Knowledge, risk assessment, practices, self‐efficacy, attitudes, and behaviour's towards venous thromboembolism among nurses: A systematic review

Abstract Aim This study reviewed the literature on nurses' knowledge, risk assessment practices, self‐efficacy, attitudes, and behaviours towards venous thromboembolism (VTE). Design A systematic review following PRISMA guidelines. Methods CINAHL (via EBSCO), MEDLINE (via PubMed), and Web of Science were electronic databases used to find studies published from 2010 to November 2020 in English language. A Hoy critical appraisal checklist was used to assess the risk of bias and methodologic quality. Results This study included fourteen studies conducted on 8628 Registered Nurses. Nine of the fourteen studies examined nurses' general knowledge level regarding VTE, and five showed that most nurses had a good knowledge of VTE. Of the 14 studies, six assessed nurses' risk assessment knowledge regarding VTE, and three showed that nurses had low knowledge of VTE risk assessment. Eleven studies assessed nurses' practices concerning VTE prophylaxis; 5 of the 11 studies reported that nurses had poor and unsatisfactory levels of VTE practice. Three of the 14 studies showed that nurses had low self‐efficacy and varied beliefs. The most frequent recommendations were to create continuous educational programs and in‐service training programs (n = 11), followed by creating institutional protocols standardizing VTE (n = 6). Conclusions Comprehensive educational programs and campaigns based on well‐established and standardized tools should be provided to nurses to improve their VTE knowledge.


| INTRODUC TI ON
Thromboembolic diseases have become a primary cause of death, responsible for 1 in 4 deaths globally (Wendelboe & Raskob, 2016).
Venous thromboembolism (VTE) is one of these diseases and includes deep vein thrombosis (DVT) and pulmonary embolism (PE; Centers for Disease Control and Prevention, 2016;Di Nisio et al., 2016). VTE has been acknowledged as the main complication among medical and surgical patients and is also known as the 'silent killer' of hospitalized patients (CDC, 2016).
The population-based estimates for thrombotic conditions are limited in many countries, especially those categorized as developing (Wendelboe & Raskob, 2016). A global study was conducted to explain the epidemiology of thromboembolic diseases, which reported that the total incidence of these diseases has decreased in developed countries but is still rising in developing countries (Wendelboe & Raskob, 2016). In developed countries, VTE still significantly contributes to increased mortality and morbidity. For example, estimates suggest 60,000-100,000 Americans die from thromboembolic conditions (CDC, 2016). In developing countries in Asia, the situation is not reassuring. A study has shown that, despite the common belief that VTE is less common in Asian countries than in Western countries, the incidence rate of DVT in Asia was between 3% and 28% (Gerotziafas et al., 2018).
Venous thromboembolism can cause life-threatening complications, prolonged hospitalization, and increased care costs (Dawoud et al., 2018;Lovely et al., 2020). According to the Centers for Disease Control (CDC), DVT increases the possibility of post-thrombotic syndrome and PE, which affect an estimated 50% of DVT cases (CDC, 2016). In the United States, the monthly cost of treatment for DVT is an estimated $700 to $1400, and non-pharmacological prophylaxis is estimated to cost $465 to $875 per patient (Dawoud et al., 2018).
Although VTE is a potentially life-threatening condition, it is preventable (Khalafallah et al., 2016;Xu et al., 2018). Several organizations have developed VTE prevention guidelines to decrease VTE mortality and enhance prevention. The primary pharmacological and non-pharmacological preventive practices recommended in these guidelines are graduated compression stockings, intermittent pneumatic compression, and anticoagulation therapy (CDC, 2016; National Institute for Health and Care Excellence, 2018). Recently, the Centers for Disease Control and Prevention has developed three main strategies to promote VTE: strengthening monitoring, best practices, and increased education about VTE (CDC, 2016).
Inadequate knowledge and practice are the causes most associated with increased VTE prevalence worldwide (Silva et al., 2020).
Several studies revealed inadequate knowledge of deep vein thrombosis risks and poor practices concerning the prevention of deep vein thrombosis (Ahmed et al., 2020;Al-Mugheed & Bayraktar, 2018). Studies have also indicated that low self-efficacy and behaviours contribute to improving the quality of VTE patient care (Silva et al., 2020;Yan et al., 2020). Increasing the knowledge and improving the practices on VTE risks and prevention to avoid complications are necessary; they may also help improve awareness and prevent this essential public health problem. However, this is the first systematic review examining relevant studies of nurses' knowledge, risk assessment, practices, self-efficacy, attitudes, and behaviours towards VTE prophylaxis. This review may help establish appropriate nursing education and management strategies for VTE prevention and management.

| Eligibility criteria
The literature search for this systematic review was adopted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist (PRISMA) guidelines. The inclusion criteria were: • Studies using the cross-sectional design, randomized controlled trial or quasi-experimental study design, and pre-post-test design; • Studies examining knowledge, risk assessment, practices, selfefficacy, attitudes, and behaviours towards VTE prophylaxis; • Studies conducted on nurses; and • Studies using self-reports or observation methods for data collection.
The exclusion criteria from this review were the following: • Studies that combined nurses and other health care providers; • Studies published as a short report or review studies; • Studies with low quality, such as conference proceedings, dissertations, and theses; and • Studies non English language.  Table 1 were combined with Boolean operators, including AND, OR.

| Selection of studies and data extraction
Two independent researchers inspected abstracts and titles; then, the full text was reviewed regarding eligibility criteria. If the text matched, it was coded as 'include'. Disagreements regarding the study's inclusion were resolved between study authors by consensus. Studies with appropriate data were included in the systematic review. The required data included study characteristics (year of publication, data collection method, participants, and sampling method), level of knowledge, risk assessment, attitudes, behaviours, self-efficacy, practice, and recommendations of VTE.

| Quality assessment and abstraction
The Hoy critical appraisal checklist assessed the risk of bias and methodologic quality. The main reasons to use it were that it is an easily applied tool based on an exhaustive literature review and items that showed high interrater agreement (Al-Mugheed, Bani-Issa, Rababa, et al., 2022;Al-Mugheed, Bayraktar, Nashwan, et al., 2022;Hoy et al., 2012). The Hoy critical appraisal checklist includes a 10-item checklist with two domains: External validity (target sample, frame of the sample, sampling method, and nonresponse bias minimal) and internal validity (data collected, case definition, validity and reliability of study instrument, and data collection mode). Two assessors assessed each paper for bias risk, and discussions resolved any discrepancies.

| Study characteristics
A total of 3511 articles were identified from the initial search in four different electronic databases. After the deletion of duplicates, 1978 studies were addressed for further screened. After reading the abstract and full texts, 1952 articles were excluded.

| Nurses' general knowledge of VTE
In Al-Mugheed and Bayraktar's (2018) study, most nurses had numerous correct answers regarding the definition and causes of VTE.
In one study, half of the nurses answered questions correctly regarding the initial diagnostic test of VTE (Silva et al., 2020). In Antony et al. (2016), nurses correctly answered items regarding VTE's pathophysiology, signs, and symptoms. In contrast, Oh et al. (2016) found that nurses had low correct answering rates regarding VTE diagnosis; only 15% correctly knew a CT scan as the initial diagnostic test for PE, see Table 2.

| Nurses' knowledge of risk assessment VTE
Of the 14 studies, six assessed nurses' risk assessment knowl-

Study authors (year)
Knowledge level

Selfefficacy and beliefs
Risk assessment knowledge Practice Attitudes Behaviour's  Table 2.

| Self-efficacy, beliefs, attitudes, and behaviours of the nurses towards VTE prevention
Only three of the 14 studies considered the nurses' self-efficacy, attitudes, and behaviours towards VTE prevention (Elder et al., 2016;Silva et al., 2020;Yan et al., 2020); these studies showed that nurses had low self-efficacy and varied beliefs. Two studies were conducted among nurses concerning attitudes and behaviours towards VTE; one reported positive attitudes and a low level of behaviours towards VTE prevention (Yan et al., 2020). However, most nurses had a high behaviour rate related to regularly assessing the VTE risks of those hospitalized and providing VTE prevention education for patients (Yan et al., 2020). The nurses showed varied attitudes in using their clinical decision-making to offer and administer low-molecularweight heparin doses to the patient (Elder et al., 2016), see Table 2.

| Risk of bias
In general, most studies reported having a high-quality level with low bias. The most commonly found 'Definitely High' and 'Probably High' were related to confounding and performance. Of the 14 studies, two reported 'Definitely High' in terms of confounding, and two reported 'Probably High' related to performance, see Table 4 for further details.

| DISCUSS ION
Venous thromboembolism prevention is the most potent way to positively impact patient outcomes and decrease extended hospitalizations, as VTE incidence has increased over time among hospitalized patients (Yan et al., 2020). This is the first systematic review to examine nurses' knowledge, risk assessment, practices, self-efficacy, This finding does not align with a recent study that found medical staff had poorly scored regarding the causes and pathology of VTE (Zhou et al., 2019). The possible reasons may be a result of methodological variations by using different questionnaires in the studies and a lack of nursing staff participation.
The present study results indicate that most participants had inadequate and poor knowledge of VTE risk assessment. Other studies also showed poor knowledge of VTE risk assessment among other healthcare providers (Kesieme et al., 2016;Shah et al., 2020;Zobeiri & Najafi, 2011). This poor knowledge of VTE risk assessment could indicate that nurses thought VTE risk assessment was not among their daily tasks. However, little literature has determined that nurses are fully aware of their role in monitoring VTE risk assessment (Ma et al., 2018).
According to American College of Chest Physicians (ACCP) guidelines, the risk of VTE is classified as low, moderate, high, and very high risk (Kearon et al., 2012). In the identified literature, nurses showed poor knowledge regarding high and very high-risk items of VTE risk assessment, such as hormone replacement therapy, surgery, obesity, inflammatory bowel disease, and cancer (Al-Mugheed & Bayraktar', 2018;Ma et al., 2018;Oh et al., 2016). Conversely, Korubo et al. (2015) found that most participants had correctly answered regarding risk factors and clinical presentation of VTE.
However, nurses must perform a routine daily assessment for patients at risk of VTE.
Nurses can play a crucial role in VTE prevention by applying their knowledge to provide suitable prophylactic measures and assessing VTE risk for VTE patients (Al-Mugheed & Bayraktar, 2018).
The most recommended solutions were continuous educational programs to improve nurses' knowledge. The studies revealed that teaching session interventions significantly improved practice and risk assessment (Gaston & White, 2013;Lau et al., 2017;Walker et al., 2010). Continuing VTE education programs play a significant role in VTE prevention, and departmental managers should expand efforts for nurses' training (Gaston & White, 2013).
Venous thromboembolism prophylaxis protocols are recommended to improve the practices of healthcare providers regarding VTE prevention (Li et al., 2020). The National Institute for Health and Care Excellence recently endorsed the VTE prophylaxis protocol as one of the 10 most crucial patient safety practices (NICE, 2018).
Creating institutional protocols standardizing VTE was the second most frequent recommendation in the studies. Using protocols standardizing VTE showed significant improvement in VTE patient outcomes and saved lives by preventing complications (Amira et al., 2018;Collins & MacLellan, 2010).

| Implications for nursing practice
This review provides nurse managers and policymakers with evi-

| Limitations
The present study used the PRISMA checklist to consider all possible VTE dimensions and recommendations from identified studies.
Most studies were of good quality. Among the limitations were that most studies used descriptive design, few studies were conducted in developing countries, and the studies were conducted in only eight countries.

| CON CLUS ION
This is the first systematic review to examine nurses' knowledge, risk assessment, practice, self-efficacy, attitudes, and behaviours towards VTE. Across the identified studies, the nurses' knowledge level regarding VTE was higher than in risk assessment and practice, thus highlighting the gap between theory and practice, which must be addressed systematically to enhance patient care and reduce VTE incidences.

ACK N O WLE D G E M ENTS
Thanks to the Near East University library staff.

FU N D I N G I N FO R M ATI O N
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors declare no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data available on request from the authors.