Ophthalmic nurses’ knowledge, attitude, and practice toward venous thromboembolic prevention: a dual-center cross-sectional survey

Introduction

Venous thromboembolism (VTE), a disease entity comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a leading cause of morbidity and mortality in hospitalized patients (Kahn et al., 2018; Tritschler et al., 2018; Anderson et al., 2019). Globally, VTE causes a significant disease burden, affecting nearly 10 million people a year (ISTH Steering Committee for World Thrombosis Day, 2014; Khan et al., 2021). The estimated annual healthcare costs for VTE ranged between €1.5–3.3 billion in Europe, and US $7–10 billion in the USA (Barco et al., 2016; Grosse et al., 2016). Hence, VTE prevention ranked top one of the 79 patient safety practice strategies in hospitals (Shojania et al., 2001).

Although the incidence of VTE is relatively low in Asian counties, including China, it has increased steadily in recent years (Liew et al., 2017). Between 2007 and 2016, hospitalization rates for VTE increased from 3.2 to 17.5 per 100,000 people in China (Zhang et al., 2019). Several reasons may account for the apparent rise, including population aging, lifestyle changes, increasing awareness, and better detection (Liew et al., 2017; Zhang et al., 2019; Di Nisio, Van & Buller, 2016). Therefore, over the last decade, China has developed a variety of evidence-based consensus, guidelines, and national programs to focus on VTE prevention and treatment (Expert Committee of the National Capacity Building Project for Prevention and Treatment of Pulmonary Embolism and Deep Vein Thrombosis, 2022; Li, Zhang & Wang, 2017; The National Health Commission , 2021).

Although VTE among ophthalmic surgical patients is less reported, a growing body of evidence suggests that ophthalmic surgical patients are at an increased risk of VTE (Kaplan & Reba, 1972; Huang & Wei, 2016; Brill et al., 2019; Law, Chan & Cheng, 2018; Wang et al., 2016). Studies have shown that VTE is the leading cause of death in patients undergoing ophthalmic surgery (Kaplan & Reba, 1972; Kanbay et al., 2011). Most ophthalmic surgical patients are middle-aged or older adults (Lei et al., 2019) and are comorbid with other chronic illnesses such as obesity, coronary heart disease, and diabetes (Liu et al., 2017; Gong et al., 2021), which are all well-known risk factors for VTE. In addition, most ophthalmic surgeries take more than 30 min and the prolonged immobility in a postoperative prone position after retina surgery also predisposes patients to VTE (Brill et al., 2019). Therefore, VTE prevention for ophthalmic surgical patients deserves closer attention.

Most VTE is preventable (Khan et al., 2021; Liew et al., 2017; Cohen et al., 2007). It is safer and more cost-effective to prevent the occurrence of VTE than to treat VTE after it develops (Khan et al., 2021). However, the implementation of VTE prevention remains inadequate or inappropriate (Kahn et al., 2018). As the front-line health workers providing the most direct care and spending the most time with patients, nurses play a crucial role in the effective identification, prevention, and management of VTE in clinical practice. Hence, it is important for nurses to clearly understand the therapeutic and prophylactic measures of thrombosis in order to adequately prevent VTE in hospitalized patients. A number of studies have demonstrated that correct knowledge, a positive attitude, and effective practice on VTE prevention are vital for the prevention and management of VTE among patients in various conditions (Wang et al., 2021; Oh, Boo & Lee, 2017; Ma et al., 2018). However, to our knowledge, no study has ever explored the KAP of VTE prevention among ophthalmic nurses, despite the increased risk of VTE associated with ophthalmic surgery.

To bridge the research gap, we conducted the current study to (a) examine the KAP of ophthalmic nurses towards VTE prevention, and (b) evaluate factors associated with the practice of ophthalmic nurses regarding VTE prevention. Our findings would provide a scientific basis for the development of future KAP training programs targeted at VTE prevention among ophthalmic nurses to prevent VTE in ophthalmic surgery patients.

Materials and Methods

Results

Discussion

The current study investigated ophthalmic nurses’ knowledge, attitude, and practice levels toward venous thromboembolic prevention and examined the factors associated with ophthalmic nurses’ practice. Nurses’ KAP is critical for VTE prevention and control and is paramount for intervention development and policy implementation. To our knowledge, this is the first KAP survey of venous thromboembolic prevention among ophthalmic nurses. The results showed that the ophthalmic nurses had a relatively higher level of KAP in VTE prevention compared to previous studies on nurses from other specialties (Wang et al., 2021; Oh, Boo & Lee, 2017; Ma et al., 2018; Yan et al., 2021; Xu et al., 2017). However, nurses had low scores in certain items of each dimension, indicating the need for improvement. In addition, province, hospital type, department, previous VTE prevention training, VTE prevention management in hospitals, and attitude towards VTE prevention were significantly associated with ophthalmic nurses’ practice.

Our study showed that the ophthalmic nurses’ KAP towards VTE prevention was at a desirable level, which may be explained by two reasons (Ay, Pabinger & Cohen, 2017). First, the Chinese government’s involvement has played a significant role in the promotion and implementation of VTE prevention. VTE prevention was listed among the top ten aims of the National Medical Quality and Safety Improvement Targets for 2021 (The National Health Commission , 2021), which provided significant momentum for developing VTE prevention. Secondly, the high score of the overall KAP might be due to the respondent’s characteristics. In our study, most respondents came from advanced hospitals with more training opportunities and better management systems for VTE prevention.

Although the ophthalmic nurses showed a satisfactory correct rate in VTE prevention knowledge (76.4%), they held some misunderstandings in the following three items with low correct rates: DVT complication (22.8%), the physical prevention of VTE (27.5%), and the Caprini risk assessment model (44.8%). These findings suggest that there is still room for improvement in these areas related to VTE prevention, which may be trained through professional courses. Our findings indicated that attending professional training in a hospital or department is one of the main sources of knowledge for participants (83.8%). Furthermore, Lee and colleagues have reported that nurses with previous VTE training had higher self-efficacy in VTE assessment and prevention (Lee et al., 2014). Therefore, it is suggested that providing high-quality training in VTE prevention may effectively improve ophthalmic nurses’ knowledge of VTE prevention. The training can take multiple forms, such as academic workshops, knowledge lectures, and nursing rounds, which may not only strengthen the employees’ professional knowledge but also the management system (Bartholomew, 2017; Ortel et al., 2020).

Our study showed that the ophthalmic nurses’ attitudes toward VTE prevention were at a desirable level. The nurses’ positive attitude toward VTE prevention may be explained by their high level of VTE prevention knowledge, as studies have consistently shown a positive association between knowledge and attitude (Zhang et al., 2021). As for practice in VTE prevention, our study showed a favorable correct rate of 81.6%, indicating most nurses have been taking active actions to prevent VTE. However, they had low performance in the following two areas: prevention assessment of risks and health education for the high-risk population, indicating room for improvement in these areas. Further multivariate regression analysis identified seven influencing factors that were associated with nurses’ practice in VTE prevention, which may be classified into the following three categories: (a) environmental factors such as province, hospital type, and department; (b) training and management; and (c) knowledge and attitude toward VTE prevention, each discussed below:

In terms of environmental factors, the practice scores in VTE prevention were significantly higher in Hunan Province than in Zhejiang Province, in general hospitals than in specialty hospitals, and in inpatient or outpatient departments than in operating rooms. These differences may reflect the unequal distribution of prevention resources, training systems, and management systems. Furthermore, it may also be caused by the unequal distribution of high-risk VTE patients. For example, general hospitals are more likely to admit patients with comorbidities or complications that predispose them to VTE risk. As a result, nurses in general hospitals encounter VTE patients more frequently and thus have higher practice in VTE.

In terms of training and management, nurses who received previous VTE prevention training and had VTE prevention management in the hospital had significantly higher practice scores than those without. These findings were consistent with previous studies showing the effectiveness of strengthening training and management in improving nurses’ KAP towards VTE prevention (Yan et al., 2021; Zhang et al., 2021). These findings suggest that it is essential to provide regular and professional academic courses or conferences on VTE prevention for nurses, which not only requires support and arrangement from the hospital but also a better management system. In order to better evaluate the effect of training and make appropriate adjustments, there need to be measurable goals for each activity and timely feedback from nurses (Maynard & Stein, 2010). From the hospital’s perspective, the systematic redesign of the VTE training system is crucial to VTE prevention and improvement. In addition, the managers’ attention could be a facilitator for the organizational climate (Bartholomew, 2017; Jönsson et al., 2018), which is conducive to the improvement of nurses’ KAP level for VTE prevention. Therefore, the managers’ involvement is key to VTE management.

In terms of knowledge and attitude towards VTE prevention, nurses with better knowledge and a positive attitude toward VTE prevention had significantly higher scores in VTE prevention practice, a finding also consistent with previous studies (Yan et al., 2021; Zhang et al., 2021). A positive attitude indicates high levels of self-efficacy and responsibility regarding VTE prevention. Nurses with positive attitudes toward VTE prevention had higher awareness of the importance of self-education as well as patient education on VTE prevention (Lee et al., 2014). However, according to the present data, nearly 20% of nurses did not provide timely and necessary health education for patients, which may lead to an increased risk of VTE and related morbidity and mortality (Bauer et al., 2019; Lavall & Costello, 2015). Our findings suggest that more education and support may be needed to improve nurses’ knowledge and attitudes toward VTE prevention, especially in the aspect of patient education. In addition, the management system should be supportive and effective in optimizing the nurse workflow, which can start with improving the nurse-patient ratio and reducing unnecessary paperwork to allow more bedside time for the nurse. A better environment and lower workload may help foster better knowledge and a positive attitude among nurses, which will consequently lead to improved practice in VTE prevention (Van Bogaert et al., 2013).

Limitations

This study has several potential limitations. First, the nurses were mostly recruited from tertiary hospitals in two provinces using non-random sampling methods, which may limit the sample representativeness and the result generalizability. Second, the cross-sectional study design may preclude any causal inferences between nurses’ practice in VTE prevention and its influencing factors. Third, the assessment of KAP was based on a newly developed measurement tool instead of an internationally standard tool, making it difficult to make comparisons with other studies. Fourth, all data collection relied on nurses’ self-report, which may be subject to recall bias and social desirability bias. Finally, although the knowledge, attitudes, and practice subscale scores showed significant associations with each other, all the correlation coefficients were below 0.60, which may be related to the large sample size and thus warrants further examination in future studies.

Conclusions

Our study provided a comprehensive understanding of the ophthalmic nurses’ knowledge, attitude, and practice in VTE prevention, as well as identified specific items in each dimension for improvement. In addition, our study showed multiple factors were associated with ophthalmic nurses’ practice in VTE prevention, including environmental factors, training and management, knowledge and attitudes toward VTE prevention. Our findings provide important implications and guidance for future intervention programs to improve the ophthalmic nurses’ knowledge, attitude, and practice in VTE prevention.

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