Views of inpatients on the prevention of venous thrombosis with ankle pump exercise: A cross-sectional survey

Abstract

Introduction

This study investigated the current status of patients' knowledge and clinical compliance with ankle pump exercises in order to better enhance patient education and improve patient compliance with ankle pump exercises.

Methods

A cross-sectional survey of the current status of ankle pump exercise awareness and compliance was conducted using a self-designed questionnaire. The questionnaire consisted of a general demographic information questionnaire, a questionnaire on patients’ perceptions of ankle pump exercise and a compliance questionnaire.

Results

A total of 2,203 patients from 53 clinical departments participated in this survey. 87.8% of patients considered ankle pump exercise important, 92.1% could grasp the knowledge of ankle pump exercise, 48.5% could self-monitor and exercise daily as instructed, 81.5% of health care workers would often supervise patients to complete ankle pump exercise, poor self-control (34.6%), lack of physical strength (21.1%) and perceived hassle (18.9%) were the top 3 factors contributing to patients' inability to complete the ankle pump exercise. Regression analysis showed that the factors influencing patients' compliance with the ankle pump exercise were literacy, economic level, number of comorbidities and caprini risk class (p < .05).

Conclusion

The patient’s cognition of ankle pump exercise is good, but the compliance needs to be improved. It is suggested that the compliance of ankle pump exercise in hospitalized patients should be improved in the future to reduce the incidence of Venous thromboembolism.

Keywords

Ankle pump exercise cognition compliance venous thromboembolism prevention

Venous thromboembolism (VTE) is a common complication in clinical patients. According to statistics, about 100,000 people die from VTE every year.¹ Studies have shown² that blood stasis is one of the three major risk factors for thrombosis, so promoting lower extremity venous return can effectively prevent the formation of VTE. Ankle pump exercise refers to the formation of a pump-like effect through the flexion, extension and orbiting movement of the ankle joint, squeezing the venous sinuses, better promoting the blood and lymphatic return of the limbs, and alleviating the blood stasis state.³ It is a simple, feasible and costless. Basic preventive measures with high clinical availability can effectively promote blood return and reduce the risk of thrombosis. It has been recommended by many books and experts,^4–6 and clinical safety and reliability have also been further Confirmed.⁷ Whether the patient can complete the exercise completely and effectively is the key to ankle pump exercise. However, there are differences in patients’ understanding of ankle pump exercise and the standards for clinical application of ankle pump exercise is very different so as the patient’s compliance with the ankle pump movement. All these issues need to be resolved urgently.⁸ In the provincial hospital affiliated to Shandong First Medical University, where the authors work, the total number of hospital admissions in 2021 was 215,990 and the number of VTEs occurred in 553, with a VTE incidence rate of 256.03/100,000 per year. Therefore, this study investigated the cognitive status and clinical compliance of 2203 patients to the ankle pump exercise, aiming to provide a reference for the clinical implementation of the ankle pump exercise.

Method section

Respondents

This study adopts the convenient sampling method, 53 clinical departments of Provincial Hospital of Shandong First Medical University, including vascular surgery, orthopaedics, oncology and obstetrics and gynaecology, which are prone to VTE, and 2203 inpatients were selected for the survey. All survey subjects have signed consent form and voluntarily participate in the survey. Inclusion criteria: Patients at risk of thrombosis assessed using the Caprini Thrombosis Assessment Tool⁹; patients with no contraindications for lower limbs and ankles; and patients who can answer questions correctly, have normal cognitive functions and can communicate through language and text. Patients and main caregivers voluntarily participate, agree to cooperate in the research and sign the consent form; Exclusion criteria: Patients who require absolute immobilization of the lower limbs; Patients with other systemic comorbidities that affect activities; Patients with mental, physical or legal defects; and Patients with deep vein thrombosis of lower extremities at admission.

4VTE events occurred during hospitalisation in the 2203 patients in this study, 2 in the orthopaedic department, one in the obstetrics and gynaecology department and one in the oncology department. At the study centre, health care professionals will give VTE prevention education or measures to patients who are at risk of VTE, such as in the investigator’s department, nurses taught patients to initiate plantarflexion + dorsiflexion 30 times/minute for 3 minutes every hour of the day, when the patient’s condition allowed. If the patient’s condition does not allow the patient to perform active ankle pump exercises, such as post-operative patients under general anaesthesia or patients with fractures, the nurses help the patient to perform passive plantarflexion + dorsiflexion 10 times/min for 3 minutes, once an hour. However, not all patients participating in the study had VTE prophylaxis. Intermittent pneumatic compression devices are used in the operating theatres of the study centres if there are no contraindications and the operation is performed in a horizontal position, if the operation is prolonged and if the condition requires it, such as gastrointestinal malignancy, but they are currently used relatively infrequently. The device was not used during surgery in the 2203 patients involved in this study.

Investigation method

Survey tools

The self-designed ankle pump movement cognition and compliance status survey questionnaire is used for investigation. The first draft is formulated by the literature review method^10–12 and discussed with 5 clinical thrombosis prevention experts.

The questionnaire content package includes: (1) Part 1: General demographic data survey form, including 8 items such as gender, age, department, education level, hospitalization days, comorbid diseases and caprini risk assessment level. (2) Part 2: The table for patient’s knowledge of ankle pump exercise contains 9 items, which are the knowledge of deep vein thrombosis of the lower extremities, the knowledge of ankle pump exercise, the significance of ankle pump exercise, the importance of ankle pump exercise, and the standard exercise of ankle pump exercise, Ankle pump exercise contraindications, ways to understand ankle pump exercise, medical staff instructing the ankle pump exercise method, the patient’s activity during hospitalization. Among them, ‘the way to understand ankle pump exercise’ and ‘ankle pump exercise standard movement’ are multiple choice questions. (3) Part 3: Patient’s compliance with ankle pump exercise questionnaire, including 13 items such as whether the patient is able to self-promote and perform the exercise as required on a daily basis, reasons for not being able to complete the ankle pump as required, and whether the patient is able to accept supervision by health care professionals and family members, including ‘whether the patient is able to self-promote and perform the exercise as required on a daily basis’ This section contains 13 graded or multiple choice questions, including ‘whether you are able to supervise yourself and do the exercise as required’, ‘the need for post-operative ankle pump’ and ‘reasons for not being able to complete the ankle pump as required’.

Before the formal survey, a pre-survey is conducted on 20 patients, and the Cronbachα coefficient of the questionnaire was 0.757. The questionnaire was evaluated by 6 thrombosis prevention experts, and the measured validity was 0.844.

Data collection method

The researcher sends the questionnaire and filling instructions to each department through WeChat group. The responsible nurse of the department sends the questionnaire link or QR code to the survey subjects who meet the inclusion criteria. The researcher sets all objective question items as mandatory questions to ensure that the questionnaire is filled out completely From May to September 2021, a total of 2291 patients participate in the questionnaire survey. After reviewing by two individuals, 88 questionnaires with obvious logical issues are excluded, and the rest 2203 questionnaires are included for analysis in the study with an effective collection rate of 96.2%.

Statistical methods

Use SPSS21.0 for data analysis. Counting data is described by frequency and percentage, and measurement data is described by mean ± standard deviation. Univariate analysis adopts ANOVA, and multivariate analysis is described by multiple stepwise linear regression. p < .05 indicates that the difference is statistically significant.

Results

General information of survey subjects

A total of 2203 patients from 53 clinical departments participate in this survey. The general information of the patients are illustrated in Table 1.

Table 1.

General information of the patients and the results of the one-way analysis of variance of the patients’ daily ankle pump exercises according to the instructions (n = 2203).

	Number	Percentage (%)	Statistical value (F)	p value
Gender
Male	1048	47.6	2.417	0.065
Female	1155	52.4	2.417	0.065
Age (years)
18–25	260	11.8	0.669	0.571
26–35	424	19.2
36–60	1000	45.4
>60	519	23.6
Residence
City	1137	51.6	0.239	0.869
Rural	1066	48.4	0.239	0.869
Education level
Primary school and below	373	16.9	13.845	0.000
Middle school	1017	46.2
University and above	813	36.9
Economic level (month: RMB)
<2000	439	19.9	16.678	0.000
2000–6000	965	43.8
>6000	799	36.3
The number of other underlying diseases combined*
None	318	14.4	22.841	0.000
1	516	23.4
2	675	30.6
≥3	694	31.5
Caprini risk assessment
High or extremely high risk	638	28.9	22.916	0.000
Medium risk	431	19.6
Low risk	482	21.9
None	652	29.6

Note: *① Hypertension; ② Diabetes; ③ Hyperlipidaemia; ④ Tumour; ⑤ Immune system diseases; ⑥ Others.

The patient’s cognition of ankle pump movement

87.8% of patients think that ankle pump exercises are important. 92.1% of patients can master the related knowledge of ankle pump exercises. 64.4% of patients can also accurately understand the contraindications of ankle pump exercises. In addition, most patients express that they are more willing to accept medical staff to coach them about ankle pump exercises through bedside explanations and specific demonstrations. (Table 2)

Table 2.

Patient’s cognition of ankle pump movement (n = 2203).

	Number	Percentage (%)		Number	Percentage (%)
1. Understand the path of ankle pump exercise			5. Knowledge about deep vein thrombosis of lower extremities
Nurse mission	2147	97.5	Don’t understand at all	22	1.0
Doctor’s mission	800	36.3	do not know much	150	6.8
Network query	337	15.3	Better understand	836	38.0
Related books	300	13.6	Know very well	1195	54.2
2. Publicity and education methods for medical staff			6. Mastery of related knowledge of ankle pump exercise
Oral explanation at the bedside	507	23.0	Don’t understand at all	17	0.8
Bedside explanation and specific demonstration	1008	45.8	do not know much	90	4.1
Health education manual	49	2.2	Better understand	835	37.9
Ankle pump exercise video	73	3.3	Know very well	1261	57.2
Other	10	0.5	7. Ankle pump exercise contraindications
All of the above	556	25.2	Don’t understand at all	129	5.9
3. Which way the patient prefers to learn ankle pump exercise			Partial understanding	656	29.8
Oral explanation at the bedside	484	22.0	Learn	1418	64.3
Bedside explanation and specific demonstration	1283	58.2	8. Standard action of ankle pump exercise
Health education manual	304	13.8	A	2091	94.9
Ankle pump exercise video	99	4.5	B	1915	86.9
Other	33	1.5	C	1788	81.2
4. The importance of ankle pump exercise			9. Activities during hospitalization
Unimportant	66	3.0	Absolutely bedridden	221	10.0
Generally important	202	9.2	Long-term bed rest	250	11.3
Important	826	37.5	Can get out of bed and go to the toilet	508	23.1
Very important	1109	50.3	Free to move	1224	55.6

Note. A. Hook your feet as hard as you can and let the toes face you; B. Extend the instep and press the toes down as best as you can; C. Rotate the ankle 360°.

The patient’s compliance with the ankle pump exercise

The compliance of 2203 patients to the ankle pump exercise is at a moderate level. 72.4% of patients were able to achieve maximum angulation in plantarflexion and dorsiflexion during ankle pump exercises, 48.5% of the patients are able to self-supervise daily and exercise following the instructions, 50.1% are able to do ankle pump exercises without missing a single step, 59.69% of the patients could accept supervision by family members or medical staff, and 81.5% of the patients complete ankle pump exercise under the supervision of medical staff. Poor self-control (34.6%), lack of physical strength (21.1%) and feeling troubled (18.9%) are the major causes of the patient’s inability to complete the ankle pump exercise. (Table 3)

Table 3.

Patients’ compliance with ankle pump exercise (n = 2203).

	Number	Percentage (%)		Number	Percentage (%)
1. The angle of ankle pump exercise			8. Able to do any movement without missing ankle pump movement
A	243	11.0	Completely possible	1104	50.1
B	259	11.8	Basically done	953	43.3
C	107	4.9	Occasionally	130	5.9
D	1594	72.3	Can’t do it at all	16	0.7
2. Holding time of each movement of ankle pump exercise			9. Strictly complete the number of exercises per day
1–3s	301	13.7	Completely possible	1069	48.5
3–5s	449	20.4	Basically done	972	44.1
5–10s	617	28.0	Occasionally	145	6.6
>10s	836	37.9	Can’t do it at all	17	0.8
3. Duration of each ankle pump exercise			10. Be able to actively observe and evaluate the effect of ankle pump exercise
<1min	147	6.7	Completely possible	1070	48.6
1–2min	386	17.5	Basically done	951	43.2
2–3min	375	17.0	Occasionally	159	7.2
3–5min	757	34.4	Can’t do it at all	23	1.0
>5min	538	24.4	11. When the conscious effect is not obvious, you can actively seek suggestions to improve the effect
4. The number of ankle pump exercises per day			Completely possible	1120	50.8
0 times	37	1.7	Basically done	913	41.4
1–3 times	710	32.2	Occasionally	147	6.7
3–5 times	557	25.3	Can’t do it at all	23	1.0
5–10 times	664	30.1	12. Ankle pump exercise helps oneself
>10 times	235	10.7	Very helpful	1580	71.7
5. Ability to self-supervise daily and exercise according to instructions			More helpful	557	25.3
Completely possible	1069	48.5	Not sure	56	2.5
Basically done	949	43.1	No help	10	0.5
Occasionally	166	7.5	13. The reason why the ankle pump cannot be completed as required
Can’t do it at all	19	0.9	Did not master the method	256	11.6
6. Able to be supervised by family members or medical staff			Feel troublesome	416	18.9
Completely possible	1315	59.7	Poor self-control	762	34.6
Basically done	786	35.7	Pain	336	15.2
Occasionally	93	4.2	Lack of physical strength	465	21.1
Can’t do it at all	9	0.4	Lack of physical strength	80	3.6
7. Medical staff supervise the patient to complete the ankle pump exercise			Worried about bleeding from the wound	203	9.2
Often	1795	81.5	Other	452	20.5
Ankle pump exercise	383	17.4
Will not	25	1.1

Note. a. Hook up the toe 10–20°, and press the toe down 5–10°; b. Hook the toe up 20–30°, and press the toe down 10–20°; c. Hook the toe up 30–40°, and press down Tiptoes 20–30°; d. Try to achieve the maximum angle.

Analysis of factors affecting patient compliance with ankle pump exercise

Regression analysis shows that the factors affecting patient compliance with ankle pump exercise are education level, economic level, number of comorbid diseases, and caprini risk level (p < .05), among which economic level, number of comorbid diseases and caprini risk level are related to ankle pump exercise compliance by a negative correlation, and education level is positively correlated with ankle pump exercise compliance. (Tables 4 and 5)

Table 4.

Factors and assignments affecting patient compliance with ankle pump exercise.

Influencing factors	Variable factors	Assignment description
Education level	X1	Elementary school and below = 1, middle school = 2, university and above = 3
Economic level	X2	<2000 = 1, 2000-6000 = 2, >6000 = 3
Number of combined diseases	X3	None = 1, 1 disease = 2, 2 diseases = 3, 3 and above = 4
Caprini risk level	X4	No risk = 1, low risk = 2, medium risk = 3, high risk or extremely high risk = 4

Table 5.

Results of multiple stepwise linear regression analysis of patients' ankle pump exercise compliance (n = 2203).

Variable	Regression coefficients	Standard error	Standardized regression coefficient	t value
Constant	1.438	0.024	—	59.972
Education level	0.201	0.040	0.221	5.040
Economic level	−0.187	0.039	−0.213	−4.795
Number of combined diseases	−0.100	0.022	−0.162	−4.630
Caprini risk level	−0.546	0.016	−1.014	−33.758

Discussion

Our study shows that 92.1% of patients could master the relevant knowledge of ankle pump exercises and 64.4% of the patients could also accurately understand the contraindications of ankle pump exercises, indicating that the clinical staff had reasonable propaganda and education, the patients had a good understanding of ankle pump exercise and most of the patients could grasp the principles and knowledge about ankle pump exercise. However, patients’ knowledge of contraindications related to ankle pump exercise was slightly inadequate, which may be related to the fact that health care providers focused on explaining the movements of ankle pump exercise during education, but neglected to teach about risk factors and contraindications. Health education is an important source of disease-related information for patients. It is critical to establish the correct cognition of the patient’s ankle pump movement and form a good code of conduct.^13,14 This study shows that the way for patients to understand ankle pump exercise is mainly from nurses’ education. The methods of education include written explanations, demonstrations and videos. Most of the patients are more willing to accept ankle pump exercise education by medical staff through bedside explanations and specific demonstrations. It’s possible that the combination of theories and demonstrations in education is more interactive and can more intuitively and clearly be understood by the patients, which is consistent with related research.¹⁵ Some data show that,¹⁶ in addition to the difference in the patient’s own ability to accept knowledge, the way of propagating and educating disease knowledge will affect the patient’s acceptance and compliance with knowledge. Zuo Yaqin¹⁷ and others use knowledge explanations and action demonstrations for health education, which improves patients' awareness and understanding of diseases, enhances patients’ intuitive feelings and promotes patients to master disease knowledge and improves cognitive ability. Cho Lee and others believed¹⁸ that video teaching is another effective learning tool, while Hashim¹⁹ believed that written health education is more effective. In addition, with the development of ‘Internet + Nursing Services’, it is also possible to make full use of the public account and medical APP platform²⁰ to integrate the principles, actions, taboos and precautions of ankle pump exercises for patients to check at any time. It is recommended that clinical staff adequately assess weaknesses in patients' knowledge of ankle pump exercises and incorrect daily behaviour, and provide reasonable health education to further improve patients' knowledge of ankle pump exercises.

In the results of this survey, 48.5% of patients are able to self-supervise daily and perform ankle pump exercises following the instructions, 50.1% are able to do any movement of ankle pump exercises without missing a single step and 59.7% of patients could accept the supervision of family members or medical staff. It shows that the compliance of patients to ankle pump exercise is at a moderate level, and poor self-control, lack of physical strength and conscious trouble are the main factors causing patients to fail to complete ankle pump exercise. Reasonable supervision could promote the effective implementation of ankle pump exercise.²¹ Although more than 80% of the medical staff can regularly supervise the patients to complete the ankle pump exercise, it is recommended to encourage the patient’s family members to participate the supervision. If the patient has difficulty in active ankle pump exercises due to objective reasons such as disturbance of consciousness, poor muscle strength of the lower limbs or surgery, passive ankle pump exercises are particularly important in these situations. Shimizu²² produced a leg movement device to assist patients with ankle pump exercises, which can effectively promote blood circulation in the veins of the lower extremities, improve the venous dysfunction of the lower extremities and prevent the occurrence of VTE. In the present study, the angles, movements, maintenance time, duration and frequency of the ankle pump exercises of patients in this study are very different, this is due to: different clinical application standards of ankle pump exercises and nursing staff in various departments does not have a uniformed standard or guideline to instruct patients. Quantifying the ankle pump exercise intervention measures can effectively encourage patients to complete all exercise plans under fully ensuring the frequency, time, intensity and effect of the ankle pump exercise.²³ Clinical nurses should establish a scientific, reasonable, standardized and unified implementation plan for ankle pump exercise based on the best effectiveness of ankle pump exercise, blood flow speed, compliance, lower limb fatigue and individual functional differences. The quantification and standardization of pump movement are conducive to promoting patient enthusiasm and initiative, and improving patient compliance.

We found that education level, economic level, number of comorbid diseases and Caprini risk level are factors that affect patients’ ankle pump exercise compliance. Multivariate stepwise linear regression analysis shows that education level is positively correlated with ankle pump exercise compliance. Obviously it may be related to the high level of education in patients with high ankle pump awareness, the ability to actively avoid unhealthy behaviours and compliance behaviours. This is similar to the results of Kaori.²⁴ Results also show the higher the economic level of patients, the lower the compliance of ankle pump exercise. The analysis is related to the higher economic level of patients who rely more on instrument assistance and poor initiative. It is recommended that medical staff should determine the timing, time, frequency for using auxiliary devices based on the patients’ realistic situation, encourage the patient’s enthusiasm and initiative and increase the patient’s attention to ankle pump exercise.²⁵ Caprini score, as an individual risk assessment model for venous thromboembolism, can identify the degree of VTE risk in patients and help clinical staff determine effective prevention plans,⁹ which mainly include age, surgery, comorbid diseases, thrombotic history and other items. Caprini risk level and the number of comorbid diseases are negatively correlated with the patient’s ankle pump exercise compliance. The higher the Caprini risk level and the greater the number of comorbid diseases, the lower the patient’s trust in ankle pump exercise, and the dependence on drugs and surgery. It is desirable that medical staff in clinical work could provide targeted prevention and treatment measures based on the different risk levels and underlying disease conditions of the Caprini score, and show patients that ankle pump exercise can also effectively increase blood flow speed. Prevent the occurrence of VTE and improve patient compliance in addition to physical and drug prevention.

Conclusions

In this study, a representative sample of 2203 patients from Provincial Hospital of Shandong First Medical University was investigated. The results of the survey showed that patients' knowledge of ankle pump exercise is good, but compliance needs to be improved. It is recommended that clinical staff should further improve patients’ awareness of ankle pump exercise in conjunction with their condition, and strengthen supervision to quantify and standardize ankle pump exercise to improve patients’ compliance. Although this study mainly investigated patients’ knowledge about ankle pump exercise and factors influencing compliance with ankle pump exercise, but did not analyse the effects of different disciplines, diseases and disease states on the occurrence of VTE, for example, there should be differences in patient compliance between different disciplines such as general surgery, orthopaedics and obstetrics and gynaecology, which were not refined in this study, which is a limitation of our study. More factors should be included in the future to provide a more comprehensive analysis of the risk factors for the occurrence of VTE and to provide a basis for improving the prevention and treatment of VTE.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Shandong Province Medicine and Health Science and Technology Development Plan Project and National Natural Science Foundation of China.

ORCID iD

Yujie Liu

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