Nurses' Knowledge, Perceived Practice, and their Associated Factors regarding Deep Venous Thrombosis (DVT) Prevention in Amhara Region Comprehensive Specialized Hospitals, Northwest Ethiopia, 2021: A Cross-Sectional Study

Introduction Deep venous thrombosis is a preventable and treatable cause of death among hospitalized patients. Nurses' knowledge and proper assessment can play a major role in improving deep venous thrombosis prevention care. Objective To assess the knowledge, practice, and associated factors towards deep venous thrombosis prevention among nurses working at Amhara region hospitals. Methods Institutional-based cross-sectional study was conducted among nurses working at Amhara region comprehensive specialized hospitals, Northwest, Ethiopia, from April 1 to 30, 2021. A simple random sampling technique was used to select 423 samples. A structured pretested self-administered questionnaire was used to collect data. Data were entered in epi-info version 7, analyzed using SPSS version 25, and presented by frequencies, percentages, and tables. Bivariable and multivariable logistic regression was computed, and P value < 0.05 was considered to identify statistically significant factors. Result Good knowledge and practice of nurses towards DVT prevention were 55.6% and 48.8%, respectively. Working at the medical ward [AOR 3.175, 95% CI (1.42, 7.11)], having a BSc degree [AOR = 3.248(1.245, 8.469)], Master's degree [AOR = 3.48, 95% CI (1.22, 9.89)], obtaining a formal training about deep venous thrombosis [AOR = 1.59; 95% CI (1.03, 2.47)], and working experience of ≥11 years [AOR = 2.11; 95% CI (1.07, 4.16)] were associated with good knowledge of nurses on the prevention of deep venous thrombosis. While having good knowledge about deep venous prevention AOR = 1.75; 95% CI (1.15, 2.65)] and working experience ≥11 years [AOR = 3.44; 95% CI (1.45, 8.13)] were significantly associated with nurses' practice about deep venous thrombosis prevention. Conclusion Knowledge and practice of the nurses regarding the prevention of deep venous thrombosis were found to be inadequate. Therefore, providing training, creating a conducive environment for sharing of experience, and upgrading the academic status of nurses are measures to scale up the knowledge and practice of nurses regarding deep venous thrombosis prevention.


Background
Deep venous thrombosis (DVT) is a common and serious pathology among hospitalized patients, which is a potentially preventable and treatable health problem that contributes to patients' morbidity and mortality [1].
Both deep vein thrombosis (DVT) and pulmonary embolism (PE) are the elements of venous thromboembolism (VTE), become a major public health concern of population of the USA affecting more than 900,000 people, and nearly 60,000-100,000 of them are died because of venous thromboembolism (VTE) each year [2]. e European Union also experiences a substantial venous thromboembolism burden of nearly 684,019 deep venous thrombosis, 434,723 pulmonary embolisms, and 610,138 post-thrombotic syndrome events that occur annually and cost billions of dollars each year [3].
According to the center for disease control and prevention (CDC), venous thromboembolism is the 5 th most reason for unplanned hospital readmissions of patients after surgery, and from this, 70% of cases of hospital-acquired venous thromboembolism (HA-VTE) are preventable through preventive measures [2].
Based on the systematic review done in Africa, the prevalence of pulmonary embolism (PE) in medical patients ranges up to 61.5%, with a mortality rate between 40% and 69.5%. And the case-fatality rate of pulmonary embolism (PE) after surgery was 60% [4].
A study conducted on assessing nurses' knowledge and practice about venous thromboembolism prevention for cancer surgery patients in Aswan Oncology Center of Egypt revealed that a total score of nurses' knowledge and observed practice level regarding prevention was unsatisfactory [5].
A study conducted in teaching hospitals of Ethiopia shows that out of 200 medically admitted patients, 186 (93%) of them have at least two risk factors for VTE development. Only 75 (40%) patients received thromboprophylaxis, and VTE has prevented in 61 (32.8%) patients who received prophylaxis [6].
Venous thrombus embolism accounts for almost 10% of all hospital deaths, and over half of VTE incidents are hospital-acquired. Appropriate preventive practice (e.g., pharmacological and mechanical prophylaxis) can significantly reduce the incidence of VTE by 70% for both medical and surgical patients [7].
Deep venous thrombosis is considered the third most common cardiovascular condition following myocardial infarction and stroke, and it is a growing public health problem with 26.4% of recurrent after the patients have been diagnosed, and this results in further cost of treatment for patients and intensifies hospital's burden [8].
Deep venous thrombosis (DVT) prevention includes the three arms, pharmacological, mechanical, and general care (early mobilization, exercising, and hydration) of hospitalized patients can reduce the incidence of DVT in both medical and surgical patients significantly [9].
Nurses are key components to assess and recognize risk factors of deep venous thrombosis of patients in the hospital care setting. When sufficient knowledge along with proper patient care including graduated compression stockings, administration of the correct dose of an anticoagulation agent with careful assessment, and monitoring of risk factors by nurses help to minimize the burden of DVT and its complication [10,11].
Studies have shown that having a poor level of knowledge and expressed practice of nurses on prevention of deep venous thromboembolism could increase hospitalization and ultimately leads to poor health care outcome [9,12].
Despite the advance in medical care, the presence of effective strategies, and standard guidelines, deep vein thrombosis (DVT) prevention is not possible as it is needed and expected. So, this study was aimed to assess the actual gap in knowledge, practice, and its associated factors of DVT prevention among nurses working at Amhara region comprehensive specialized hospitals, Northwest, Ethiopia.

Study Design, Area, and
Period. An institution-based cross-sectional study was conducted from April1 30, 2021, at five comprehensive specialized hospitals of the Amhara region, Northwest, Ethiopia.
e study was conducted in Amhara Regional State Referral Hospitals, Northwest, Ethiopia.
ere are five government comprehensive specialized hospitals found in Amhara regional state, Northwest, Ethiopia such as University of Gondar Comprehensive Specialized Hospital (UoGCSH), Felegehiwot Comprehensive Specialized Hospital (FHCSH), Tibebegion Specialized Teaching Hospital (TGSTH), Debre Markos Comprehensive Specialized Hospital (DMCSH), and Debre Tabor Comprehensive Specialized Hospital (DTCSH). All hospitals provide outpatient and inpatient services for more than 22,000,000 people living in their catchment area. Currently, these hospitals have 1682 nurses, and the total number of nurses who are working in surgical, medical, ICU, emergency, and Gyn-obs wards were around 728.

Source Population and Study
Population. Source populations were all nurses who were working in medical, surgical, emergency, ICU, and Gyn-obs wards of Amhara Region comprehensive specialized hospitals, Northwest, Ethiopia. Whereas all nurses who were working in selected units or wards (medical, surgical, emergency, ICU, and Gynobs) at UoGCSRH, FHCSH, TGSTH, DTCSH, DMCSH, and available during the data collection period are included in the study.

Inclusion and Exclusion
Criteria. All nurses working in surgical, medical, ICU, emergency, and Gyn-obs units of Amhara region Comprehensive Specialized hospitals, Northwest, Ethiopia, during the study period were included in the study, while those who are working as matron and an administrator were excluded in the study.

Sample Size Determination.
e sample size was calculated using the single population proportion formula. Since there was no similar published study found in our country addressing knowledge and practice on prevention of DVT, so considered the proportion of knowledge and practice (p) as 50% using the following formula where n � minimum sample size required for the study, Z � standard normal distribution (Z � 1.96) with CI of 95% and α � 0.05, P � population proportion (p � 0.5), d � is a tolerable margin of error (d � 0.05), and n � 1.96(1.96) (0.5(1-0.5))/0.05(0.05) � 384. By adding a 10%, nonresponse rate the final sample size was 423.

Sampling Technique.
A stratified simple random sampling technique was employed to recruit the required participants for the study. First, we stratified participants from each hospital and working ward/unit, and then we allocated the required sample for each stratum proportionally. Finally, we selected study participants from each stratum by simple random sampling.

Operational Definitions.
Good knowledge: respondents were labeled to have "good knowledge of DVT prevention" if they score the mean score or above, on the closed-ended knowledge questions of DVT prevention. Good practice: respondents were labeled to have "good practice of DVT prevention" if they score the mean score or above, on the closed-ended knowledge questions of DVT prevention.
2.6. Data Collection Tool and Procedure. Data were collected using a self-administered structured questionnaire to obtain information from participants. e questionnaire has three parts, the first section is regarding the sociodemographic characteristics of nurses and included 10 questions. e second section consists of 34 questions regarding knowledge of nurses on DVT prevention with 3 choices (true, false, and I do not know). e last section consisted of 13 questions concerning the practices of nurses on DVTprevention with 3 points Likert scale (always � 2, sometimes � 1, and never-� 0), Which were adopted from a study conducted in the Near East University hospital, North Cyprus, Turkey [9].
Eligible study participants were approached in each ward unit. Participants were provided with appropriate information about the study, then informed consent was be obtained to assure their willingness to participate in the study. Five trained BSc nurses collected the data, and five trained MSc nurses closely followed the data collection process. e instruments were distributed among the study population, after guarantying their willingness to take part in the study, and then it was collected by the data collectors after completion. During data collection, data collectors and supervisors followed the recommended precautions to prevent COVID-19.

Data Quality Assurance.
A self-administered structured questionnaire was prepared, and training was given for both collectors and supervisors about the concept of the questionnaire and the rights of the participants two days before the actual day of data collection. Moreover, the tool was pretested in 10% of the total sample size at Dessie comprehensive specialized hospital a week before the actual data collection period was conducted. Based on the finding, necessary modifications were done to the wording and phrases. e reliability of the tool used for measuring the dependent variable was 0.786 and 0.760 for knowledge and practice, respectively. ere was regular supervision, spotchecking, and reviewing the completed questionnaire to maintain data quality. Data were checked again for completeness before data entry and during the data cleaning process.

Data
Processing and Analysis. Data were cleaned, coded, and entered into Epi-info version 7 and then exported to SPSS version 25.0 for analysis. Descriptive statistics including frequencies, proportions, mean, and SD was computed and displayed by using tables, charts, and texts. Multicollinearity was checked. Model adequacy was checked by using Hosmer and Lemeshow with 0.21 and 0.456 for knowledge and practice, respectively. Bivariable and multivariable logistic regression analyses were computed to examine the association between the dependent variable and independent variables. Variables with p < 0.05 at multivariable logistic regression analysis were considered statistically significant.

Sociodemographic Characteristics of Respondents.
A total of 412 participants were included in the analysis with a response rate of 97.4%. Among respondents, 202 (49.0%) were female and 210 (51.0%) were male. e mean age of the participants was 31.6 years +5.1 standard deviations. Most of the participants 311 (75.5%) of the nurses had a bachelor's degree, nearly 223 (54.1%) were married (Table 1).

Work-Related Characteristics.
Most of the participants 180 (43.7%) had 6-10 years of working experience, out of 412 nurses who participated in the study, 120 (29.1%) nurses were working in surgical units and only 153 (37.1%) of nurses responded that they have received formal training on the prevention of DVT. Among all participants, only 141 (34.2%) participants responded to the presence of DVT prevention guidelines in their hospital, and only 221 (53.6%) of them were read professional literature about DVT prevention (Table 2).

Nurses' Knowledge regarding Deep Venous rombosis
Prevention. From all 412 study participants, more than half 55.6% 95% CI (51.0, 60.4) of the respondents were found to have good knowledge, while 44.4% of the respondents were found to have poor knowledge regarding DVT prevention.
Participants were asked 34 questions to assess their knowledge on the prevention of DVT, and they were categorized into two groups based on their score with their mean. e mean score was 22.8 (SD � ±4.43). Among all questions "DVT occurs as a result of stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation" was the most frequently answered question (97.3%) whereas "Alcohol may predispose to DVT" was the least frequently answered (Table 3).

Nurses' Practice regarding Prevention of DVT.
By using 13 practice-based questions, the mean practice score of the respondents was found to be 20.19 (SD � ± 4.84). From all questions, " encouraging early ambulation surgical patients (70.4%)" was the most frequently answered question on the contrary "Using of the graduated compression stockings" was the least frequently answered question (Table 4).

Discussion
e study has attempted to assess knowledge, practice, and associated factors of nurses on DVT prevention, and it revealed that only 55.6% with 95% CI (50.6, 60.4) of the    Critical Care Research and Practice e result of this study is lower than the studies conducted in China with 72.8% and 68.9%, respectively [14,15]. is might be due to differences in the study setting and the use of data collection tools. In this study, nurses working in different wards were included, and a tool with 34 knowledge questions has been employed; whereas in a study that was done in China, the study subjects were only orthopedic nurses and the tool had only 9 knowledge questions.
However, the result of this study was higher than the studies conducted in Zagazig University of Egypt, 27.5% [16] and Port said hospitals of Egypt. 28.9% [17]. is might be due to differences in sample size on which only 90 staff nurses were included in a study conducted at port said hospitals of Egypt, And differences in the tool used (merely about thromboembolism prophylaxis) and differences in cut point as good, average, and poor.
In a multivariable logistic regression analysis, variables like work experience, having training, working unit, and academic qualification were found to have a significant effect on nurses' knowledge regarding DVT prevention.
Working in the Medical ward was found to be 3.175 times more likely to have good knowledge as compared to nurses working at Gyn-obs [AOR 3.175, 95% CI (1.42, 7.11)].
is finding was consistent with the study conducted in South Korea [18]. However, it differ from a study conducted in the University Hospital of China in which the higher  [20]. is could be attributed to the possibility of an increase in academic qualification increases the exposure to different academic disciplines, which directly or indirectly help nurses to develop a theoretical background of knowledge on the prevention of DVT.
Study participants whose working experience was greater or equal to 11 years were found to be 2.11 times more likely to be knowledgeable about DVT prevention as compared to nurses whose working experience is less than 5 years [2.11, 95% CI (1.07, 4.16)]. is finding was consistent with the study done in Cyprus, Turkey [9]. e possible explanation might be, the increased years of working  [21]. Nurses who took training related to DVT prevention were found to be 1.59 times more likely to have good knowledge than those who had not taken any training [AOR � 1.59, 95% CI (1.03, 2.47)]. is finding was in line with the study conducted in China [12]. e possible explanation might be training may sensitize nurses to retain and ensure a consistent background of knowledge [22]. e result of this study showed that only 48.8% with 95% CI (43.9, 53.7) had good practice about DVT prevention.
is finding was consistent with the study conducted in São Paulo that was 44% [13]. On the contrary, the finding of the study is higher than the study conducted in Amrita Institute of medical sciences of India that was 14% [12]. is might be due to the sampling difference on which convince sampling method and only 100 nurses were included a study conducted in Amrita institute of medical science of India. And lower than a study conducted in China (55.4%) [19]. is discrepancy may be due to the study conducted in China has only assessed the practice of nurses exclusively on prophylactic prevention of DVT.
In a multivariable logistic regression analysis, variables like work experience and having good knowledge were found to have significantly associated with the practice of nurses towards DVT prevention.
Nurses with work experience of ≥11 years were found to be 3.44 times more likely to have good practice when compared to those with work experience of <5 years [AOR � 3.44, 95% CI (1.46, 8.13)]. e reason might be nurses with more years of working experience would have more chances to learn from their coworkers. Moreover, a greater year of experience creates a chance for nurses to work in different wards that help nurses to interact and act appropriately as compared to less experienced nurses [23].
Nurses who had good knowledge related to DVT prevention were found to be 1.75 more times to have good practice compared to those who had poor knowledge [AOR � 1.75, 95% CI (1.15, 2.65)]. e finding of this study is in line with the study conducted in port said hospitals of Egypt [17], and the possible justification could be having a theoretical background of knowledge enabled nurses to put their knowledge into practice [24]. Whereas it contradicted with the studies conducted in the intensive care units of Amrita Institute of Medical Sciences, Kochi, India [12]. is might be the difference in sample size and the study population where only ICU nurses with convenience sampling techniques were included in the study conducted in Amrita Institute of Medical Sciences, Kochi, India.

Conclusion
is study revealed that the knowledge and practice of nurses working in different wards of Amhara region comprehensive specialized hospitals, Northwest, Ethiopia, were not good enough for DVT prevention.
Having higher educational status, attending formal training, being more experienced, and working in medical wards showed a positive and significant association with good knowledge of nurses on DVT prevention; on the other hand, having good knowledge about DVT and higher working experience were found to be associated with good practice of nurses on prevention of DVT.

Strength and Limitations of the Study
A self-reported questionnaire measure of knowledge and practice of nurses on prevention of DVT is prone to social desirability bias and recall bias. Despite these limitations, this study clearly showed the knowledge, practice, and associated factors of nurses towards DVT prevention among nurses working at the comprehensive specialized hospitals for the first time in Ethiopia.

AOR:
Adjusted odds ratio COR: Crude odds ratio CDC: Centers

Data Availability
All data are available upon reasonable request and the readers could contact the corresponding author.

Ethical Approval
Ethical clearance was obtained from the University of Gondar College of Medicine and Health Science School of Nursing, Ethical Review Committee.

Consent
An official letter was written by each comprehensive specialized hospital. en permission and support letter was written to each respected department and wards. e purpose of the study was explained to the study subjects, and verbal consent was taken from the participants to confirm whether they are willing to participate or not. Confidentiality of responses was also ensured throughout the research process.

Authors' Contributions
Senay Yohannes carried out the study starting from conception, analysis, and interpretation of data and reviewing the manuscript. Tarkie Abebe participated in proposal writing, data analysis, interpretation, and critical review of the manuscript. Kidist Endalkachew and Destaw Endeshaw participated in reviewing, data analysis, drafting, and commenting on the manuscript. All authors are involved in writing, reviewing, and approving the final draft of the manuscript. All authors read and approved the manuscript before submitting it to the journal for publication.