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Original research
Knowledge, attitudes and practice towards postoperative nursing of patients with digit replantation and skin flap transplantation among new nurses in Beijing: a cross-sectional survey
  1. Shuang Zhang1,
  2. Yuchen Li1,
  3. Mingxiao Tong2,
  4. Zheng Wen3,
  5. Yunhao Xue4
  1. 1 Department of Sports Medicine and Hand Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
  2. 2 Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
  3. 3 Department of Nursing, Beijing No 6 Hospital, Beijing, China
  4. 4 Department of Hand Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
  1. Correspondence to Dr Shuang Zhang; snowzhsh{at}139.com

Abstract

Objective To explore the knowledge, attitudes and practice (KAP) towards the postoperative nursing of patients with digit replantation and skin flap transplantation among new nurses.

Design Cross-sectional survey.

Setting Two tertiary medical centres in Beijing, China.

Participants New nurses with working experience within 2 years.

Primary and secondary outcome measures The demographic characteristics of the nurses and their KAP towards the postoperative nursing of patients with digit replantation and skin flap transplantation were collected using a self-administered questionnaire. The primary outcome was the KAP scores towards the postoperative nursing of patients with digit replantation and skin flap transplantation. The secondary outcomes were the factors associated with the KAP scores and how the KAP dimensions interacted among them.

Results A total of 206 valid questionnaires were collected. The mean KAP scores were 7.72±3.28 (total score 13; 59.3%), 37.95±6.05 (total score 50; 75.9%) and 38.23±6.12 (total score 45; 84.9%), indicating poor knowledge, moderately favourable attitudes and active practice. The structural equation model analysis showed that knowledge directly influences attitudes (β=0.82, 95%CI 0.60 to 1.05, p<0.001) and that attitudes directly influence practices (β=0.72, 95%CI 0.62 to 0.83, p<0.001). Knowledge had no direct influence on practices (β=0.10, 95%CI −0.09 to 0.29, p=0.313), but the indirect influence was significant (β=0.60, 95%CI 0.41 to 0.78, p<0.001).

Conclusion The lack of sufficient knowledge towards the postoperative nursing of patients with digit replantation and skin flap transplantation among nurses with <2 years of experience and the correlation among the KAP dimensions suggested the importance of proper training.

  • nurses
  • surgery
  • nursing care

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • A strength of this study is the inclusion of a relatively homogeneous sample of participants with a high response rate.

  • The present study lacks generalisability since it was performed on new nurses from the Beijing area.

  • Cross-sectional studies cannot determine causality, but a structural equation modelling analysis was performed to examine the relationships among knowledge, attitudes and practice dimensions.

  • This study might suffer from a selection bias, a small sample size, and a social desirability bias, limiting the generalisability of this study.

Introduction

Digit replantation aims to maximise the functional outcomes instead of the simple survival of the severed part. Indeed, the simple survival of the severed part involves a proper oxygenation and nutrient supply of the reattached part, while the functional outcomes depend on the restoration of the anatomical characteristics such as bones, tendons, blood vessels and nerves.1–4 Anatomical considerations include the level of amputation and the degree of injury to the arterial intima and other soft tissue structures. Skin flap transplantation can be necessary depending on the degree of soft tissue damage of the severed finger. Other considerations include patient factors such as age, occupation, and cultural/occupational significance of the hands.1–4 Although a surgeon properly trained in microsurgical techniques is central to performing digit replantation, nurses play a central role in the daily nursing of the injured digit and patient monitoring. Nurses are on the frontline to monitor for complications such as bleeding, infection, replant failure, haematoma and necrosis during hospitalisation and to react promptly if any complication occurs.5–8 Nurses will observe the condition of the affected finger of the patient every hour after vascular anastomosis. The nurses will give timely feedback on any changes to the surgeon, and early intervention can save the replanted finger.

Hence, the nursing of replanted fingers and skin flap transplantation requires specific and precise knowledge of the signs, symptoms and management of complications (eg, vascular compromise).7 8 Poor knowledge of how to properly nurse replanted fingers with skin flap transplantation would probably harm proper practice, prognosis and the prevention of complications. As in other countries, the standard training curriculum of nurses in Beijing is general. Even though it covers the topic of organ transplants, it does not have the intention of building skills in organ transplants and, of course, does not include the nursing of replanted fingers. Newly hired will experience department rotation, and they will receive specific training before they enter a department, including the departments involving nursing for replanted fingers. Still, new nurses can have gained some knowledge and skills related to finger replantation during courses or training at different nursing schools and hospitals. Determining the state of that knowledge and skills would help design educational and training activities for new nurses regarding finger replantation.

Knowledge, attitudes and practice (KAP) surveys are quantitative and qualitative tools used to evaluate a specific population on a specific subject. KAP surveys are particularly useful for identifying gaps and deficiencies towards a specific subject and providing specific points that can be improved through training and teaching.9 10 There are no available studies on the KAP towards the postoperative nursing of patients with severed digit replantation and skin flap transplantation in new nurses.

Therefore, this study aimed to explore the KAP towards the postoperative nursing of patients with severed fingers replantation and skin flap transplantation among new nurses. We hypothesised that this study could help identify KAP deficiencies and their nature and design or improve training activities.

Methods

Patient and public involvement in research

Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.

Study design and participants

This cross-sectional study was conducted between October 2022 and December 2022 at Beijing Jishuitan Hospital and Beijing No. 6 Hospital. The participants were the new nurses who had been in the profession for less than 2 years. Beijing Jishuitan Hospital is an 1819-bed general tertiary hospital in Beijing harbouring a National Orthopedic Center. The hospital has 1744 nurses. Beijing No. 6 Hospital is a 632-bed general tertiary hospital in Beijing. The two hospitals collectively performed a total of 500–700-related surgeries each year, including digit replantation and skin flap transplantation.

The inclusion criteria were (1) work experience between 3 months and 2 years, (2) freshly graduated when employed and (3) volunteered to participate in the study. Those on leave for more than 1 month after being employed were excluded. This study was reported following the Checklist for Reporting Of Survey Studies. All surveys were completed anonymously. All completed surveys were kept on a secured server.

The minimal sample size was calculated as 5–10 times the number of questions.11 There were 32 KAP items. Therefore, the minimal sample size was 160. The questionnaires were distributed to all nurses who met the inclusion criteria using ‘Sojump’ (https://www.wjx.cn). The participants could complete the questionnaires by clicking the link or scanning the quick response code distributed through the author’s social media.

Procedures

The questionnaire was designed by referring to the relevant nursing guidelines,2 12–15 as no instrument was found in the literature that assessed KAP for postoperative nursing of patients with reimplantation of severed digits and skin flap transplantation. The first version of the questionnaire was revised based on the comments made by three senior experts in nursing. The experts had 17, 20 and 28 years of nursing experience. Two of them teach nursing techniques, and one of them specialises in hand surgery nursing. Based on their recommendations, similar or repeated questions were deleted, and the questions that were not clearly formulated were adjusted and refined to ensure content validity. Besides, the items that were still considered uncertain or confusing were deleted to ensure face validity. The questionnaire was pilot tested in 160 nurses, and Cronbach’s α was 0.939.

The questionnaire contained four dimensions: demographic information (age, gender, residence, ethnicity, education, years of work, nursing experience, training experience, independent learning experience for severed fingers replantation and skin flap transplantation), knowledge dimension, attitude dimension and practice dimension. The knowledge dimension consisted of 13 questions, with 1 point for correct answers and 0 points for incorrect or unclear answers, and the total score ranged from 0 to 13 points. The attitude dimension consisted of 10 questions answered using a 5-point Likert scale and was scored from ‘strongly agree’ (5 points) to ‘strongly disagree’ (1 point), except for the second question, which was reversely scored; the total scores were ranging from 10 to 50 points. The practice dimension consisted of nine questions, also using a 5-point Likert scale, and all scored from 5 to 1 points, with the total score ranging from 9 to 45 points. For the evaluation of their overall knowledge (defined as poor, moderate and good), attitude (defined as unfavourable, moderate and favourable) and practice (defined as inactive, moderate and active), the boundaries were <60%, 60% to 80% and>80% of total scores.

Statistical analysis

Stata 17.0 (College Station, Texas) was used for analysis. All continuous data were confirmed to a normal distribution and were presented as means±SD and compared by Student’s t-test or one-way ANOVA (Analysis of Variance). Categorical data were presented as n (%). The associations between demographic characteristics, KAP were analysed using multivariable logistic regression with KAP scores as the dependent variables. The KAP scores were converted to binary variables using 75 percentiles of participants’ scores. Considering collinearity between the variables, variables with a variance inflation factor ≤5 were included in the multivariable analysis. A structural equation model (SEM) analysis was performed to examine how KAP influence each other. SEM fitting was evaluated using the root mean square error of approximation, comparative fit index, Tucker-Lewis index and standardised root mean squared residual.16 17 A confirmatory factor analysis (CFA) was performed to confirm the construct validity. A two-sided p<0.05 was considered statistically significant.

Results

Characteristics of the participants

During the study period, Beijing Jishuitan Hospital had 161 new nurses, and Beijing No. 6 Hospital had 46 new nurses. One nurse in Beijing Jishuitan Hospital was on leave, resulting in 206 valid questionnaires and a response rate of 100%. The participants were 22.0±2.0 years of age, and most were women (87.8%), had a non-urban residence (58.2%), were Chinese Han (93.6%), had a junior college education or below (83.9%), worked for 1–2 years (51.9%) and had no nursing experience (64.5%), no training experience (72.3%) and no independent learning experience (66.9%) for patients with digit replantation and skin flap transplantation (online supplemental table S1).

Supplemental material

KAP towards nursing of patients with digit replantation and skin flap transplantation

The mean knowledge score was 7.72±3.28 (total score 13; 59.3%), indicating poor knowledge. The knowledge scores significantly differed among participants with different statuses of education (p=0.011), nursing experience (p=0.002), training experience (p<0.001) and independent learning experience (p<0.001) (table 1). The specific knowledge items with the lowest correct rates were K7 (7. The main manifestations of venous crisis are pale finger colour, deepened skin lines, decreased skin temperature, and slowed CRT; 9.2%), K6 (6. The main manifestations of arterial crisis are dark purple finger colour, loss of skin lines, decreased skin temperature and accelerated CRT; 12.6%), K3 (3. After digit replantation, the colour of the severed finger is redder compared with the normal finger’; 34.9%) and K12 (12. Patients should change posture, turn and pat their backs after digit replantation/skin flap transplantation; 45.6%) (online supplemental table S2).

Table 1

The direct and indirect influences among knowledge, attitudes and practices (KAP) Scores

The mean attitude score was 37.95±6.05 (total score 50; 75.9%), indicating moderately favourable attitudes. The attitude scores significantly differed among participants with different statuses of nursing experience (p=0.001), training experience (p<0.001) and independent learning experience (p<0.001) (table 1). The items with the lowest scores were A1 (1. I am familiar with the postoperative nursing requirements for digit replantation/skin flap transplantation) and A2 (2. I think nursing for patients with digit replantation/skin flap transplantation is a tricky business) (online supplemental table S3).

The mean practice score was 38.23±6.12 (total score 45; 84.9%), indicating active practice. The practice scores significantly differed among participants with different statuses of gender (p=0.002), residence (p=0.038), nursing experience (p=0.003), training experience (p<0.001) and independent learning experience (p<0.001) (table 1). The responses to the practice questions are in online supplemental table S4.

Risk factors associated with KAP

The multivariable logistic regression showed no variables collected in this study were independently associated with the knowledge. Good knowledge (scores >75 percentiles of participants’ score) (OR=2.55, 95% CI 1.18 to 5.49, p=0.017) was independently associated with favourable attitude (scores >75 percentiles of participants’ score). Favourable attitude (OR=9.03, 95% CI 3.88 to 21.00, p<0.001) was independently associated with active practice (scores >75 percentiles of participants’ scores) (online supplemental table S5).

SEM analysis

The SEM analysis showed that knowledge directly influences attitudes (β=0.82, 95% CI 0.60 to 1.05, p<0.001) and that attitudes directly influence practices (β=0.72, 95% CI 0.62 to 0.83, p<0.001). Knowledge had no direct influence on practices (β=0.10, 95% CI −0.09 to 0.29, p=0.313), but the indirect influence was significant (β=0.60, 95% CI 0.41 to 0.78, p<0.001) (figure 1 and table 1). The fitting of the SEM was good (table 2).

Figure 1

The structural equation model (SEM) of the influences among knowledge, attitudes and practices.

Table 2

Evaluation of the structural equation model (SEM) fitting

Questionnaire validity

A CFA (online supplemental figure S1) was performed to determine construct validity. All model fit indicators indicated that the model had a good fit (online supplemental table S6).

Discussion

This study found that the new nurses in Beijing have relatively poor knowledge, moderately favourable attitudes and appropriate practice towards digit replantation and skin flap transplantation. Good knowledge was independently associated with a favourable attitude, and a favourable attitude was independently associated with active practices. Knowledge influenced attitudes directly and practices indirectly, while attitudes directly influenced practices. This study might help identify the nature of KAP deficiencies and design or improve training activities.

A precise knowledge of the signs, symptoms and management options of complications (eg, vascular compromise) is essential for the nurses and nursing patients after digit replantation.7 8 In the present study, the participants had poor knowledge, neutral attitudes and good behaviours and practices towards digit replantation and skin flap transplantation. The reason for poor knowledge with good practices may be that the content investigated in the knowledge section is not necessary for having a good practice level.

In addition, many practice points are part of the basic skills that the nurses learn during training, indicating that the nurses can properly take care of replanted digits but without having the specific knowledge of why they are performing specific actions in the specific context of digit replantation. On the other hand, the results of the practice levels were self-reported, and they could have been reported according to what the participants knew would be appropriate to perform instead of what they were actually doing.18 19 Indeed, the social desirability bias is a well-known bias in KAP and qualitative studies.18 19 Even though the participants are aware that the KAP survey is anonymous and that the investigators are unable to know who answered what, the participants often tend to answer what they should be doing, sometimes simply due to an unconscious will to project a good image.18 19

The present study showed that the nurses generally had a favourable attitude towards finger replantation care. Nevertheless, only 36.41% had a positive attitude towards being familiar with the nursing requirements for digit replantation or skin flap transplantation, while only 17.96% disagreed that nursing replanted fingers was a tricky business. The nurses showed favourable attitudes towards the remaining attitude items, which were mainly dealing with general nursing features. Hence, the nurses’ confidence in nursing replanted fingers needs to be improved, probably through improving their knowledge.

Still, the results highlighted specific knowledge points that should be the focus of future teaching programmes, training or continuous education. Indeed, the knowledge about the signs and symptoms of complications appeared to be especially deficient, especially the knowledge more specific to replanted fingers, while more general knowledge about wound care, proper circulation and thrombus prophylaxis was relatively good. In addition, knowledge about the proper positioning of the patients in the context of finger replantation was also poor. A study showed that standardised patient-based training on surgical nurses’ competencies for managing hand injuries improved long-lasting knowledge, clinical performance and clinical efficacy.20 Another study showed that a nursing case management model could reduce the uncertainty in illness recovery in patients with vascular crises after digit replantation.21 Indeed, nurses play a role not only in the physical care of the patients but also in their psychological care, especially when facing the fear of losing a body part. Still, the psychological aspect of nursing was not explored in the present study.

Nevertheless, in the present study, nursing, training and independent learning experience of digit replantation were associated with higher KAP scores. The multivariable analyses showed that none of the demographic variables had an independent influence on the KAP scores. It is probably because all participants were young and shared similar levels of knowledge and experience since they were new nurses. Still, the lack of clear guidance and consensus in the literature leads to ambiguity and insufficient understanding of appropriate and effective management.7 Therefore, specific nursing guidelines should be published first, guiding nursing activities and training. Indeed, in this study, knowledge was independently associated with attitudes, and attitudes were independently associated with practice. In addition, knowledge directly influenced attitudes, attitudes directly influenced practices and knowledge indirectly influenced practices. Therefore, improving knowledge should improve attitudes, which, in turn, should improve practice.22 Such correlations and inter-relationships among the three KAP dimensions have been demonstrated on various medical subjects.23–26 Of note, experience with nursing for replanted digits, training on replanted digits and independent studies on replanted digits were associated with higher knowledge scores, suggesting that future training programmes should contain basic theoretical and practical teaching about replanted fingers. With such basic training, the nurses should possess a basis on which they could build knowledge and attitude to improve their practice and gain meaningful and positive experience.

This study enrolled a homogeneous sample of participants with a response rate of 100%. Although completion of the survey was not mandatory in any way, the purpose of determining the KAP level of new nurses to be able to design education and training activities was explained to them, and they were glad to be of help. The distribution of the electronic questionnaire was done through social media (WeChat, a widely used social media and real-time communication software in China). The survey was anonymous, and the data were kept on a secured server. The participants were informed of that to dispel any concerns about their privacy.

This study had limitations. As for any KAP survey, the present study lacks generalisability since it was performed on new nurses from the Beijing area. In addition, considering the number of nurses graduating each year, the sample size was relatively small. KAP surveys are often socially biased because the participants might be more inclined to give socially desirable responses rather than based on their reality.18 19

In conclusion, the new nurses in the Beijing area have relatively poor knowledge, moderately favourable attitudes and appropriate practice towards severed digit replantation and skin flap transplantation. Good knowledge was associated with favourable attitudes, and favourable attitudes were associated with active practices. Hence, proper training and teaching should be designed to improve the KAP towards digit replantation. Especially knowledge about the signs and symptoms of complications should be emphasised as well as the proper patient positioning.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Ethics approval

The study was approved by the Medical Ethics Committee of Beijing Jishuitan Hospital. All participants provided signed informed consent before completing the survey. All methods were performed in accordance with the relevant guidelines and regulations.

References

Footnotes

  • Contributors SZ carried out the studies, drafted the manuscript, performed the statistical analysis and participated in its design. MT and ZW participated in the acquisition of data. SZ and YL participated in the collection, analysis or interpretation of data. YX guided paper writing and revision. SZ is responsible for the overall content. All authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer-reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.