Hidden Barriers to Delivery of Pharmacological Venous Thromboembolism Prophylaxis: The Role of Nursing Beliefs and Practices

Background Standardized electronic order sets for venous thromboembolism prophylaxis have increased the proportion of patients receiving venous thromboembolism prophylaxis. However, ordering venous thromboembolism prophylaxis does not ensure consistent administration. Objective To explore causes of variability in the rate of administration of ordered doses of pharmacological venous thromboembolism prophylaxis among hospital units. Design Mixed methods study, including qualitative observation and quantitative nursing survey administration. Subjects Nurses included in observations were practicing on an inpatient unit, caring for patients with orders to receive venous thromboembolism prophylaxis consisting of low-dose unfractionated heparin or low-molecular weight heparin. Nurses on 12 inpatient units with disparate rates of administration were included in the survey. Measures Qualitative observation data were collected until thematic saturation was achieved. Survey was conducted to identify beliefs and practices surrounding nursing administration of venous thromboembolism prophylaxis. Results During observations, some nurses presented pharmacological venous thromboembolism prophylaxis to their patients as an optional therapy. Nurses on low-performing units are more likely to believe that pharmacological venous thromboembolism prophylaxis is ordered for patients who do not require it. More often, they also acknowledge that nurses use their clinical decision-making skills to determine when to omit unnecessary doses of prescribed venous thromboembolism prophylaxis. Conclusions Nurses on units with low administration rates often believe they have the skills to determine which patients require pharmacological venous thromboembolism prophylaxis. They are also more likely to believe that ordered doses are discretionary and offer the medication as optional to patients.