Presenting Author:

Lindsey Kreutzer, M.P.H.

Principal Investigator:

Julie Johnson, Ph.D.

Department:

Surgery

Keywords:

Venous thromboembolism, patient refusal, nurses, nursing, qualitative, Theoretical Domain Framework (TDF), behavior chan... [Read full text] Venous thromboembolism, patient refusal, nurses, nursing, qualitative, Theoretical Domain Framework (TDF), behavior change, implementation science, chemoprophylaxis [Shorten text]

Location:

Ryan Family Atrium, Robert H. Lurie Medical Research Center

C129 - Clinical

Why Do Patients Refuse VTE Prophylaxis? A Nursing-Focused Qualitative Evaluation

INTRODUCTION: Venous thromboembolism (VTE) is a potentially preventable medical condition resulting in morbidity and mortality. Hospitalized postoperative patients who refuse comprehensive VTE prophylaxis (ambulation, sequential compression devices, and chemoprophylaxis) increase their risk of VTE. Previous studies have shown that nurses can influence patient compliance with VTE prophylaxis. Our objectives were to identify nursing-related drivers of patient refusal and develop interventions to reduce refusal rates. METHODS: We conducted focus group interviews (n=14) with day and night shift nurses from five units (2 medical, 3 surgical) at one hospital to assess nurse understanding of VTE prophylaxis and perception of why patients refuse each prophylaxis component. Four units were selected for participation by their high patient refusal rate along with the unit that had the lowest rate. Focus groups were recorded and transcribed verbatim. Nurse perception of drivers of patient refusals of VTE prophylaxis were analyzed using the Theoretical Domain Framework (TDF), which is an integrative framework that applies theoretical approaches to interventions aimed at behavior change. RESULTS: The process for ordering and administering VTE prophylaxis allows identification of potential points of patient refusal. Focus group findings highlight that patient refusals are influenced by three main TDF domains: environmental context and resources, knowledge, and skill. One key environmental context and resource barrier identified was the lack of patient education materials on VTE prophylaxis. Nurses did not have the resources required to supplement their explanation to patients about the significance of prophylaxis. Furthermore, the knowledge barrier was highlighted by many nurses who don’t know that all three components of prophylaxis are necessary e.g., chemoprophylaxis is necessary in ambulating patients. Nurses also felt unequipped to manage patient refusal because they lacked the skills to handle those situations. Five customized interventions were developed to address these barriers: 1. Revised patient education materials 2. Nurse educational module 3. Unblinded unit- and nurse-level comparative patient refusal reports 4. Simulation exercises to equip nurses to counsel patients who refuse 5. Educational bulletin boards on units promoting ambulation CONCLUSION: Nursing-related barriers to patient refusal of VTE prophylaxis include knowledge, skill, and resources. These barriers provide insights for modifiable targets for quality improvement, particularly by focusing on equipping nurses to address potential patient refusals and by engaging patients in their care. Future initiatives will use similar methods to identify how physicians can influence patient refusals of VTE prophylaxis.