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
Venous thromboembolism (VTE), comprising deep venous thrombosis and pulmonary embolism (PE),1 is a serious medical condition that results in preventable morbidity and mortality.1-5 VTE affects all age groups, all races/ethnicities, and both genders, but there are known factors that increase the risk of developing VTE (eg, advanced age, undergoing surgery, hospitalization, and immobility).1-3,5-7 Prevention of VTE among hospitalized patients is of paramount importance to avoid preventable death, chronic illness/long-term complications,8 longer hospital stays, and increased hospital costs.9 Fortunately, there is clear evidence that provision of appropriate prophylaxis can decrease the risk of a VTE event occurring, and broadly accepted best-practice guidelines reflect this evidence.3,5
Given the inadequacy of current VTE-related quality measures to identify actionable failures in the provision of VTE prophylaxis, our group created a VTE process-of-care measure to assess adherence to the components of VTE prophylaxis: (1) early ambulation, (2) mechanical prophylaxis (sequential compression devices [SCDs]), and (3) chemoprophylaxis administered at the correct dose and frequency for the duration of the patient’s hospital stay.3,10,11 This quality measure was conceived, created, and iteratively revised to measure whether optimal care is provided to patients throughout their hospitalization and identify actionable areas in which failures of care occur, in order to decrease the risk of a VTE event. Data from our institution provided evidence that while ambulation and SCD component measure adherence is high, chemoprophylaxis adherence required significant improvement.10 When chemoprophylaxis process measure adherence data were analyzed further, a major failure mode was patient refusal of one or more doses. However, the drivers of patient refusal are not well defined in the literature, and previous studies have called for a greater focus on developing interventions to improve VTE chemoprophylaxis administration.12
Previous research has shown that nurses can influence patient compliance with VTE prophylaxis.13-15 A mixed-methods study by Elder et al. found that nurses in units with high rates of failure to provide optimal chemoprophylaxis offered the medication as optional, leading researchers to conclude that nurses perceived chemoprophylaxis as discretionary.13 Another study by Lee et al., conducted a survey of bedside registered nurses and identified nurses’ lack of education on VTE prevention as a significant barrier to providing care.14 These studies show that multiple levels of influence impact how nurses provide VTE chemoprophylaxis, particularly when they encounter patients who refuse chemoprophylaxis.
To explore the nuance and interplay of multiple influences, we used the Theoretical Domains Framework (TDF), an integrative framework that applies theoretical approaches to interventions aimed at behavior change.15-18 The framework contains 14 interrelated domains that characterize the behavior being studied, in this case, administration of VTE chemoprophylaxis. Consequently, we designed a nurse-focused, qualitative evaluation with the objective to identify nursing-related barriers to administration of VTE chemoprophylaxis.
