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Table of Contents
Year : 2016  |  Volume : 17  |  Issue : 2  |  Page : 31-35

Knowledge, attitude, and practice of nurses regarding use of anti- Embolism stockings

1 Nursing Officer, All India Institute of Medical Sciences, New Delhi, India
2 Consultant, Indian Nursing Council, New Delhi, India
3 Professor, College of Nursing, CMC, Vellore, India
4 Professor, Department of Surgery, CMC, Vellore, India
5 Lecturer, Department of Bio statistics, CMC, Vellore, India

Date of Web Publication9-Jun-2020

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Appropriate thromboprophylaxis can prevent venous thromboembolism - the most prevalent potentially preventable complication among surgical patients. Anti-embolism stockings are a simple and effective mechanical thromboprophylactic modality which is widely used. This study was undertaken to assess the knowledge, attitude and practice of nurses regarding the use of anti-embolism stockings. Convenience sampling was used to recruit nurses working in surgical wards of a tertiary hospital. A knowledge questionnaire, an attitude scale and an observation checklist were used in the study. Sixty four nurses were observed for knowledge / attitude and 72 nurses were observed for practice regarding the use of anti- embolism stockings. It was found that 65.6% had moderately adequate knowledge and 90.6% had highly favourable atttitude. Majority of the nurses (91.7%) demonstrated inadequate practice in the use of stockings. Prevention of venous thrombo-embolism and the use of anti- embolism stockings needs to be added as an in-service education topic for nurses and clinical teaching for the nursing students. It can also be considered as a component of health education to the patients. Use of a protocol and documentation form can ensure appropriate use of the anti- embolism stockings. Incorporating this topic in the syllabus and as a procedure in the log book can ensure mandatory learning about use and application of anti- embolism stockings.

Keywords: knowledge, attitude, practice, venous thrombo-embolism, anti-embolism stockings

How to cite this article:
Varghese BA, Ezhilarasu P, Rajan A, Jesudason MR, Jeyaseelan V. Knowledge, attitude, and practice of nurses regarding use of anti- Embolism stockings. Indian J Cont Nsg Edn 2016;17:31-5

How to cite this URL:
Varghese BA, Ezhilarasu P, Rajan A, Jesudason MR, Jeyaseelan V. Knowledge, attitude, and practice of nurses regarding use of anti- Embolism stockings. Indian J Cont Nsg Edn [serial online] 2016 [cited 2021 May 8];17:31-5. Available from: https://www.ijcne.org/text.asp?2016/17/2/31/286296

  Introduction Top

Patient safety, the most challenging conventional facet of high quality nursing care is considered to be the chief priority in today’s technologically advanced health care system. Nurses play a critical role in promoting patient safety by ensuring that the patient does not experience any harm (Mitchell, 2008). Deep Vein Thrombosis (DVT) is a dangerous complication that can occur following surgery or long periods of rest in the hospital. As DVT is recognised as a major health risk for hospitalised patients, anti embolism stockings (AES) are widely used to reduce the risk of thrombus formation. The use of AES is based on strong evidence that it reduces venous thrombo embolism (VTE) by passive pressure (Minet et al., 2015 ). AES improve blood circulation especially the venous velocity in the leg veins by applying graduated compression. Proper sizing and correct application of the stockings is vital to ensure maximum effect and good outcome. Unfortunately, these stockings also pose a potential risk to patients. It can unintentionally act as a tourniquet if not used appropriately especially if rolled tightly at the top thereby causing rather than preventing the stasis. Its improper application and use can also result in other hazards like ulceration and skin damage (National Institute for Health and Clinical Excellence, 2010; Smeltzer, Bare, Hinkle & Cheever,2012).

Nurses are therefore accountable to measure the patients’ legs and confirm that the stockings of appropriate size are prescribed and worn correctly by the patients (Lewis, Heitkemper, Dirksen, Brien & Butcher, 2007). Cock’s (2006) audit on nurses knowledge and practice regarding AES reported that the nurses were knowledgeable about the care of patients on AES, but were found to have deficient practice in implementing the procedure and documenting the use. A study conducted by Winslow and Brosz (2008) reported that the stockings were used incorrectly in 29% of the patients and sized incorrectly in 26% of the patients. The incorrect use was commonly seen in obese patients and in patients for whom above knee-length stockings were used. In a clinical audit conducted among the surgical patients to assess its correct usage, it was found that in 29% of patients, the limbs were not measured properly for its appropriateness and 38.75% of them had incorrect application of the stockings (Miller, 2011). Adequate and continuous training of health professionals on VTE and various modalities of thromboprophylaxis can improve their practice thereby contributing to patient safety (McFarland et al., 2014).

The investigator in her clinical practice found that nurses in surgical and critical care areas did not follow uniform methods in application and maintenance of stockings. Some patients also developed complications such as pressure ulcers. No evidence-based procedural protocol exists at present in the institution regarding the use of anti- embolism stockings. Patients often express discomfort in wearing anti embolism stockings as they are either too tight or loose and did not comply with the therapy as they were not aware of its significance. Therefore this study was undertaken with the following objectives.

  • To assess knowledge and attitude of staff nurses regarding venous thromboembolism and use of anti- embolism stockings
  • To assess practice of staff nursesregarding use of anti- embolism stockings
  • To determine relationship between knowledge, attitude and practice of staff nurses regarding venous thromboembolism and use of anti- embolism stockings
  • To determine association between knowledge, attitude and practice of staff nurses regarding venous thromboembolism and use of anti- embolism stockings with selected demographic variables

  Methods Top

Design and Sampling

A descriptive research design was adopted for the study. The study was conducted among nurses, who had more than six months of experience, in selected surgical and orthopaedic wards of a tertiary care hospital in India. Convenience sampling technique was used to select the staff nurses from each shift of the selected wards to assess their knowledge, attitude, and practice on VTE and AES. In order to minimize casual contamination among study participants, the investigator selected a particular ward every day and nurses in that particular ward were observed once during the study period. The nurses on each shift during the time period between 6 a.m. to 10 a.m. and 3 p.m. to 7 p.m. in that particular ward were observed for the practice of use of anti- embolism stockings. Six surgical wards were selected for the study. The number of staff nurses observed for practice per day varied according to the staffing of the ward.

The instrument used for data collection was prepared by the investigator and was validated. A self-administered knowledge questionnaire and attitude scale was prepared to assess staff nurses regarding VTE and use of anti- embolism stockings. The observation checklist developed by the researcher was used to assess the practice of the staff nurses in the use of anti- embolism stockings. The instrument was divided into following sections:

  • Part I included demographic profile of the staff nurses
  • Part II had 20 multiple choice questions regarding knowledge of VTE and use of anti-embolism stockings. For every right answer, a score of one was awarded and for every wrong answer a score of 0 was given.
  • Part III was an attitude scale consisting of 10 positive items and 5 negative items. These items were scored on scale ranging from ‘strongly agree to strongly disagree’.
  • Part IV was an observation checklist consisting of 35 items to observe the practice of assessment, application, maintenance, teaching and documentation. A score of one was awarded for each step that was done and 0 when not performed.

Knowledge, attitude and practice scores of the subjects were converted into percentages. The knowledge score of above 74% was considered as adequate. A score of 49 -74% was taken as moderately adequate and a score of below 49% as inadequate. The attitude scale score of above 74%, 49- 74 % and < 49% was interpreted as highly favourable, moderately favourable, and less favourable. The observation checklist score of above 74.9%, > 49.9 - 74%, and < 49.9% was interpreted as adequate practice, moderately adequate practice, and inadequate practice respectively.

Content validity index (CVI) of the knowledge questionnaire, attitude scale, and the observation checklist were .92, .9, and .98 respectively. The reliability of these tools was checked during the pilot study using split half method and the reliability coefficient. Cronbach’s alpha was found to be .9, .91, and .86 respectively for the knowledge questionnaire, attitude scale, and the observation checklist.

During the first 2 weeks of the study, the investigator observed the practice of the staff nurses regarding use of anti- embolism stockings. On the day of observation, the investigator requested the nurses who consented to participate in the study to demonstrate the application of AES on their patients. The procedure was carried out within the patients’s bedside. The staff nurses of the night shift were observed by the investigator during 6 a. m. to 7.30 a. m. The nurses of the day shift were then observed one after the other by the investigator and were not allowed to communicate with those nurses who were yet to be observed. Similarly, the nurses of the evening shift were observed during 3.30 p. m. to 4.15 p. m. Thus, the investigator observed the practice of application of anti-embolism stockings. Approximately a maximum of 10 minutes was taken to observe the practice of each staff nurse.

Following the assessment of practice, after a period of three weeks, the investigator gathered all the staff nurses who were observed for practice and administered knowledge questionnaire and attitude scale and assessed for knowledge and attitude on the same day. Seventy two staff nurses were observed for their practice on use of AES. Among them, only 64 nurses were assessed for their knowledge and attitude. An attrition of 8 participants had occurred for assessing knowledge and attitude, as they were unable to come on the day of assessment. In order to limit the causal contamination, they could not be assessed on any other day The data collection procedure was repeated in all the selected wards.

Informed consent was obtained from the staff nurses prior to commencement of the study. Ethical clearance was obtained from Institutional Review Board.

  Results and Discussion Top

The data was analysed using Statistical Package for Social Sciences (SPSS) version 17.0. A p value of < .05 was considered to be statistically significant in this study. Descriptive statistics was used to present the frequency and percentage of the demographic variables. Chi-square test and correlation coefficient were used to analyse the study findings.
Figure 1: Knowledge of staff nurses regarding venous thromboembolism and use of anti-embolism stockings

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Figure 2: Attitude of staff nurses regarding venous thromboembolism and use of anti-embolism stockings

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Figure 3: Practice of staff nurses regarding the use of anti-embolism stockings

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Demographic characteristics indicated that the majority of the study subjects were females (97.2%) and 2.8% were males. The majority of subjects had completed General Nursing and Midwifery (86.1%). About 11.1 % of them were graduates in nursing and 2.8% of them had completed other certificate courses. According to the Central Bureau of Heath Intelligence (2011), a larger proportion of nurses in India are diploma holders. Regarding the total years of experience as staff nurse, about 56.9% had more than six years, 16.7% had four to six years, 20.8% had one to three years, and 5.6% had less than one year of clinical experience.

The findings revealed that majority of the subjects (65.6%) had moderately adequate knowledge and 34.4% had inadequate knowledge. Unfortunately none of the study subj ects had highly adequate knowledge. The mean score was found to be 10.11 + 2.495. In a similar study where the nurses awareness of the procedure of the stocking application was audited (Cock, 2006), majority of them knew (85%) about some contraindications for AES. Only 50% knew about importance of assessing the heels regularly and no one knew how frequently stockings had to be changed. The study also identified poor nursing documentation regarding the application or care connected to stockings. In another study, 21% had knowledge about applying compression stockings appropriately (Donnelly & McNeely, 2015).

The lack of adequate knowledge can be attributed to the lack of reinforcement or in-service education on thromboprophylaxis and its effects which can also have an adverse effect if not used judiciously. In another study about 60% of nurses were aware of the policies regarding AES indicating awareness about importance of VTE (Gaston & White, 2013). A similar study found that 74% of patients had been given incorrectly sized stockings prior to an educational intervention (Thompson et al., 2011).

The study findings indicate that a large part of the subjects (90.6%) had a highly favourable attitude towards thromboprophylaxis and the use of anti- embolism stockings. About 9.4% of them had moderately favourable attitude and fortunately none of them had a less favourable attitude towards the same. These study findings go hand in hand with the findings of an exploratory study done by Chapman, Lazar, Fry, Lassere, and Chong (2011) among doctors in two tertiary level hospitals in Australia which unveiled the fact that they too had a very positive attitude towards thromboprophylaxis and agreed that its effective utilization can prevent VTE.

A greater part of the study subjects (91.7%) had inadequate practice in the application of anti- embolism stockings. A minority of the subjects (8.3%) of them had moderately adequate practice in the use of AES. None of the subjects demonstrated highly adequate skill in application of AES. This may be attributed to the lack of a protocol in the institution for the use of AES. These findings are in congruence with the results of the study by Bowling, Ratcliffe, Townsend, and Kirkpatrick (2014) who found that in 20% of patients, stockings were not applied correctly and 14% of the stockings provided the appropriate gradation of reduced pressure between ankle and calf.

In an audit on the use of thromboembolism stockings by Donnelly and Mc Neely (2015) similar results were found about the practice related to application of AES. The audit revealed that about 50% of patients did not have correct measurement taken and 57% of patients were not given information on post-operative use of the stockings. Documentation regarding AES and related observation was found to be greatly lacking (Gaston & White, 2013), including the current study.

The relationship between knowledge, attitude, and practice of the staff nurses regarding use of anti- embolism stockings were established using the correlation coefficient. The r = .19 implied that there is a slight positive relationship between knowledge and attitude. It was found to have a positive correlation between the level of knowledge and practice, but the magnitude of the correlation was found to be low (r =. 119). The analysis also showed that there is a slight positive relationship between attitude and practice as revealed by r = .15. The study conducted by Gao & Kause (2010) reveal that even if the knowledge of the nurses regarding VTE was adequate, their practice towards thromboprophylaxis was not satisfactory. It was also revealed from the study that there is no evidence of association between the demographic variables of the nurses with their knowledge, attitude and practice.


Limitations of the study included limited sample size, single observation, and the Hawthorne effect during observation of practice.

  Conclusion Top

VTE, a common complication among hospitalised surgical patients is preventable through administration of appropriate thromboprophylaxis. Although, nurses play a significant role in its prevention, this study has revealed that nurses had moderately adequate knowledge and favourable attitude towards VTE and use of anti- embolism stockings, but their practice was grossly deficient. An increase in knowledge and attitude can improve their practice. There is a need to educate and reinforce the students and staff nurses on appropriate use of anti-embolism stockings by considering it as an important topic for in-service education and clinical teaching. Incorporation of use of anti- embolism stockings as a procedure in the log book and the procedure manual of the institution can ensure its proper use by the nurses thereby contributing to its efficiency and prevention of complications associated with it. Policy on AES should be established and should be made available for nurses and other health team members to ensure proper use in clinical settings.

Conflicts of Interest: The authors have declared no conflicts of interest.

  References Top

Bowling, K., Ratcliffe, C., Townsend, J., & Kirkpatrick, U. (2015). Clinical thromboembolic detterrent stockings application: Are thromboembolic deterrent stockings in practice matching manufacturers application guidelines. Phlebology, 30(3), 200-203. doi:10.1177/ 0268355514542843  Back to cited text no. 1
Central Bureau of Health Intelligence- India. (2011). Human resources in health sector. Retrieved from http://www.cdhidghs.nic.in  Back to cited text no. 2
Chapman, N. H., Lazar, S. P., Fry, M., Lassere, M. N., & Chong, B. H. (2011). Clinicians adopting evidence based guidelines: A case study with thromboprophylaxis. BioMedCentral Health Services Research, 11, 240.doi: 10.1186/1472-6963-11 -240.  Back to cited text no. 3
Cock, K. A. (2006). Anti-embolism stockings: Are they used effectively and correctly? British Journal of Nursing, 15(6).  Back to cited text no. 4
Donnelly, T., & McNeely, B. (2015). The shocking stocking audit: An audit on the use of thromboembolic deterrent stockings (TEDS) for patients having surgery at Sligo regional hospital. Journal of Perioperative Practice, 25(4), 83-86.  Back to cited text no. 5
Gaston, S., & White, S. (2013). Venous thromboembolism (VTE) risk assessment: rural nurses’ knowledge and use in a rural acute care hospital. International Journal of Nursing Practice, 19(1), 60-64.  Back to cited text no. 6
Gao, F., & Kause, J. (2010). Thromboprophylaxis awareness among hospital staff. British Journal of Nursing, 19(18), 1175-1178.  Back to cited text no. 7
Lewis S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, G.P., Butcher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems (7th ed.). Philadelphia: Mosby Elsevier Publishers.  Back to cited text no. 8
McFarland, L., Murray, E., Harrison, S., Heneghan, C., Ward, A., Fitzmaurice, D., & Greenfield, S. (2014). Current practice of venous thromboembolism prevention in acute trusts: A qualitative study. British Medical Journal, 4(6). e005074. doi:10.1136/bmjopen-2014-005074  Back to cited text no. 9
Miller, J. A. (2011). Use and wear of anti-embolism stockings: A clinical audit of surgical patients. International Wound Journal, S(l), 7483. doi:10.1111/j. 1742-481X.2010.00751.X  Back to cited text no. 10
Minet, C., Potton, L., Bonadona, A., Hamidfar-Roy, R., Somohano, C. A., Lugosi, M., Timsit, J.-F. (2015). Venous thromboembolism in the ICU: Main characteristics, diagnosis and thromboprophylaxis. Critical Care, 19( 1). https://doi.org/10.1186/sl3054- 015-1003-9  Back to cited text no. 11
Mitchell, P. H. (2008). Defining patient safety and quality care. In R. G Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/ books/NBK2681/  Back to cited text no. 12
National Institute for Health and Clinical Excellence. (2010). Venous thromboembolism: Reducing the risk. London: NICE  Back to cited text no. 13
Smeltzer, S.C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2012). Brunner and Suddharth’s textbook of medical surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins Publishers.  Back to cited text no. 14
Thompson, A., Walter, S., Brunton, L. R., Pickering, G. T., Mehendale, S., Smith, A. J., & Bannister, G C. (2011). Anti-embolism stockings and proximal indentation. British Journal of Nursing, 20(22).  Back to cited text no. 15
Winslow, E. H., & Brosz, D. L. (2008). Graduated compression stockings in hospitalized postoperative patients: correctness of usage and size. The American Journal of Nursing, 108(9), 4050.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3]


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