Prevalence,presentation and occupational risk factors of chronic venous disease in nurses

Abstract

Objective

In this study involving a group of nurses employed in a number of different medical services with relatively well-defined working conditions, the presence and symptoms of chronic venous insufficiency were screened and their association with work burden and physical working conditions was explored.

Methods

Of the 294 actively employed nurses during the study period, 232 (79%) were recruited on the basis of their willingness for participation and fulfilment of the inclusion criteria.

Results

Among the study subjects, 62.9% had at least one symptom of chronic venous insufficiency, and 50.4% were found to have chronic venous insufficiency according to Clinical–Etiology–Anatomy–Pathophysiology classification criteria. A significant association was found between the diurnal ankle circumference difference in the left–right ankles and the mean duration of hospital stay.

Conclusions

Our results have shown that the average duration of hospital stay, which is among the variables used to estimate the work burden of nurses, is associated with an increased frequency of the signs and symptoms of chronic venous insufficiency.

Keywords

Ambulatory venous pressure Clinical–Etiology–Anatomy–Pathophysiology clinical class chronic venous disease chronic venous insufficiency occupational leg swelling

Introduction

Chronic venous insufficiency (CVI) is an important public health problem that is thought to affect up to 50% of the population in industrialized countries.¹ If not treated, it may be lead to severe symptoms and complications.² Despite the presence of a variety of different etiological factors, most CVI cases are due to anatomical changes or thrombotic events in the deep venous system.³ In individuals who are anatomically inclined for the development of CVI, the increase in venous hydrostatic pressure results in the emergence of CVI symptoms. The venous pressure measured during walking is approximately 20 mm H₂O, while it rises up to 70 mm H₂O while sitting, and up to 100 mm H₂O when standing up. In standing subjects, this physiological increase in the pressure is usually asymptomatic, while in CVI patients, it is associated with progressive symptoms due to the venous damage and valvular pathology.⁴

Studies in different populations or in different occupational groups generally suggest that CVI signs and symptoms occur more frequently in those who have to stand for prolonged periods of time, in the elderly, and in women.^1,5–8 Therefore, although this condition is initially associated with slowly progressing and mostly cosmetic complaints in individuals who spend most of their working hours standing, it may result in chronic and severe symptoms and medical complications in the long term. Thus, it follows that such complaints inevitably lead to loss of productivity.

In this study involving a group of nurses with relatively well-defined working conditions, the presence and symptoms of CVI were screened and their association with work burden and physical working conditions was explored. The association between clinical outcomes, workload, and working conditions was explored in order to define the factors that may lead to increased frequency of disease, to determine preventive measures, and finally to provide information that may assist in therapeutic interventions in those individuals affected by the condition.

Materials and methods

This cross-sectional study was undertaken between January and June 2013 at the Research and Training Hospital of Hitit University with 600 patient beds. Of the 294 actively employed nurses during the study period, 232 (79%) were recruited on the basis of their willingness for participation and fulfilment of the inclusion criteria.

Information about workload indexes was obtained from the hospital administration on average duration of hospital stay, patient bed occupancy rate, and patient beds per nurse for each clinical department during the study period. Nurses who were on sick leave, annual leave, or temporarily employed in other sites other than the study site were excluded. All participants enjoyed an adequate duration of rest after each night duty. Nurses having medications of diuretics, calcium channel blockers, venotonic drugs, or chronic pain relievers and who have chronic heart failure, chronic renal failure, lymphedema, nephrotic syndrome, or cirrhosis were not included into the study. Pregnancy and usage of compression stockings were considered as exclusion criteria to avoid probable biases.

Also all study subjects were examined by one of the doctors and one of the nurses from the investigator team at baseline to determine the Clinical–Etiology–Anatomy–Pathophysiology (CEAP) class and signs–symptoms of CVI. The demographic data and environmental–occupational risk factors (family history of venous disease, history of deep venous thrombosis, current oral contraceptive therapy, obesity, regular participation in sports or frequent use of saunas or sunbaths, and long periods of standing during work) were recorded. Symptoms of CVI are heaviness or fullness, aching, restlessness, tiredness, fatigue, pain, throbbing, burning, itching, and muscle cramping of the legs which were increasing during standing at the work or after long periods of standing during work.

Leg swelling is a major symptom of CVI. Studies examining this specific sign have reported a variety of different techniques to determine the diurnal changes in leg circumference.^5,6 In our study, leg swelling was documented by the measurement of the ankle circumference just above the level of malleolus while the participant was standing erect. The measurements were done thrice on different days during the study period and on each measurement day, two measurements were performed, one before and one at the end of the work shift. All participants were examined during their day shifts and measurements were performed by the same nurse. Care was practised to perform the measurements during the mid-menstrual period in female subjects.

Statistical analyses

Statistical analyses were performed using Statistical Package for the Social Sciences v16.0 (SPSS Inc., Chicago, IL, USA) software package. Continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as percentage. For the comparison of continuous variables, t-test was used, while chi-square test was used for the categorical variables. Correlation analysis was done using Pearson’s test. A P value <.05 was considered statistically significant.

Results

The mean age of the study subjects was 34.68 ± 8.0 years, and majority were females (n = 184; 79.3%). Table 1 depicts the demographic characteristics of the study population. None of the nurses were previously diagnosed or had symptoms/findings of deep vein thrombosis (DVT).

Table 1.

Baseline demographic characteristics of all study participants (n = 232).

Variable	CEAP > 0 N = 117	CEAP = 0 N = 115	P	Symptomatic N = 146	Asymptomatic N = 86	P
Age	33.97 ± 8.24	35.40 ± 7.77	0.17	33.97 ± 7.97	35.87 ± 8.01	0.08
Female gender	94 (80.3)	90 (78.3)	0.70	117 (80.1)	67 (77.9)	0.68
Body mass index	25.03 ± 4.06	24.44 ± 3.96	0.26	24.68 ± 4.13	24.84 ± 3.82	0.77
Occupation
Nurse	94 (80.3)	87 (75.7)	>0.05	116 (79.5)	65 (75.6)	>0.05
Assistant nurse	12 (10.3)	8 (7.0)	>0.05	14 (9.6)	6 (7.0)	>0.05
Care giver	11 (9.4)	20 (17.4)	>0.05	16 (11.0)	15 (7.4)	>0.05
Tobacco use	37 (31.6)	32 (27.8)	0.52	41 (28.1)	28 (32.6)	0.47
Oral contraceptives	5 (4.3)	5 (4.3)	0.97	8 (5.5)	2 (2.3)	0.33
History of venous disease	20 (17.1)	5 (4.3)	0.002	21 (14.4)	4 (4.7)	0.02
Previous venous surgery	7 (6.0)	3 (2.6)	0.20	7 (4.8)	7 (3.5)	0.74
Systemic disease	35 (29.6)	25 (21.7)	0.15	40 (27.4)	20 (23.3)	0.48
Venous disease in family	60 (51.3)	26 (22.6)	0.001	69 (47.3)	17 (19.8)	0.001
Constipation	27 (23.1)	11 (9.6)	0.005	28 (19.2)	10 (11.6)	0.13
Hemoroidal disease	33 (28.2)	14 (12.2)	0.002	33 (22.6)	14 (16.3)	0.24
Shift per day (hours)	8.79 ± 0.94	8.91 ± 0.38	0.20	44.86 ± 3.59	44.58 ± 3.20	0.54
Shift per week (hours)	44.50 ± 3.18	45.01 ± 3.69	0.23	8.83 ± 0.84	8.88 ± 0.47	0.60

Note: CEAP, Clinical–Etiology–Anatomy–Pathophysiology; P<0.05 was considered as statisticaly significant.

For each clinical unit, the number of admissions, total admission days, average duration of hospital stay, number of patient beds, number of employees, patient beds per nurse, and bed occupancy rates were recorded as shown in Table 2. While the longest duration of hospital stay was at the Department of Physical Therapy (14.52 days), the occupancy rate was highest in the orthopedics (70.59%).

Table 2.

Hospital data of institutional departments.

Department	Number of inpatients	Number of inpatient days	Mean length of stay	Number of beds	Number of staffs	Bed per nurse	Bed occupancy (%)
Intensive care unit	275	2778	10,10	19	21	0,90	40,05
Neurosurgery and plastic surgery	916	4666	5,09	30	11	2,73	42,61
Obstetrics and gynecology	1642	4375	2,66	64	22	2,91	18,72
Newborn	597	3371	5,65	37	25	1,48	24,96
Pediatrics and Pediatric Surgery	1669	7338	4,40	68	18	3,78	29,56
Cardiology	794	2272	2,86	35	19	1,84	17,78
Infectious diseases	170	1352	7,95	15	8	1,88	24,69
Urology	734	3030	4,13	15	8	1,88	55,34
Cardiovascular and thoracic surgery	513	2615	5,10	32	10	3,20	22,38
General surgery	1927	9231	4,79	62	30	2,07	40,79
Orthopedics	1601	15461	9,66	60	30	2,00	70,59
Internal medicine and oncology	1035	7385	7,14	60	30	2,00	33,72
Neurology	800	5866	7,33	30	15	2,00	53,57
Physical therapy	542	7871	14,52	45	11	4,09	47,92
Outservice and other	327	2255	6,90	20	10	2,00	30,89

The distribution of the participants according to clinical units is shown in Table 3. While 13.8% of the study subjects were employed at the intensive care unit, the percentage of those employed at urology, neurology, and physical therapy departments comprised the smallest participant group (2.6% each). Overall, 49.6% of the subjects had C0 status according to CEAP classification. No subjects had advanced stage (C5–C6) disease. On the other hand, 62.9% had at least one symptom of CVI (Table 4).

Table 3.

Distribution of study participants by departments.

Department	n (%)
Intensive care unit	32 (13.8)
Neurosurgery and plastic surgery	12 (5.2)
Obstetrics and gynecology	18 (7.8)
Newborn	10 (4.3)
Pediatrics and pediatric surgery	9 (3.9)
Cardiology	24 (10.3)
Infectious diseases	7 (3.0)
Urology	6 (2.6)
Cardiovascular and thoracic surgery	12 (5.2)
General surgery	24 (10.3)
Orthopedics	22 (9.5)
Internal medicine and oncology	20 (8.6)
Neurology	6 (2.6)
Physical therapy	6 (2.6)
Outservice and Other	24 (10.3)

Table 4.

Clinical–Etiology–Anatomy–Pathophysiology (CEAP) classification of participants.

Class	N (%)
C0 No visible or palpable signs of venous disease	115 (49.6)
C1 Telangiectasies or reticular veins	91 (39.2)
C2 Varicose veins	2 (0.9)
C3 Edema	17 (7.3)
C4 Pigmentation or eczema	7 (3.0)
C5 Healed venous ulcer	0 (0)
C6 Active venous ulcer	0 (0)
Symptomatic	146 (62.9)

The definition of workload includes the duration of admission index, occupancy index, and patient bedside index, all of which were grouped into four equal subscales (Table 5). While a longer duration of hospital stay was observed in the intensive care, infectious disease, orthopedics, and physical therapy units, the average duration of hospital stay was found shorter in gynecology and obstetrics, pediatrics, cardiology, and urology units (Table 6).

Table 5.

Categories of the main hospital variables to define workload.

Scale (quartiles)	Index of mean length of stay	Index of occupancy	Index of bed per nurse
1	2.78–4.59	18.3–24.82	1.24–1.88
2	4.60–5.65	24.83–33.72	1.89–2.00
3	5.66–7.64	33.73–45.26	2.01–2.82
4	7.65–11.86	45.27–61.44	2.83–3.90

Table 6.

Workload indices of the departments.

Department	Index of mean length of stay	Index of occupancy	Index of bed per nurse
Intensive care unit	4	3	1
Neurosurgery and plastic surgery	2	3	3
Obstetrics and gynecology	1	1	4
Newborn	2	2	1
Pediatrics and pediatric surgery	1	2	4
Cardiology	1	1	1
Infectious diseases	4	1	1
Urology	1	4	1
Cardiovascular and thoracic surgery	2	1	4
General surgery	2	3	3
Orthopedics	4	4	2
Internal medicine and oncology	3	3	2
Neurology	3	4	2
Physical therapy	4	4	4
Outservice and other	3	3	2

When the association of average duration of stay, occupancy rate, and nurse bedside parameters with CEAP class, morning–evening difference in ankle circumference (bilateral), and CVI symptoms was examined, a significant association was found between the average duration of hospital stay and morning–evening difference in ankle circumference and CVI symptoms. Increasing average duration of hospital stay was associated with significantly lower diurnal ankle circumference differences (P = .02, P = .04) and CVI symptoms (P = .009). On the other hand, patient bed occupancy rate and nurse-related bedside parameters did not exhibit a significant association (Table 7).

Table 7.

Correlation among workload indices and study parameters.

Indices	Mean CEAP class	Right ankle morning–evening difference	Left ankle morning–evening difference	Positive symptoms
Index of mean length of stay
1	0.89 ± 0.93	0.55 ± 0.67	0.52 ± 0.65	43 (75.4)
2	0.87 ± 1.07	0.51 ± 0.49	0.62 ± 0.53	38 (65.5)
3	0.50 ± 0.73	0.41 ± 0.47	0.44 ± 0.49	29 (58.0)
4	0.70 ± 1.14	0.36 ± 0.42	0.38 ± 0.42	36 (53.7)
Correlation β	−0.102	−0.145	−0.131	−0.170
P	0.12	0.02	0.04	0.009
Index of occupancy
1	0.73 ± 0.99	0.50 ± 0.67	0.53 ± 0.67	37 (60.7)
2	0.90 ± 0.92	0.41 ± 0.40	0.47 ± 0.43	30 (69.8)
3	0.70 ± 1.06	0.46 ± 0.51	0.50 ± 0.53	54 (61.4)
4	0.70 ± 0.99	0.43 ± 0.39	0.42 ± 0.36	25 (62.5)
Correlation β	−.0.029	−0.032	−0.052	−0.06
P	0.65	0.62	0.43	0.93
Index of bed per nurse
1	0.74 ± 0.94	0.48 ± 0.62	0.48 ± 0.60	50 (63.3)
2	0.56 ± 0.93	0.39 ± 0.43	0.40 ± 0.44	40 (55.6)
3	0.83 ± 1.08	0.56 ± 0.53	0.63 ± 0.56	25 (69.4)
4	0.97 ± 1.13	0.42 ± 0.45	0.54 ± 0.48	31 (68.9)
Correlation β	0.092	−0.012	0.079	0.050
P	0.16	0.86	0.86	0.45

Note: CEAP, Clinical–Etiology–Anatomy–Pathophysiology; P<0.05 was considered as statisticaly significant.

Discussion

In this study involving a group of nurses with relatively better defined working conditions compared to other health staff, the association between CVI signs/symptoms, CEAP class, and workload was explored. The definition of workload encompasses a variety of different factors.⁹ In this study, three important components of workload have been taken into consideration for study purposes. These are the average length of stay, bed occupancy rate, and number of patient beds per nurse. The major finding of our study indicates a negative association between average duration of hospital stay and these parameters. In our facility, the average duration of hospital stay was longer in the intensive care, infectious diseases, orthopedics, and physical therapy units. A lower rate of CVI signs and symptoms among nurses employed in these department may probably associated with an increased familiarity between the nurse and the patient, and with the obtainment of a more regular daily treatment schedule along with increasing length of stay. Initial work-up such as anamnesis, examination, weight and height measurements, laboratory tests, organization of consultations, and maintenance resulting in a physically demanding working condition with each new admission may contribute to the development or worsening of CVI signs and symptoms.

The first possible limitation of our study to be mentioned is the clinical detection of CVI. Since it was not feasible to perform an ultrasound examination in all participants, this method of assessment was preferred. CEAP is an easy-to-use classification system with proven validity and reliability. Previous studies have suggested that although CEAP was not as specific as ultrasound imaging, it was able to show a good correlation with ultrasound results.^8,10–12 Thus, the large sample size necessitated the use of CEAP. A second limitation is that although the workload was defined using globally accepted parameters, some patients in certain units might have required more frequent treatments or more intensive use of nursing care, which were not taken into account in our study. Despite the importance of this potential limitation, first it should be stressed that its detection is not an easy task, and secondly it is a phenomenon with a lower likelihood of persistence. Finally, there was no homogeneity between different units of our health facility in terms of physical conditions. Factors such as the distance to the restaurant, pharmacy, or canteen facilities or horizontal versus vertical placement of the building blocks within which the units are located may also affect the physical activity level during working hours with a resultant influence on CVI outcomes. However, standardization is almost universally very difficult to achieve with regard to abovementioned difficulties.

At least one symptom of CVI was present in 62.9% of the participants. According to the CEAP classification, while there were no observable changes in 49.6% of the study subjects, 51.4% had CVI signs. Of the latter, the CEAP class was C1 in 39.2%. Compared to the data from population-based studies, these figures are slightly higher. In cross-sectional population-based studies examining the CVI incidence, the reported figure is 14.9% for Greece, 34.8% for Pakistan, 57.1% in Budapest, and 44.0% in Bulgaria.^13–16 In studies where a higher incidence of CVI was reported, use of Doppler ultrasound as the diagnostic tool might have increased the detection rate in subclinical patients. On the other hand, in a study by Ziegler et al.¹⁷ involving participants representative of all units of a hospital, CVI was found in 34%, as compared to 52% among vascular surgeons in a study focusing on this specialty by Labropoulos et al.¹⁸ In studies examining the workers who have to stand, even higher rates of CVI detection can be noted.^4,6–8 In most of these studies, in addition to hereditary and personal factors, other elements such as the total duration of standing or sitting, lifting of heavy objects, and hot or humid working conditions have been found to lead to an increased incidence of CVI signs and symptoms. Most of the participants in our study comprised of nurses with a well-defined working condition who had to stand during most of the working hours. Clearly, this might have contributed to an increased incidence of CVI signs and symptoms.

CVI may be the result of a number of factors such hereditary, personal, or environmental factors, either alone or in combination. Increased hydrostatic pressure in conjunction with valvular damage and inflammation play a major role in the pathophysiology. Alterations in working conditions of the individuals may be associated with positive effects on CVI symptoms. For instance, use of rubber for floor covering has been shown to provide a certain degree of clinical benefit through increased efficiency of the muscular pump effect in the leg. On the other hand, high heels have been found to adversely affect this function.¹⁹ Humidity and high temperature may lead to increased severity of the lower extremity oedema via venous dilatation and capillary leakage, particularly in individuals who need to stand during working hours.¹⁷ In those subjects with signs and/or symptoms of CVI, information has been provided on these simple lifestyle changes, while those with findings suggestive of more advanced disease were referred to the appropriate outpatient unit. It can be speculated that improvement in such symptoms may also be associated with increased work productivity and patient-care quality. Conversely, elimination of the aggravating factors may also play a key role in the prevention of this condition. Obviously, several measures such as increasing the number of personnel or shortening the total duration of working hours in clinical units with short duration of patient stay or high patient turnover may provide beneficial effects. If that is not possible, then educational activities and prophylactic measures targeting “at risk” populations along with improved physical conditions may also help achieve positive results. Further studies examining the efficiency of such preventive or corrective activities are warranted.

This study is designed in cross-sectional format. Associations derived from this study should be subjected to further studies. Although this is an important limitation, it is almost impossible to reduce all of the limitations among the nurses due to uncertain conditions such as walking distance to hospital, holiday periods, off-work high heels, home workload, etc. So, the findings of this study may be considered regardless from these limitations.

Conclusion

Protocols used for the provision of health care services are evolving in the direction of activities targeting increased quality. Increased productivity of the health care personnel constitutes an important element of these current approaches. Our results have shown that the average duration of hospital stay is associated with an increased frequency of the signs and symptoms of CVI. Arrangements aimed at improving these parameters related with nurse health may be expected to provide positive contributions to patient and nurse health.

Footnotes

Conflict of interest

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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