Barriers to Providing VTE Chemoprophylaxis to Hospitalized Patients: A Nursing-Focused Qualitative Evaluation
BACKGROUND: Venous thromboembolism (VTE) is a serious medical condition that results in preventable morbidity and mortality.
OBJECTIVES: The objective of this study was to identify nursing-related barriers to administration of VTE chemoprophylaxis to hospitalized patients.
DESIGN: This was a qualitative study including nurses from five inpatient units at one hospital.
METHODS: Observations were conducted on five units to gain insight into the process for administering chemoprophylaxis. Focus group interviews were conducted with nurses and were audio-recorded, transcribed verbatim, and analyzed using the Theoretical Domains Framework to identify barriers to providing VTE chemoprophylaxis.
RESULTS: We conducted 14 focus group interviews with nurses from five inpatient units to assess nurses’ perceptions of barriers to administration of VTE chemoprophylaxis. The barriers identified included nurses’ misconceptions that ambulating patients did not require chemoprophylaxis, nurses’ uncertainty when counseling patients on the importance of chemoprophylaxis, and a lack of comparative data for nurses regarding their specific refusal rates.
CONCLUSIONS: Multiple factors act as barriers to patients receiving VTE chemoprophylaxis. These barriers are often modifiable targets for quality improvement. There is a need to focus on behavior changes that will remove or minimize barriers and equip nurses to ensure administration of VTE chemoprophylaxis by engaging patients in their care.
© 2019 Society of Hospital Medicine
Skills
Nurses felt inadequately equipped to handle patient refusals. Many said that patient refusal of treatments was never discussed in nursing school. As a result, when patients refused treatments, the nurses did not know how to handle the situation. They felt that they lacked the tools and techniques to persuade the patient to comply.
Beliefs about Capabilities
Nurses did not know their own patient refusal rate or benchmarks of an acceptable refusal rate in contrast to one that is too high. Without this feedback, they were unable to assess their own behavior or performance related to providing VTE chemoprophylaxis.
DISCUSSION
Nurses play a critical role in providing VTE chemoprophylaxis to patients throughout their hospitalization. This study provided a unique opportunity to perform an in-depth, qualitative analysis of the barriers nurses face in providing patients with VTE chemoprophylaxis as part of their daily work caring for patients. We discovered several nursing-related barriers to the provision of VTE chemoprophylaxis, including lack of knowledge, resources, skill, and misconceptions of their capability to provide VTE chemoprophylaxis. We used a bottom-up approach by incorporating the voices of unit nurses, clinical coordinators, and nurse managers to understand potential barriers. Our findings brought to light the challenge of delivering standardized care in an area of care that is generally agreed upon, yet not fully followed. Some nurses display greater proficiency than others at communicating with patients who do not understand their risk for VTE and need for chemoprophylaxis. Furthermore, there is a pronounced misconception around the delivery of VTE chemoprophylaxis. Nurses have the inaccurate belief that even if ordered, chemoprophylaxis is not required. This misconception was widespread among nurses taking care of both medical and surgical patients. These factors appear to be modifiable targets for quality improvement and highlight the need for a skills-based education during the new hire onboarding process, as well as ongoing reeducation to ensure nursing staff have the skills to appropriately provide best-practice care for VTE chemoprophylaxis. Nurses felt ownership of the results of the qualitative evaluation because they were included in every aspect from the beginning.27 This sense of ownership will support future quality improvement efforts to develop a skills-based intervention to improve the provision of VTE chemoprophylaxis.18,27
This study has certain limitations. First, it was a qualitative study assessing nursing-related barriers to providing VTE chemoprophylaxis at a single institution, and the results cannot be generalized broadly. However, the techniques and results are transferable to other hospital settings and other clinical care situations. Thus, we believe that other institutions can utilize our methods and that similar lessons can be learned and applied. Furthermore, the validity of our study is bolstered by concordance between the results of this study and those of other studies conducted on the topic of provision of VTE prophylaxis by nurses.13-15,21 Other studies utilized observations and surveys to determine potential nurse-related barriers to the provision of VTE prophylaxis, such as lack of knowledge and the belief that the need for prophylaxis can be determined based on whether or not the patient is ambulating;13,14 however, by utilizing focus group interviews, we allowed nurses to speak in their own voices about their experiences with VTE prophylaxis, and we were able to delve deeper and identify additional barriers that emerged from discussions with nurses, such as the lack of skill and misconceptions of capability.28,29 Second, the study focused solely on nurses. Additional initiatives are underway to assess the roles of resident physicians, attending physicians, and patients in the provision of VTE prophylaxis.
Nursing-related barriers to the provision of VTE chemoprophylaxis include a lack of knowledge, resources, skills, and misconceptions of the consequences of missed elements of VTE prophylaxis. Future initiatives will focus on equipping nurses to have meaningful conversations with patients and engaging patients in their care through development of a multifaceted bundle of interventions. Furthermore, similar methods of qualitative inquiry will be used to identify the role of resident and attending physicians and patients in the provision of VTE chemoprophylaxis.
