.797–1.001)	4.69
23	0.885	0.885	0.866	(0.729–0.976)	4.62
24	0.885	0.885	0.894	(0.768–0.992)	4.65
25	0.846	0.846	0.865	(0.729–0.976)	4.62
26	0.923	0.923	0.885	(0.755–0.989)	4.58
27	0.961	0.961	0.894	(0.768–0.992)	4.69
28	0.846	0.846	0.827	(0.678–0.953)	4.46
29	0.808	0.807	0.856	(0.715–0.971)	4.65
30	0.808	0.807	0.817	(0.666–0.946)	4.5
31	0.846	0.846	0.827	(0.678–0.953)	4.58
32	0.808	0.807	0.837	(0.690–0.959)	4.62
33	0.731	0.728	0.788	(0.630–0.927)	4.54
34	0.885	0.885	0.865	(0.729–0.976)	4.58
35	0.923	0.923	0.894	(0.768–0.992)	4.58
36	0.885	0.885	0.837	(0.690–0.959)	4.38
37	0.808	0.807	0.808	(0.654–0.940)	4.35
38	0.846	0.846	0.837	(0.690–0.959)	4.46
39	0.885	0.885	0.855	(0.715–0.971)	4.38
40	0.769	0.768	0.788	(0.630–0.927)	4.27
41	0.923	0.923	0.885	(0.755–0.987)	4.54
42	0.808	0.807	0.810	(0.656–0.941)	4.35
43	0.923	0.923	0.875	(0.741–0.982)	4.58
44	0.923	0.923	0.875	(0.741–0.982)	4.54
45	0.923	0.923	0.904	(0.782–0.997)	4.62
46	0.923	0.923	0.913	(0.997–1.000)	4.62
47	0.885	0.885	0.904	(0.782–0.997)	4.65
Mean	0.866 (S-CVI)	-	-		4.53

. Likewise, all items achieved a minimum score of 4 and therefore were considered highly comprehensible. Ninety-one percent of the items reached CVI values above 0.78, which are considered acceptable. Only four items scored below 0.78 (two of them scored 0.77). The overall CVI of the questionnaire (S-CVI) was 0.87. The items showed Aiken’s V values ranging from 0.952 to 0.779.

3.3. Comprehensibility Analysis/Linguistic Validation

The results showed an overall mean score of 4.53 out of 5, with values ranging from 4.27 to 4.73. The highest-scoring items were item 5 and item 7, both with 4.73, while the lowest-scoring items were item 15 and 40, both with 4.27. All of them were considered to have values of “high comprehensibility.”

3.4. Internal Validity

Based on the responses obtained in the pilot study, Cronbach’s alpha for the overall questionnaire was 0.85. The internal consistency of the questionnaire sections, as originally conceptualized by Persenius et al. [11], was also adequate, with coefficients of 0.82 for responsibility, 0.90 for knowledge, and 0.92 for documentation.

3.5. Pilot Study Results

A total of 99 registered nurses completed the questionnaire throughout the study. This group of professionals had an average age of 39 years. 83% of the nurses who participated had at least two years of professional work experience in the ICU. Regarding academic training in nutrition for critically ill patients, most nurses reported taking continuing education courses, and only 4% reported taking expert or master courses (8 nurses left this field blank) (

Table 4. Characteristics of the participants’ pilot study.

-	Mean ± SD	N (99)	(%)
Age	39.1 ± 11.7	-	-
Sex	-	-	-
Women	-	75	75.75%
Men	-	24	24.24%
Professional experience in the ICU	10.86 ± 10.27	-	-
Academic background	-	-	-
Graduate	-	66	53.85%
Master	-	30	38.46%
Doctorate	-	3	7.69%
Training in nutrition for critically ill patients	-	-	-
Continuing formation	-	83	83.83%
Expert or diploma courses	-	4	4%
Master	-	4	4%

).

As shown in

Table 5. Nurses’ knowledge of written guidelines and nutritional key persons.

-	Yes (N)	No (N)	Don’t Know (N)
1. Are there any written guidelines regarding enteral nutrition on your ward?	75	16	8
2. Is there a nurse responsible for nutrition on your ward?	3	88	8
3. Is there a nutritional team on your ward?	19	67	13
4. Is there a nutritional team at the hospital?	71	6	22
5. Are there other key persons to consult at the hospital?	62	8	29
6. Are there other key persons to consult outside the hospital?	17	27	55

, most nurses reported having protocols in their ICUs regarding EN, but none had a nurse responsible for this aspect.

Table 6. Nurses’ source of knowledge; perceptions of responsibility, knowledge, and documentation; nursing interventions.

Source of Knowledge	Mean	SD
10. Consulting colleagues	3.41	1.03
11. In-service training	2.81	1.09
12. Lectures	1.96	1.1
13. Specialist education	2.65	1.26
14. Scientific journals	2.41	1.18
15. Other literature	2.21	1.04
16. Nursing school	2.76	1.11
17. Courses	3.11	1.11
18. Intranet and Internet	3.11	1.16
Responsibility	-	-
19. Assessment of nutritional status	3.14	1.01
20. Goals	2.6	1.06
21. Planning and implementing of interventions	2.69	0.99
22. Prevention of complications	3.81	0.94
23. Evaluation	3.13	1.09
Knowledge	-	-
24. Assessment of nutritional status	2.87	0.97
25. Goals	2.66	0.96
26. Planning and implementing of interventions	2.63	0.95
27. Prevention of complications	3.12	0.96
28. Evaluations	2.72	0.92
Documentation	-	-
29. Assessment of nutritional status	2.54	1.07
30. Goals	2.17	0.9
31. Planning and implementing of interventions	2.29	0.9
32. Prevention of complications	2.55	0.99
33. Evaluation	2.31	0.96
Enteral feeding interventions	-	-
34. Flush tube before administration of nutrition or medication	4.19	1.23
35. Flush tube after administration of nutrition or medication	4.85	0.44
36. Daily inspection of nostrils	4.1	1.05
37. Medications not to be crushed are administered in crushed form through feeding tube	2.75	1.21
38. Clean syringe after each use	4.47	0.86
39. Continuous feed	4.16	0.85
40. Bolus feed	2.09	0.91
41. Check gastric residual	4.5	0.91
42. Does feeding schedule allow for a night rest	2.57	1.38
43. Use of feeding pump	4.72	0.54
44. Confirm tube placement	4.55	0.82

summarizes findings on sources of knowledge, perceptions of responsibility, self-reported knowledge, documentation practices, and enteral nutrition (EN)-related interventions performed by ICU nurses. The highest-scoring items were consultation with colleagues as a source of knowledge; perceived responsibility, knowledge, and documentation concerning the prevention of complications; and routine flushing of the feeding tube after the administration of nutrition or medication (items 10, 22, 27, 32, 35).

4. Discussion

Given the increasing prevalence of malnutrition among critically ill patients and the adverse consequences associated with it, this study achieved its aims of translating and culturally adapting the Persenius et al. questionnaire into Spanish and providing initial evidence of its content validity and internal consistency [11,23,30].

Critically ill patients exhibit an inflammatory state that correlates with illness severity, leading to increased caloric and protein requirements and, consequently, malnutrition. Through appropriate nutritional assessment, the use of screening tools, and early nutritional intervention, this vicious cycle could be interrupted [34,35].

The high S-CVI found and the internal consistency achieved support the questionnaire’s validity and reliability, consistent with the data reported by Persenius et al. [11]. These results indicate that the Spanish version of the questionnaire shows adequate content validity, high item comprehensibility, and acceptable internal consistency, suggesting that the questionnaire is understandable and relevant for assessing ICU nurses’ perceptions and self-reported knowledge regarding EN in Spain. The need for further construct validation through factor analysis and multicenter studies is evident to consolidate its psychometric properties and broaden its applicability.

Thus, the results of this study align with previous research highlighting training gaps among nurses regarding EN in the ICU and the need for standardized instruments to assess such knowledge among healthcare professionals [9,36].

However, the presence of low-scoring items in the pilot study, especially those related to sources of knowledge and feeding modalities, suggests potential divergence in clinical practice or lower conceptual clarity among professionals. This finding is consistent with recent evidence indicating a gap between theoretical knowledge and the practical implementation of nutritional care [10,34,35]. From an applied perspective, these results underscore the need to design targeted training strategies in areas with lower expert consensus, thereby strengthening professional understanding and improving clinical performance in enteral nutrition. These findings align with previous studies that have developed and validated similar instruments to measure nurses’ knowledge of NE, underscoring the importance of ensuring clear comprehension of items before clinical application [15,20,24].

Recent research has identified significant gaps in nurses’ practical knowledge of specific aspects of enteral nutrition, including formula indications, tube management, and the assessment of nutritional tolerance, highlighting the need for robust, context-sensitive instruments to identify these educational needs [37].

In this context, the presence of some lower-scoring items in the pilot study may reflect clinical knowledge domains that, as previously reported in observational studies [10,13,14] and multicenter surveys, are less consistently mastered by nursing staff and therefore warrant greater educational attention, particularly regarding practical skills and evidence-based aspects of care [38,39].

Overall, these findings support the adequacy of the Spanish version of Persenius’ questionnaire in terms of content validity and internal consistency [40]. Nevertheless, additional measurement properties, including feasibility (e.g., completion time, acceptability, and implementation costs), should be formally evaluated in future research.

The scientific literature indicates that lower CVI thresholds may be considered acceptable when panels include at least nine experts, as larger expert samples enhance representativeness and reduce the likelihood of bias in the content validation process [41]. Furthermore, several authors underscore the methodological importance of selecting appropriate statistical approaches for content validation [42]. Comparative analyses of established methods, such as those proposed by Lawshe, Lynn, and Polit, suggest that the approach developed by Polit and Beck provides greater statistical rigor and a more robust mathematical framework for estimating agreement beyond chance [23,26,30,42]. This methodological decision strengthens the present study, as content validity was calculated according to the procedures recommended by Polit and Beck [30], thereby enhancing the robustness of the results and conclusions.

Limitations and Future Research

Several limitations should be considered in future research. First, as this study relied on expert evaluation, it is possible that not all relevant aspects or dimensions of the construct were fully captured, despite the breadth of the expert panel. Additionally, the potential for selection or convenience bias among experts cannot be ruled out.

A further limitation concerns the instrument’s length. The resulting questionnaire may be perceived as moderately long, which could affect response rates in future applications. As this represents the first Spanish version of the Persenius et al. questionnaire [11], the research team is considering developing a shorter version in subsequent phases, while ensuring its psychometric properties are preserved.

Finally, test–retest reliability was not assessed; therefore, the instrument’s temporal stability remains to be established.

Our principal objective was to analyze the validity and reliability of the instrument, so we only accessed a limited population (99 nurses). There is a need for further multicenter studies that include larger populations with diverse characteristics, allowing analysis of the questionnaire’s reliability across the different contexts in which it is evaluated.

This study represents the first stage of the questionnaire’s cross-cultural adaptation. The Spanish version demonstrated adequate content validity, high item comprehensibility, and acceptable internal consistency. Therefore, future research should evaluate construct validity through exploratory and confirmatory factor analyses (EFAs and CFAs) and examine test–retest reliability in larger, more diverse samples.

5. Conclusions

The Spanish version of this instrument demonstrated satisfactory content validity and reliability, supporting its suitability as a structured measure of ICU nurses’ knowledge regarding nutritional risk in critically ill patients. Its application may facilitate the identification of specific knowledge gaps, enabling the design and implementation of targeted educational interventions. Furthermore, the availability of a validated tool creates opportunities for future experimental and quasi-experimental studies to evaluate the effectiveness of these interventions and their potential to improve the quality of care and reduce nutrition-related complications in critically ill populations.