Abstract
Background
The prevention and management of venous thromboembolism (VTE) represent crucial issues within healthcare, as they are linked to patient safety and quality of care. As such, healthcare workers are expected to demonstrate certain levels of knowledge, attitudes, and practices (KAP) regarding VTE. This study evaluated the efficacy of an existing 5-year blended interprofessional education program (BIEP) designed to improve KAP regarding VTE at a university-affiliated hospital.
Objective
To evaluate the BIEP’s effectiveness on enhancing KAP regarding VTE prevention and management.
Methods
This single-center observational study was designed to assess changes in KAP regarding VTE before and after the implementation of a BIEP. These changes were evaluated via an expert-developed electronic questionnaire distributed to healthcare workers participating in the BIEP. Knowledge items were assessed in terms of accuracy, whereas attitude and practice items were assessed using a 5-point Likert scale, with higher scores indicating improvements in attitudes and practices.
Results
Of 1817 questionnaires distributed, a total of 1145 healthcare workers completed the pre-training and post-training surveys. The average accuracy rate for knowledge-based questions increased from 36.9% before training to 50.4% after training (P < 0.001). Attitude scores improved modestly (from 18.68 ± 5.76 to 19.41 ± 4.97; P = 0.011), as did practice scores (from 19.86 ± 3.88 to 20.37 ± 3.89; P = 0.003).
Conclusions
The BIEP improved the KAP of healthcare workers regarding VTE. These findings emphasize the importance of continuous education in enhancing the quality of VTE management and provide a scientific basis for future educational interventions.
Introduction
Venous thromboembolism (VTE) is a common, potentially fatal complication that is particularly prevalent among hospitalized patients. 1 The prevention and management of VTE represent crucial issues within healthcare, as they are directly linked to patient safety and quality of care. 2 As such, healthcare workers are expected to demonstrate certain levels of knowledge, attitudes, and practices (KAP) regarding VTE. Previous research has highlighted the importance of robust knowledge regarding VTE prophylaxis, as well as the demonstration of favorable attitudes and use of effective practices for VTE prevention and management. 3 However, global surveys have uncovered deficiencies in healthcare workers’ knowledge and practices regarding VTE.4,5
In clinical practice, preventive measures for VTE encompass risk assessment, health education, and mechanical or pharmacological prophylaxis, yet the implementation of these measures remains suboptimal. 6 Healthcare workers’ inadequate understanding of VTE and lack of preventive awareness and nursing knowledge contribute to a high rate of missed and misdiagnosed cases and a low implementation rate for preventive measures.7,8 Therefore, training healthcare workers in the prevention and management of VTE is of paramount importance.
To enhance healthcare workers’ capabilities in VTE prevention and management, our institution has been using a blended interprofessional education program (BIEP) since 2019. 9 However, we have not yet established whether such training initiatives truly enhance the knowledge of healthcare workers and lead to positive transformations in attitudes and practices. In this study, we therefore sought to compare changes in KAP regarding VTE before and after training, thus allowing us to evaluate the effectiveness of the BIEP and providing reference points for future educational endeavors.
Through this research, we aspire to illuminate the direct impact of BIEP on enhancing healthcare workers’ KAP regarding VTE events, thereby offering scientific evidence to inform the development of more effective educational interventions and improve the quality of VTE prophylaxis and management.
Methods
Study Design
This single-center observational study employed a before-and-after design to evaluate an existing BIEP at a university-affiliated hospital. A waiver of written informed consent was granted by the Institutional Review Board because the survey was conducted anonymously with no collection of personally identifiable information, and the study presented no more than minimal risk to participants, consistent with the principles of the Helsinki Declaration.
Participants
All healthcare workers at our institution (n = 1817), including clinicians and nurses, participated in the BIEP. All were invited via the institution’s e-mail system to complete a questionnaire before the training was initiated. After the training, the questionnaire was sent again to the original respondents to assess changes in each healthcare worker’s KAP. The first survey was sent to workers between September 1 and September 30, 2019, and the second survey was sent between September 1 and September 30, 2024. If no survey response was received within 15 days, an email reminder was sent. Questionnaires that were not returned within the allotted time were excluded. Individuals who did not fill out either questionnaire were excluded from the study.
Intervention Details
The goal of the BIEP is to enhance the capability of healthcare workers to identify VTE risks, implement effective prophylactic measures, and manage VTE events with efficiency. The training content was collaboratively developed by staff from the departments of interventional and vascular surgery, respiratory medicine, emergency medicine, the intensive care unit, radiology, pharmacy, medical education, and hospital management.
The 5-year BIEP includes four core components, as follows:
Annual seminars: These month-long seminars deliver 24 total contact hours through weekly 6-h sessions covering fundamental and advanced VTE topics. All medical and nursing staff are required to participate in this training. The training rate for each department is expected to be more than 80%; the training rate for newly hired employees is required to be 100%. The seminars encompass a spectrum of topics, ranging from fundamentals such as the definition, epidemiology, pathophysiology, and risk factors of VTE to advanced diagnostic techniques and management strategies. Monthly online modules via the institutional WeChat platform: These modules require approximately 1 h of engagement per topic. This academic teaching public platform, which is managed by the departments of medical education and publicity, disseminates VTE-related educational content each month. As an open academic information-sharing website, all readers can freely access, view, and comment on the materials. The department chief or nurse managers of each unit encourage medical staff and resident physicians to complete the online learning courses. Eight virtual patient cases on CureFun: These cases each require 45 min for completion. CureFun is an existing smartphone-based training platform. For this program, virtual patients interact with users by simulating VTE scenarios, posing questions, and providing feedback. Users are required to follow the guidance of the virtual patients or proactively ask questions to arrive at an accurate diagnosis, while also selecting the most appropriate auxiliary tests and treatment methods. Upon completion of the virtual dialogue, the system assigns a comprehensive score to the user. Quarterly simulation drills: These drills involve 2-h multidisciplinary team sessions. For these drills, one department is randomly designated to send a rapid response team composed of five medical personnel to participate in simulated VTE emergency situations. The drill involves the practical application of basic life support skills and the simulation of VTE crisis scenarios. Following each simulation, a multidisciplinary team of instructors provides feedback and engages in discussions to foster learning and enhance skills.
Intervention Fidelity
The program has maintained rigorous consistency of implementation over its 5-year period through multiple verification mechanisms. Attendance at the seminars is systematically tracked. Digital analysis is used to monitor engagement in the online education module distributed through the institution’s WeChat platform, including assessment of the average number of publications read per month. Virtual patient case completion rates are monitored through the CureFun training portal. For the simulation exercise, the number of participants in each department’s VTE rapid response team is recorded, as well as the performance score. Together, these metrics have been used to ensure the structural integrity and reproducibility of the intervention throughout the study period.
Evaluation
The KAP questionnaire was rigorously developed through sequential validation phases. Five multidisciplinary clinical experts specializing in VTE management, each possessing more than 10 years of field experience, initially drafted items based on established clinical guidelines and relevant literature. Content validity was subsequently assessed by three independent reviewers (a vascular surgeon, an intensivist, and a nurse educator), who evaluated item relevance using a 4-point scale. This process yielded a content validity index of 0.92, exceeding the acceptable threshold. The instrument underwent pilot testing with 50 healthcare workers to assess comprehensibility and operational clarity, resulting in refinement of ambiguous terminology. Finally, internal consistency reliability was confirmed through Cronbach’s alpha coefficients, with values of 0.920 for attitudes and 0.809 for practices domains. The finalized instrument contained 23 items across 4 sections: demographic characteristics, knowledge assessment, attitude evaluation, and practice documentation.
This questionnaire was used in a study conducted 5 years ago to assess KAP regarding VTE and is still being used for this purpose. 9 All questionnaires are completed anonymously, collecting only basic information (5 items) related to the responder’s clinical work, including their profession, service years, educational level, professional title, and whether they have ever treated or cared for patients with VTE. The questionnaire assesses the responder’s knowledge (8 items) of the prevention, diagnosis, clinical management, and potential outcomes of VTE. The instrument also inquires about the responder’s attitudes (5 items) regarding the importance of VTE prevention and management, as well as their practices (5 items) in both work and study. Attitudes are evaluated using a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), including a neutral point. Practices are also evaluated using a 5-point Likert scale (never, seldom, occasionally, frequently, always). The minimum score for both the attitude and practice questionnaires is 5 (most negative), while the maximum score is 25 (most positive). The higher the score, the more positive the responder’s attitude and practice toward VTE education.
Statistical Analysis
All analyses were conducted using SPSS version 29.0. Results of the questionnaire are presented as n (%). Chi-square tests were used to compare demographics between survey completers and noncompleters. Questionnaire responses from before and after the BIEP were compared using a chi-square test or Fisher’s exact test. Results regarding attitudes and practices are shown as mean ± standard deviation. A Wilcoxon signed-rank test was used to perform intergroup comparisons between the pre- and post-intervention. A P value < 0.05 was considered statistically significant.
Results
Characteristics of Respondents
A total of 1817 questionnaires were distributed before the training, with 1548 (85.2%) completed. After the 5 years training was concluded, the same questionnaire was sent to these 1548 healthcare workers, of whom 1145 (74.0%) completed the survey. No significant differences were found between survey completers (n = 1145) and noncompleters (n = 403) in terms of profession (clinicians: 26.9% vs 27.3%, P = 0.87), sex (female: 81.6% vs 83.1%, P = 0.48), or prior VTE experience (69.3% vs 67.2%, P = 0.42). This suggests minimal selection bias due to attrition. The demographic characteristics of the study responders are summarized in Table 1.
Demographics of Individuals Who Participated in the Post-Training Survey Questionnaire (N = 1145).
Intervention Fidelity
Seminar attendance was systematically tracked, confirming annual participation rates exceeding 90% among healthcare workers. Online educational modules distributed via the institutional WeChat platform demonstrated sustained engagement, with each monthly publication averaging 1650 views. Virtual patient case completion rates were monitored through the CureFun training portal, with 78% of users completing all scenarios. For the simulation drills, 92% of randomly selected units fielded rapid response teams for each exercise.
Knowledge Regarding VTE
Overall, the average correctness rate for knowledge-based questions before the training was 36.9%, which increased to 50.4% after the training (P < 0.001). The questions with the lowest accuracy before the training pertained to the clinical symptoms of deep venous thrombus (DVT) complicated by pulmonary embolism (8.8% correct), as well as the long-term complications of lower extremity DVT (10.4% correct). After 5 years of training, the accuracy rates for these two questions increased to 52.5% and 29.7%, respectively. It is worth noting that the percentage of correct answers regarding preventing the progression of lower extremity DVT was not significantly improved after training (Table 2).
Results of the Knowledge Items for Respondents Before and After Training (N = 1145).
Attitudes Regarding VTE
The total scores for attitude questions among responders demonstrated a significant increase from before to after training (P = 0.011; Table 3). Before the training, 18.0% (206/1145) of respondents believed that VTE risk assessment would exacerbate their workload, whereas after the training, this percentage decreased to 9.3% (107/1145). Before the training, 13.4% (154/1145) of respondents underestimated the importance of educating patients about VTE; however, this figure decreased to 9.1% (104/1145) following the training. Before the training, 26.8% (307/1145) of participants were concerned that the occurrence of VTE events would subject them to financial penalties; following the training, this proportion decreased to 17.7% (203/1145) (Table 4). However, there were no significant differences in responses to questions regarding the impact of VTE prophylaxis on quality of care and medical conflicts, and nurses’ attitudes toward VTE prevention and management did not become more positive as a result of the training.
Differences in Knowledge Accuracy and Attitude and Practice Scores among All Respondents Before and After Training (N = 1145).
Results of the Attitude Items for Respondents Before and After Training (N = 1145).
Practices Regarding VTE
For the items regarding VTE practices, the mean total score increased from 19.86 ± 3.88 to 20.37 ± 3.89 (P = 0.003), signifying that participants are increasingly proactive in VTE prevention and management (Table 3). Before the training, most participants overlooked the pivotal role of specialized departments such as interventional radiology and pulmonology in VTE prevention and management. However, after the training, respondents proactively sought advice and assistance from these specialists (Table 5). The scores on the other four questions in the practice portion of the questionnaire did not improve significantly, and the clinician group did not become more active in terms of practice.
Results of the Practice Items for Respondents Before and After Training (N = 1145).
Discussion
In this study, we aimed to evaluate the impact of a BIEP on the KAP of healthcare workers regarding the prevention and management of VTE. We observed substantial improvements across all evaluated domains, highlighting the efficacy of the BIEP in bolstering healthcare workers’ competencies in VTE prevention and management. Although many of these results were statistically significant, the modest numerical increases in attitude and practice scores suggest limited clinical impact. The BIEP’s value appears to lie mainly in knowledge gains; behavioral changes may require reinforcement.
Incomplete or inaccurate knowledge regarding VTE prevention and management may negatively influence clinical practices, potentially increasing the risk of thrombus formation in hospitalized patients or affecting other VTE outcomes.10,11 The accuracy of respondents’ pre-training knowledge regarding VTE in this study (36.9%) aligns with results reported in a previous multicentric cross-sectional survey (31.1%), 7 confirming baseline knowledge gaps. The 13.5% post-training improvement seen in this study exceeds the gains from passive education typically, highlighting the value of this BIEP. 12 Notably, there was a substantial increase in the understanding of clinical symptoms of VTE complicated by pulmonary embolism, which is a critical finding given the potential severity of this condition. This improvement in knowledge is crucial as it may directly influence the quality of care provided to patients at risk of VTE. 13
The average total score for attitudes increased, reflecting a more positive and confident stance toward VTE prevention and management. The reduction in the percentage of healthcare workers who believed that VTE risk assessment would increase their workload or that educating patients about VTE was not essential suggests that the BIEP successfully addressed misconceptions and fostered a more proactive attitude regarding VTE management. Following the training, there was a small increase in concern regarding doctor-patient disputes stemming from VTE. This may be related to the training’s emphasis on real cases of disputes arising from improper VTE management, which heightened the psychological burden on healthcare workers. In future training programs, we hope to enhance healthcare workers’ communication skills and legal awareness and establish a fair and transparent mechanism for addressing medical disputes to alleviate fears of such conflicts.14,15 Additionally, by providing psychological support and fostering a culture of respect and learning, we hope to better equip healthcare workers to navigate and resolve medical disputes. 16
In this study, the increase in the average total score for items related to VTE practices indicates a shift toward more proactive behavior in VTE prevention and management. The most significant change involved healthcare workers proactively seeking specialized assistance for VTE prevention and treatment, which is a critical step in ensuring optimal patient outcomes. 17 This change reflects the training’s success in emphasizing the importance of interdisciplinary collaboration in VTE management.18,19
Persistent gaps were seen in specific domains despite the implementation of the BIEP. Knowledge regarding the most effective method for preventing VTE progression improved negligibly, suggesting that the curriculum inadequately addressed complex pharmacological concepts such as anticoagulant selection and bleeding risk management. In terms of practice items, no substantial changes were seen in the areas of risk assessment, symptom monitoring, patient education, or self-directed learning. This lack of progress likely stems from unresolved systemic barriers such as clinical workflow fragmentation impeding consistent assessment, insufficient protected time for patient counseling, and passive online learning formats failing to overcome ingrained behavioral patterns. The virtual patient and simulation components of this training program prioritized diagnostic accuracy and emergency response over reinforcing routine prophylactic practices, further explaining the disconnect between knowledge acquisition and practical implementation. 20 Notably, subgroup analyses revealed divergent outcomes. For instance, nurses showed no significant improvement in attitudes regarding VTE. This likely stems from persistent workload concerns disproportionately affecting nursing staff, combined with training content misaligned with their task-focused responsibilities in VTE prevention. Physicians, on the other hand, demonstrated significant knowledge gains but no meaningful changes in practices. This knowledge-action gap suggests that theoretical learning failed to override established clinical habits. Overreliance on specialty consultations may have further displaced autonomous execution of core practices such as risk assessment. These findings collectively indicate that future iterations of this training program must better integrate theoretical concepts with workflow-compatible tools and active skill-building strategies to translate education into sustained practice changes.
This study had several limitations. First, the absence of a control group prevents definitive attribution of observed changes to the BIEP intervention, as concurrent hospital initiatives or broader trends in VTE awareness over the study period may have contributed to the outcomes. Second, the 26% attrition rate between pre-training and post-training assessments introduced potential selection bias despite demographic similarities between completers and noncompleters. Third, reliance on self-reported practices may have introduced social desirability bias, with participants providing responses they perceived as favorable. Fourth, the gender imbalance (>80% female participants) may limit the generalizability of our findings to more gender-balanced clinical settings. Fifth, the study design did not include patient outcome measures; thus, we could not determine whether the observed improvements in KAP translated to reduced VTE incidence or better clinical management. Finally, the lack of significant improvement in specific knowledge and practice domains suggests that certain aspects of the BIEP require refinement to achieve comprehensive effectiveness.
In conclusion, the BIEP implemented at our institution significantly improved the KAP of healthcare workers regarding VTE prevention and management. These findings provide a scientific basis for the development of more effective educational interventions and highlight the importance of continuous education in enhancing the quality of VTE prophylaxis and management.
Footnotes
Ethical Considerations
The study received approval from the Third Affiliated Hospital of Nanjing Medical University Institutional Review Board and adhered to the principles outlined in the Helsinki Declaration. A waiver of written informed consent was granted by the Institutional Review Board, as the survey involving healthcare workers was conducted anonymously, presenting a risk level below the minimum threshold.
Author Contributions
Y.B.: Conceptualization, Methodology, Data Curation, Writing – Original Draft.
H.Q.: Formal Analysis, Software, Validation.
K.W.: Project Administration, Resources.
X. L. and Z.J.: Supervision, Review & Editing, Final Approval.
NO AI was utilized at ANY STAGE during research development & design, data collection, manuscript preparation etc.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability
The datasets generated and/or analyzed during the current study are not publicly available due to privacy concerns and confidentiality agreements but are available from the corresponding author on reasonable request.