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Osteoporosis knowledge and related factors among orthopedic nurses in Hunan province of China
International Journal of Orthopaedic and Trauma Nursing xxx (xxxx) xxxx
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Osteoporosis knowledge and related factors among orthopedic nurses in Hunan province of China Lingli Penga,∗, Nancy Reynoldsb, Ailan Hea, Mingming Liuc, Jiaqi Yanga, Pan Shea, Yan Zhangc a
Orthopedics Department, Xiangya Hospital, Central South University, Changsha, 410008, Hunan province, China School of Nursing, Johns Hopkins University, 525 N. Wolfe Street, Baltimore, MD, USA c Xiangya Medical College of Central South University, Changsha, 410000, Hunan province, China b
A R T I C LE I N FO
A B S T R A C T
Keywords: Orthopedic nurse Osteoporosis knowledge China
A low level of knowledge and awareness of specifics regarding osteoporosis among orthopedic nurses can compromise the quality of patient education and nursing care. There are significant variations in education levels among Chinese nurses, however, little is known about the awareness of osteoporosis among orthopedic nurses in China. The objective of this study was to assess the level of osteoporosis knowledge and identify factors that correlated with knowledge levels. A cross-sectional survey was conducted among orthopedic nurses at 13 tertiary hospitals in Hunan Province, China. Knowledge was assessed by the Osteoporosis Knowledge Assessment Test (OKAT). A total of 558 nurses completed the survey and 530 valid questionnaires were returned with a response rate of 95%. Each question had three response options of “True”, “False” and “Don't know.” The mean of scores from all OKAT questions was 11.4 (range 2–17; SD = 2.5). Factors associated with a better knowledge included age (36–45 years) marital status (married) and education (bachelor degree or above). Only 93 nurses (18%) had previously attended formal training regarding osteoporosis. Orthopedic nurses had moderate-to-low levels of knowledge regrading osteoporosis. The survey highlighted the potential areas for improvement, especially among younger single nurses with lower educational levels. In-depth education may contribute to improving service quality and offering better tutoring for fragility fracture patients through increased awareness and knowledge.
Introduction Osteoporosis and fragility fractures are major worldwide health problems. Fragility fractures create a significant impact on a patients’ health and quality-of-life, bring economic hardship to both patients and society and increase the incidence of disability and mortality (Beaudoin et al., 2014; Leal et al., 2016; Si et al., 2015; Wang et al., 2015). It has been estimated that approximately 2.33 million fragility fractures occurred in China in 2010 with a total medical cost of 9.45 billion US dollars (USD). And the number of domestic fractures may increase up to 4.66 million with an associated doubling of costs by 2035 (5.91 million USD) with a total medical cost of 25.43 billion USD by 2050 (Si et al., 2015). In some countries outside of China, multimodal interventions involving nursing education and changing models of nursing care appear effective in improving quality of service and care delivery, increasing engagement and motivation of patients (Bessette et al., 2011; Chan
et al., 2007; Outman et al., 2012) and increasing cost-effectiveness (Warriner et al., 2012). It is acknowledged that when both medical staff and nurses work together and are well prepared/knowledgeable, they are an important source of health information for the lay population (Beaudoin et al., 2014; Wei et al., 2015). Within any system it is also acknowledged that nurses play a central role in implementing and facilitating system change and practice improvement (Harrington, 2011; Zhang et al., 2012). However, nurses with a low level of knowledge will be less likely to provide appropriate education and deliver quality care for patients (Neuner and Schapira, 2012). Orthopedic nurses are directly responsible for fragility fracture nursing and providing appropriate patient education in orthopedic wards. They have important roles that require specific knowledge regarding the associated risks of osteoporosis, prevention and treatment strategies (Eloranta et al., 2015). In the literature, a number of studies have explored the knowledge and awareness of people at risk of fragility fracture and demonstrated
∗
Corresponding author. E-mail addresses: [email protected] (L. Peng), [email protected] (N. Reynolds), [email protected] (A. He), [email protected] (M. Liu), [email protected] (J. Yang), [email protected] (P. She), [email protected] (Y. Zhang). https://doi.org/10.1016/j.ijotn.2019.100714 Received 16 January 2019; Received in revised form 24 August 2019; Accepted 1 September 2019 1878-1241/ © 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Lingli Peng, et al., International Journal of Orthopaedic and Trauma Nursing, https://doi.org/10.1016/j.ijotn.2019.100714
International Journal of Orthopaedic and Trauma Nursing xxx (xxxx) xxxx
L. Peng, et al.
scores indicate more knowledge of osteoporosis. The OKAT Chinese version translated by Zhang et al. (2012) was utilized. It had a reliability of Cronbach's alpha 0.81 and a Pearson's test-retest reliability coefficient r = 0.92.
that osteoporosis knowledge and preventative care interventions are limited in this population (Fraser et al., 2011; He et al., 2013; Kung et al., 2013; Outman et al., 2012). One osteoporosis education program initiated by nurses promoted patient knowledge and preventive behaviors for osteoporosis (Chan et al., 2007). Although some studies have been conducted regarding osteoporosis knowledge and awareness of health providers, most of them were conducted in western countries (Claesson et al., 2015; Fourie et al., 2015; Atik, 2015). And the targeted participants included physicians (Atik, 2015), community nurses (Chen et al., 2005), nurse directors and nursing students (Zhang et al., 2012), but not Chinese orthopedic nurses. To the best knowledge of the authors, only two recent studies have explored the status of osteoporosis knowledge in nurses in China. One explored nursing students in mainland China (Zhang et al., 2012) and the other public health nurses in Taiwan (Chen et al., 2005). Thus a gap exists in the literature regarding osteoporosis knowledge of orthopedic nurses in mainland China. The major objective of this study was to assess the osteoporosis knowledge levels of orthopedic nurses in Hunan Province of mainland China and identify the factors that influence their level of knowledge.
Ethical considerations Ethics approval was obtained from the ethics committee of Xiangya Hospital and Hunan Medical Association. The data of participants were only used in this study and ensured the questionnaires without their names. Data analyses Descriptive statistics were used to analyze the data including means, standard deviations. Percentages were used to describe demographic data and main variables. T-test and one-way analysis of variance (ANOVA) were used for comparing the differences in knowledge based on participant demographic variables. Multivariable Logistic regression analysis was used for identifying the knowledge-related factors. All statistical analyses were performed using SPSS version 15.0. And p < 0.05 was deemed as having statistical significance.
Methods Study design
Results
A cross-sectional survey was conducted from April 1, 2014 to May 1, 2014. The authors acknowledge that while this data is dated we suggest that there is value in considering these factors as there is likely similar trends in contemporary orthopedic nurses knowledge in China today.
Demographic characteristics The response rate was 95%. All participants were females (sample is representative of the population- Chinese orthopedic nurses); 501 (95%) of them were clinical (ward) nurses (Table 1) In. terms of prior education in osteoporosis, 335 (63%) participants reported that they had education osteoporosis in nursing school. However, only 93 (18%) nurses had any formal osteoporosis education. Other methods of learning, reported by nurses included working experience (72%), textbooks and journals (66%), conferences (50%), internet (39%), DVD (7%) and other means (7%). With respect to willingness for continued education on osteoporosis, 97% (n = 512) reported that they would like to have the opportunity for more formal education regarding osteoporosis; 55% (n = 292) preferred attending the face-to-face lectures while 15% (n = 80) preferred remote online learning.
Sampling and setting A total of 558 orthopedic nurses were recruited from 13 tertiary hospitals in Hunan Province of mainland China. Cluster random sampling was used for selecting the hospitals. The sample size required by each hospital was determined according to the proportion of orthopedic nurses at each hospital. The samples were then further selected by simple random sampling. Each hospital designated one nurse as a liaison officer responsible for issuing, collecting and returning paper questionnaire after centralized training. The questionnaire was completed anonymously. Inclusion criteria for participants: Registered Nurse in mainland China.
Table 1 Demographic data: participant characteristics and knowledge of osteoporosis Participant characteristics).
Instrument A questionnaire was used to collect data of participant characteristics and their knowledge of osteoporosis. Participant characteristics: The data collected regarding demographic characteristics was age, gender, hospital area, marital status, education level, qualification, role and working experiences in orthopedics and osteoporosis educational background including amount of continued education, approaches of obtaining osteoporosis knowledge. (examples below).
Hospital location
Variables
N (%)
Hospitals in Changsha Other regional hospitals
196 (37) 334 (63)
Female ≤25 26–35 36–45 ≥46 Single Married Diploma or below Bachelor degree or above Junior nurse Senior nurse Supervisor nurse Associate chief nurse or above Clinical nurse Head nurse <3 3–5 6–9 ≥10
530 (100) 218 (41) 242 (45) 56 (11) 14 (23) 245 (46) 285 (54) 230 (43) 300 (57) 224 (42) 199 (38) 85 (16) 22 (4)
Gender Age (yrs)
• (A8: where did you learn about osteoporosis?) • Willingness to accept osteoporosis training (A10: would you like to
Marital status
learn more about osteoporosis?)
Education level
Osteoporosis knowledge The Osteoporosis Knowledge Assessment Test (OKAT) (Winzenberg et al., 2003) was utilized for measuring participants' knowledge of osteoporosis. The OKAT scale has 20 items within 4 sections that measure an understanding of the symptoms/risks of osteoporosis, knowledge of risk factors, knowledge of preventive factors (e.g. physical activity & diet relating to osteoporosis) and treatment availability. Each question has a response option of “True”, “False” and “Don't know.” A score of 1 was given for a correct answer and 0 for an incorrect answer or for option “Don't know”. The total score could range from 0 to 20. Higher
Qualification
Role Orthopedic working experiences (years)
2
501 (95) 29 (69) 190 (36) 150 (28) 105 (20) 85 (16)
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Table 2 Mean scores of OKAT dimension among orthopedic nurses. Dimension (items)
Mean
SD
N (%)
Understanding symptoms/risks of osteoporosis (Q1,2,8,9,11) Knowledge of risk factors for osteoporosis (Q3,4,5,6,7,12,18) Knowledge of preventive factors as physical activity and diet relating to osteoporosis (Q10,13,14,15,16,17) Treatment availability (Q19,20)
3.0 4.4 3.7 0.4
0.8 1.4 1.2 0.5
530 530 530 530
(60) (63) (61) (19)
Table 3 Knowledge of OKAT among orthopedic nurses. Items
No of “correct” responses
No of incorrect or “Don't know” responses
% correct responses
1.Osteoporosis leads to an increased risk of bone fractures 2.Osteoporosis usually causes symptoms (e.g. pain) 3. Having a higher peak bone mass at the end of childhood gives no protection against the development of osteoporosis in later life 4. Osteoporosis is more common in males 5. Cigarette smoking can contribute to osteoporosis 6. Short/thin stature women are at highest risk of fracture as compared to other builds 7. A fall is just as important as low bone strength in causing fractures 8. By age 80, the majority of females have osteoporosis 9. From age 50, most females can expect at least one fracture before they die 10. Any type of physical activity is beneficial for osteoporosis 11.It is easy to tell whether I am at risk of osteoporosis by my clinical risk factors 12. Family history of osteoporosis strongly predisposes a person to osteoporosis 13.An adequate calcium intake can be achieved from two glasses of milk a day 14.Sea food and soy food are good sources of calcium for people who cannot take dairy products 15.Calcium supplements alone can prevent bone loss 16.Alcohol in moderation has little effect on osteoporosis 17.A high salt intake is a risk factor for osteoporosis 18.There is a small amount of bone loss in 10 years following the onset of menopause 19.Hormone therapy prevents further bone loss at any age after menopause 20. There are no effective treatments for osteoporosis available in China
526 67 286
4 463 244
99 13 54
340 402 241 498 473 116 313 413 402 270 442 370 210 331 150 129 70
190 128 289 32 57 414 217 117 128 260 88 160 320 199 380 401 460
64 76 46 94 89 22 59 78 76 51 83 70 40 63 28 24 13
Knowledge of osteoporosis and its related factors
Table 4 Multivariable regression analysis of osteoporosis knowledge among orthopedic nurses.
The mean OKAT score was 11.4 (SD = 2.5, a range of 2–17) (58% of the possible maximum score). In terms of the OKAT dimension among orthopedic nurses,the highest mean score was 4.4 (SD = 1.4, a range of 0–5) in the dimension of knowledge of risk factors (Table 2). However, the mean score was only 0.4 (SD = 0.5, a range of 0–2) in the dimension of treatment availability (19% of the possible maximum score). In a single item analysis (Table 3), the highest correct response rate of “Osteoporosis leads to an increased risk of bone fractures” was 99%. Secondly, the correct response rate of “A fall is just as important as low bone strength in causing fractures' was 94%; However, the lowest correct rates of “Osteoporosis usually causes symptoms (e.g. pain)’” and “There are no effective treatments for osteoporosis available in China” accounted for 13% respectively. In general, knowledge was quite high (> 80%) for 4 items (Question 1,7,8,14), average (60%–80%) for 6 items (Question 4,5,11,12,15,17) and relatively low (< 60%) for 10 items (Question 2,3,6,9,10,13,16,18,19,20).
Variables
β
S.E.
Wald
p
Age Marital status Education level
0.31 0.54 −0.20
0.12 0.26 0.21
6.50 4.27 0.83
0.01 0.04 0.02
Table 5 Osteoporosis knowledge in different groups. Variables
Group
n
Mean ± SD
F/t
Age (years)
≤25 26–35 36–45 ≥46 Single Married Diploma or below Bachelor degree or above
218 242 56 14 245 285 230 300
11.1 11.6 11.8 11.7 11.4 11.9 11.1 11.6
2.40
0.05
0.64
0.04
−2.29
0.02
Marital status Education level
Related factors of knowledge
± ± ± ± ± ± ± ±
2.5 2.5 2.2 1.8 2.5 2.0 2.5 2.4
P
Mean ± SD: Range from 2 to 17
Bivariate analysis revealed that age (F = 2.40, p = 0.05), marital status (F = 0.63 p = 0.04) and educational level (t = −2.29, p = 0.02) were correlated with overall knowledge score (p < 0.05). And orthopedic nurses who were aged 36–45 years, married or having a bachelor degree or above achieved higher knowledge scores (Table 5). According to the results of multivariable analyses, the factors associated with the odds of better osteoporosis knowledge were also older age (p = 0.01), marital status (p = 0.04) or a higher level of education (p = 0.02) (Table 4).
Discussion Knowledge of osteoporosis among orthopedic nurses To the best of the authors knowledge, this is the first study that has examined osteoporosis knowledge among orthopedic nurses in mainland China. Overall knowledge of osteoporosis was moderate-to-low among orthopedic nurses. Compared to other studies (Bilal et al., 2017; 3
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The impact of educational level on knowledge has been previously examined (Etemadifar et al., 2013; Riaz et al., 2008). And individuals with a higher level of education achieved better knowledge scores in osteoporosis (Etemadifar et al., 2013; Riaz et al., 2008). Furthermore, highly educated orthopedic nurses might prevent patient mortality (Aiken et al., 2003). Therefore single orthopedic nurses with a lower educational level should be targeted for osteoporosis training.
Sayed-Hassan and Bashour, 2013) using OKAT or similar instruments, the knowledge level of orthopedic nurses was higher than that of the lay population. However, the knowledge level of the participants in this study was lower than other specialty nurses (Fourie et al., 2015) and registered nurses (Zhang and Chandran, 2011). In this study, the idenitied areas of insufficient knowledge may influence whether or not orthoapedic patients are provided with adequate (primary and secondary) fracture prevention and lifestyle information. These results were similar to those of previous studies (Sayed-Hassan et al., 2013; Zhang and Chandran, 2011). In the dimension of understanding symptoms and risks of osteoporosis, a vast majority of the orthopedic nurses were aware that osteoporosis leads to an increased risk of bone fracture. However, there was a poor knowledge that osteoporosis usually causes symptoms (e.g, pain) before an onset of fracture. Similar findings were confirmed by Sayed-hassan (Sayed-Hassan et al., 2013) and Zhang et al. (2012). This shows an important deficit of knowledge of osteoporosis among orthopedic nurses in this study. Knowledge of risk factors for osteoporosis was moderate among orthopedic nurses. These results were also found among nursing students (Sayed-Hassan et al., 2013) and orthopedic nurses (Fourie et al., 2015). In this dimension, most nurses did not grasp the knowledge of bone metabolism after menopause and during adolescence/youth. It also demonstrated a knowledge deficit of osteoporosis and associated risk factors such as ethnicity and gender. The findings show a poor knowledge of positive dietary requirements of calcium intake, physical activities and health lifestyle in the prevention of osteoporosis. As prevention is closely related to patient rehabilitation and re-fracture prevention, this is an important area of deficit. Therefore it is strongly recommend that nurses working in orthopedic type settings in China should have a stronger knowledge in this area, that not only improves awareness but can strengthen nursing practice and improve patient education/awareness. Orthopedic departments may offer training in basic theoretical knowledge (including bone metabolism, osteoporosis symptoms & preventive factors), implementations and evaluating health education at regular intervals so as to improve the care proficiency of orthopedic nurses.
Development and learning channels of osteoporosis training program The major learning sources of osteoporosis for orthopedic nurses were basic curriculum of their nursing schools and working experiences. Only 93 nurses (17.5%) received any formal training and this was contrary to the finding of Chen's study (Chen et al., 2005). There are different possible explanations. Firstly, osteoporosis curriculum has been established only at universities for Bachelor degree students in Hunan Province. Secondly, no formal provincial continuing osteoporosis training program currently targets orthopedic nurses. This could partially explain why most orthopedic nurses continued their education from working experiences. Hence, it is imperative to provide osteoporosis education for nursing students and develop a continuing education program for orthopedic nurses. Finally, textbooks and journal articles were cited as two supplemental channels of knowledge. This is somewhat similar to a previous study of Middle East nurses (Vered et al., 2008). And mass media also played an important role in the delivery of knowledge to health providers (Chen et al., 2005). So public healthcare departments or hospitals should encourage nurses to enroll into advanced degree studies and offer better patient care especially for those working in specialty areas such as orthopedics. Limitations The first limitation of this research is its cross-sectional design so that the authors made no attempt to elucidate the cause and effect relationships among variables. The second limitation is the use of OKAT questionnaire in this study. OKAT was originally was developed for assessing knowledge among a non-professional population and not among healthcare providers. Though previously used for testing the knowledge of nursing students (Zhang et al., 2012; Sayed-Hassan et al., 2013), it is the first time of assessing the nurses’ knowledge level. In addition, the questionnaire did not allow for subjects to elaborate on their views and answers. The final limitation lies in the fact that this survey was conducted in 2014. There is potential that these levels of knowledge have changed over time, since data collection, but the authors believe that there is still value in presenting this data for consideration in this specific population. . Further research in this area is recomnded.
Related factors of osteoporosis knowledge among orthopedic nurses In the present study, age, marital status and education level of orthopedic nurses were associated with a greater knowledge of osteoporosis. Riaz et al. (2008) reported that younger women (25–35 years) had a poor osteoporosis knowledge as compared to relatively older females in the groups of 36–45 years and > 45 years In this study, orthopedic nurses aged ≤25 years had the lowest scores in osteoporosis knowledge when compared to other groups. The possible explanation could be that older participants (all female) were potentially more susceptible to osteoporosis and concerned about their health in comparison to youth. The other explanation could be that the older and more experienced nurses are better aware of this disease. According to the World Health Organization (WHO, 2003), peak bone mass is achieved at skeletal maturity (around 30 years). Thus the younger group (≤25 years) may be at a low risk. Hence osteoporosis training for younger nurses should be strengthened for improving osteoporosis knowledge. Married status was also associated with the knowledge of orthopedic nurses. Also married status was positively associated with individual health awareness (Margelisch et al., 2015; Miller-Martinez et al., 2014; Neuman and Werner, 2015). A study in the United States revealed that never marrying, experiencing a divorce, widowhood or separation were associated with worse bone health in males (MillerMartinez et al., 2014). It may be related to the role of social supports in influencing patient choices of hospitals and their self-management (Neuman and Werner, 2015). Furthermore, most participants in this study who were older were also more likely to be married and this also correlated with an increase in osteoporosis knowledge.
Conclusions The knowledge of osteoporosis was identified at a moderate-to-low level among orthopedic nurses in Hunan Province during data collection. Also considerable gaps exist in the knowledge of the four dimensions. Orthopedic nurses in this population need to improve their osteoporosis knowledge in symptoms/signs, risk factors and preventative factors, especially treatment availability of nursing care/education. Married orthopedic nurses who were aged 36–45 years and with a Bachelor degree or above tended to grasp a better osteoporosis knowledge. In our study, primary learning resources of orthopedic nurses were traditional curricula in nursing schools and working experiences. Few of them attended formal continuing education courses. Thus professional associations, hospitals and/or departments of orthopedics should develop an osteoporosis program to provide continuing educational opportunities. And multi-channels including traditional face-to-face lectures and internet learning should be exploring for delivering the contents. Future studies shall focus upon developing and 4
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evaluating the programs of osteoporosis education.
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Conflicts of interest This study has no any financial and personal relationships with other people or organizations. Ethics in publishing ● "The study was granted an exemption by the institutional review board” ● The research conforms to the provisions of the Declaration of Helsinik in 1995; All participants gave informed consent for the research, and that their anonymity was preserved. Role of the funding source The study was sponsored by Xiangya Hospital and Orthopedic Nursing Branch of Hunan Medical Association. The authors also would like to acknowledge financial supports from Health & Family Planning Commission of Hunan Province (B2014-015). Acknowledgements The study was sponsored by the Xiangya Hospital and the Orthopedic Nursing Branch of Hunan Medical Association. The authors also would like to acknowledge financial support from the Health and Family Planning Commission of Hunan Province (B2014-015). Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ijotn.2019.100714. References Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., Silber, J.M., et al., 2003. Educational levels of hospital nurses and surgical patient mortality. J. Am. Med. Assoc. 290 (12), 1617–1623. Atik, O.S., 2015. Has the awareness of orthopedic surgeons on osteoporosis been increased in the past decade? Joint Dis. Relat. Surg. 26 (2), 63. Bilal, M., Haseeb, A., Merchant, A.Z., Rehman, A., Arshad, M.H., Malik, M., Rehman, A.H.U., Rani, P., Farhan, E., Rehman, T.S., Shamsi, U.S., Aminah, S., 2017. Knowledge, beliefs and practices regarding osteoporosis among female medical school entrants in Pakistan. Asia Pac. Fam. Med. 16, 6. Beaudoin, C., Bessette, L., Jean, S., Ste-Marie, L.G., Brown, J.P., 2014. The impact of educational interventions on modifiable risk factors for osteoporosis after a fragility fracture. Osteoporos. Int. 25 (7), 1821–1830. Bessette, L., Davison, K.S., Jean, S., Roy, S., Ste-Marie, L.G., Brown, J.P., 2011. The impact of two educational interventions on osteoporosis diagnosis and treatment after fragility fracture: a population-based randomized controlled trial. Osteoporos. Int. 22 (12), 2963–2972. Chan, M.F., Kwong, W.S., Zang, Y.L., Wan, P.Y., 2007. Evaluation of an osteoporosis preventioneducation programme for young adults. J. Adv. Nurs. 57 (3), 270–285. Chen, I.J., Yu, S., Wang, T.F., Cheng, S.P., Huang, L.H., 2005. Knowledge about osteoporosis and its related factors among public health nurses in Taiwan. Osteoporos. Int. 16 (12), 2142–2148. Claesson, A., Toth-Pal, E., Piispanen, P., Salminen, H., 2015. District nurses' perceptions
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Contents lists available at ScienceDirect
International Journal of Orthopaedic and Trauma Nursing journal homepage: www.elsevier.com/locate/ijotn
Osteoporosis knowledge and related factors among orthopedic nurses in Hunan province of China Lingli Penga,∗, Nancy Reynoldsb, Ailan Hea, Mingming Liuc, Jiaqi Yanga, Pan Shea, Yan Zhangc a
Orthopedics Department, Xiangya Hospital, Central South University, Changsha, 410008, Hunan province, China School of Nursing, Johns Hopkins University, 525 N. Wolfe Street, Baltimore, MD, USA c Xiangya Medical College of Central South University, Changsha, 410000, Hunan province, China b
A R T I C LE I N FO
A B S T R A C T
Keywords: Orthopedic nurse Osteoporosis knowledge China
A low level of knowledge and awareness of specifics regarding osteoporosis among orthopedic nurses can compromise the quality of patient education and nursing care. There are significant variations in education levels among Chinese nurses, however, little is known about the awareness of osteoporosis among orthopedic nurses in China. The objective of this study was to assess the level of osteoporosis knowledge and identify factors that correlated with knowledge levels. A cross-sectional survey was conducted among orthopedic nurses at 13 tertiary hospitals in Hunan Province, China. Knowledge was assessed by the Osteoporosis Knowledge Assessment Test (OKAT). A total of 558 nurses completed the survey and 530 valid questionnaires were returned with a response rate of 95%. Each question had three response options of “True”, “False” and “Don't know.” The mean of scores from all OKAT questions was 11.4 (range 2–17; SD = 2.5). Factors associated with a better knowledge included age (36–45 years) marital status (married) and education (bachelor degree or above). Only 93 nurses (18%) had previously attended formal training regarding osteoporosis. Orthopedic nurses had moderate-to-low levels of knowledge regrading osteoporosis. The survey highlighted the potential areas for improvement, especially among younger single nurses with lower educational levels. In-depth education may contribute to improving service quality and offering better tutoring for fragility fracture patients through increased awareness and knowledge.
Introduction Osteoporosis and fragility fractures are major worldwide health problems. Fragility fractures create a significant impact on a patients’ health and quality-of-life, bring economic hardship to both patients and society and increase the incidence of disability and mortality (Beaudoin et al., 2014; Leal et al., 2016; Si et al., 2015; Wang et al., 2015). It has been estimated that approximately 2.33 million fragility fractures occurred in China in 2010 with a total medical cost of 9.45 billion US dollars (USD). And the number of domestic fractures may increase up to 4.66 million with an associated doubling of costs by 2035 (5.91 million USD) with a total medical cost of 25.43 billion USD by 2050 (Si et al., 2015). In some countries outside of China, multimodal interventions involving nursing education and changing models of nursing care appear effective in improving quality of service and care delivery, increasing engagement and motivation of patients (Bessette et al., 2011; Chan
et al., 2007; Outman et al., 2012) and increasing cost-effectiveness (Warriner et al., 2012). It is acknowledged that when both medical staff and nurses work together and are well prepared/knowledgeable, they are an important source of health information for the lay population (Beaudoin et al., 2014; Wei et al., 2015). Within any system it is also acknowledged that nurses play a central role in implementing and facilitating system change and practice improvement (Harrington, 2011; Zhang et al., 2012). However, nurses with a low level of knowledge will be less likely to provide appropriate education and deliver quality care for patients (Neuner and Schapira, 2012). Orthopedic nurses are directly responsible for fragility fracture nursing and providing appropriate patient education in orthopedic wards. They have important roles that require specific knowledge regarding the associated risks of osteoporosis, prevention and treatment strategies (Eloranta et al., 2015). In the literature, a number of studies have explored the knowledge and awareness of people at risk of fragility fracture and demonstrated
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Corresponding author. E-mail addresses: [email protected] (L. Peng), [email protected] (N. Reynolds), [email protected] (A. He), [email protected] (M. Liu), [email protected] (J. Yang), [email protected] (P. She), [email protected] (Y. Zhang). https://doi.org/10.1016/j.ijotn.2019.100714 Received 16 January 2019; Received in revised form 24 August 2019; Accepted 1 September 2019 1878-1241/ © 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Lingli Peng, et al., International Journal of Orthopaedic and Trauma Nursing, https://doi.org/10.1016/j.ijotn.2019.100714
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scores indicate more knowledge of osteoporosis. The OKAT Chinese version translated by Zhang et al. (2012) was utilized. It had a reliability of Cronbach's alpha 0.81 and a Pearson's test-retest reliability coefficient r = 0.92.
that osteoporosis knowledge and preventative care interventions are limited in this population (Fraser et al., 2011; He et al., 2013; Kung et al., 2013; Outman et al., 2012). One osteoporosis education program initiated by nurses promoted patient knowledge and preventive behaviors for osteoporosis (Chan et al., 2007). Although some studies have been conducted regarding osteoporosis knowledge and awareness of health providers, most of them were conducted in western countries (Claesson et al., 2015; Fourie et al., 2015; Atik, 2015). And the targeted participants included physicians (Atik, 2015), community nurses (Chen et al., 2005), nurse directors and nursing students (Zhang et al., 2012), but not Chinese orthopedic nurses. To the best knowledge of the authors, only two recent studies have explored the status of osteoporosis knowledge in nurses in China. One explored nursing students in mainland China (Zhang et al., 2012) and the other public health nurses in Taiwan (Chen et al., 2005). Thus a gap exists in the literature regarding osteoporosis knowledge of orthopedic nurses in mainland China. The major objective of this study was to assess the osteoporosis knowledge levels of orthopedic nurses in Hunan Province of mainland China and identify the factors that influence their level of knowledge.
Ethical considerations Ethics approval was obtained from the ethics committee of Xiangya Hospital and Hunan Medical Association. The data of participants were only used in this study and ensured the questionnaires without their names. Data analyses Descriptive statistics were used to analyze the data including means, standard deviations. Percentages were used to describe demographic data and main variables. T-test and one-way analysis of variance (ANOVA) were used for comparing the differences in knowledge based on participant demographic variables. Multivariable Logistic regression analysis was used for identifying the knowledge-related factors. All statistical analyses were performed using SPSS version 15.0. And p < 0.05 was deemed as having statistical significance.
Methods Study design
Results
A cross-sectional survey was conducted from April 1, 2014 to May 1, 2014. The authors acknowledge that while this data is dated we suggest that there is value in considering these factors as there is likely similar trends in contemporary orthopedic nurses knowledge in China today.
Demographic characteristics The response rate was 95%. All participants were females (sample is representative of the population- Chinese orthopedic nurses); 501 (95%) of them were clinical (ward) nurses (Table 1) In. terms of prior education in osteoporosis, 335 (63%) participants reported that they had education osteoporosis in nursing school. However, only 93 (18%) nurses had any formal osteoporosis education. Other methods of learning, reported by nurses included working experience (72%), textbooks and journals (66%), conferences (50%), internet (39%), DVD (7%) and other means (7%). With respect to willingness for continued education on osteoporosis, 97% (n = 512) reported that they would like to have the opportunity for more formal education regarding osteoporosis; 55% (n = 292) preferred attending the face-to-face lectures while 15% (n = 80) preferred remote online learning.
Sampling and setting A total of 558 orthopedic nurses were recruited from 13 tertiary hospitals in Hunan Province of mainland China. Cluster random sampling was used for selecting the hospitals. The sample size required by each hospital was determined according to the proportion of orthopedic nurses at each hospital. The samples were then further selected by simple random sampling. Each hospital designated one nurse as a liaison officer responsible for issuing, collecting and returning paper questionnaire after centralized training. The questionnaire was completed anonymously. Inclusion criteria for participants: Registered Nurse in mainland China.
Table 1 Demographic data: participant characteristics and knowledge of osteoporosis Participant characteristics).
Instrument A questionnaire was used to collect data of participant characteristics and their knowledge of osteoporosis. Participant characteristics: The data collected regarding demographic characteristics was age, gender, hospital area, marital status, education level, qualification, role and working experiences in orthopedics and osteoporosis educational background including amount of continued education, approaches of obtaining osteoporosis knowledge. (examples below).
Hospital location
Variables
N (%)
Hospitals in Changsha Other regional hospitals
196 (37) 334 (63)
Female ≤25 26–35 36–45 ≥46 Single Married Diploma or below Bachelor degree or above Junior nurse Senior nurse Supervisor nurse Associate chief nurse or above Clinical nurse Head nurse <3 3–5 6–9 ≥10
530 (100) 218 (41) 242 (45) 56 (11) 14 (23) 245 (46) 285 (54) 230 (43) 300 (57) 224 (42) 199 (38) 85 (16) 22 (4)
Gender Age (yrs)
• (A8: where did you learn about osteoporosis?) • Willingness to accept osteoporosis training (A10: would you like to
Marital status
learn more about osteoporosis?)
Education level
Osteoporosis knowledge The Osteoporosis Knowledge Assessment Test (OKAT) (Winzenberg et al., 2003) was utilized for measuring participants' knowledge of osteoporosis. The OKAT scale has 20 items within 4 sections that measure an understanding of the symptoms/risks of osteoporosis, knowledge of risk factors, knowledge of preventive factors (e.g. physical activity & diet relating to osteoporosis) and treatment availability. Each question has a response option of “True”, “False” and “Don't know.” A score of 1 was given for a correct answer and 0 for an incorrect answer or for option “Don't know”. The total score could range from 0 to 20. Higher
Qualification
Role Orthopedic working experiences (years)
2
501 (95) 29 (69) 190 (36) 150 (28) 105 (20) 85 (16)
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Table 2 Mean scores of OKAT dimension among orthopedic nurses. Dimension (items)
Mean
SD
N (%)
Understanding symptoms/risks of osteoporosis (Q1,2,8,9,11) Knowledge of risk factors for osteoporosis (Q3,4,5,6,7,12,18) Knowledge of preventive factors as physical activity and diet relating to osteoporosis (Q10,13,14,15,16,17) Treatment availability (Q19,20)
3.0 4.4 3.7 0.4
0.8 1.4 1.2 0.5
530 530 530 530
(60) (63) (61) (19)
Table 3 Knowledge of OKAT among orthopedic nurses. Items
No of “correct” responses
No of incorrect or “Don't know” responses
% correct responses
1.Osteoporosis leads to an increased risk of bone fractures 2.Osteoporosis usually causes symptoms (e.g. pain) 3. Having a higher peak bone mass at the end of childhood gives no protection against the development of osteoporosis in later life 4. Osteoporosis is more common in males 5. Cigarette smoking can contribute to osteoporosis 6. Short/thin stature women are at highest risk of fracture as compared to other builds 7. A fall is just as important as low bone strength in causing fractures 8. By age 80, the majority of females have osteoporosis 9. From age 50, most females can expect at least one fracture before they die 10. Any type of physical activity is beneficial for osteoporosis 11.It is easy to tell whether I am at risk of osteoporosis by my clinical risk factors 12. Family history of osteoporosis strongly predisposes a person to osteoporosis 13.An adequate calcium intake can be achieved from two glasses of milk a day 14.Sea food and soy food are good sources of calcium for people who cannot take dairy products 15.Calcium supplements alone can prevent bone loss 16.Alcohol in moderation has little effect on osteoporosis 17.A high salt intake is a risk factor for osteoporosis 18.There is a small amount of bone loss in 10 years following the onset of menopause 19.Hormone therapy prevents further bone loss at any age after menopause 20. There are no effective treatments for osteoporosis available in China
526 67 286
4 463 244
99 13 54
340 402 241 498 473 116 313 413 402 270 442 370 210 331 150 129 70
190 128 289 32 57 414 217 117 128 260 88 160 320 199 380 401 460
64 76 46 94 89 22 59 78 76 51 83 70 40 63 28 24 13
Knowledge of osteoporosis and its related factors
Table 4 Multivariable regression analysis of osteoporosis knowledge among orthopedic nurses.
The mean OKAT score was 11.4 (SD = 2.5, a range of 2–17) (58% of the possible maximum score). In terms of the OKAT dimension among orthopedic nurses,the highest mean score was 4.4 (SD = 1.4, a range of 0–5) in the dimension of knowledge of risk factors (Table 2). However, the mean score was only 0.4 (SD = 0.5, a range of 0–2) in the dimension of treatment availability (19% of the possible maximum score). In a single item analysis (Table 3), the highest correct response rate of “Osteoporosis leads to an increased risk of bone fractures” was 99%. Secondly, the correct response rate of “A fall is just as important as low bone strength in causing fractures' was 94%; However, the lowest correct rates of “Osteoporosis usually causes symptoms (e.g. pain)’” and “There are no effective treatments for osteoporosis available in China” accounted for 13% respectively. In general, knowledge was quite high (> 80%) for 4 items (Question 1,7,8,14), average (60%–80%) for 6 items (Question 4,5,11,12,15,17) and relatively low (< 60%) for 10 items (Question 2,3,6,9,10,13,16,18,19,20).
Variables
β
S.E.
Wald
p
Age Marital status Education level
0.31 0.54 −0.20
0.12 0.26 0.21
6.50 4.27 0.83
0.01 0.04 0.02
Table 5 Osteoporosis knowledge in different groups. Variables
Group
n
Mean ± SD
F/t
Age (years)
≤25 26–35 36–45 ≥46 Single Married Diploma or below Bachelor degree or above
218 242 56 14 245 285 230 300
11.1 11.6 11.8 11.7 11.4 11.9 11.1 11.6
2.40
0.05
0.64
0.04
−2.29
0.02
Marital status Education level
Related factors of knowledge
± ± ± ± ± ± ± ±
2.5 2.5 2.2 1.8 2.5 2.0 2.5 2.4
P
Mean ± SD: Range from 2 to 17
Bivariate analysis revealed that age (F = 2.40, p = 0.05), marital status (F = 0.63 p = 0.04) and educational level (t = −2.29, p = 0.02) were correlated with overall knowledge score (p < 0.05). And orthopedic nurses who were aged 36–45 years, married or having a bachelor degree or above achieved higher knowledge scores (Table 5). According to the results of multivariable analyses, the factors associated with the odds of better osteoporosis knowledge were also older age (p = 0.01), marital status (p = 0.04) or a higher level of education (p = 0.02) (Table 4).
Discussion Knowledge of osteoporosis among orthopedic nurses To the best of the authors knowledge, this is the first study that has examined osteoporosis knowledge among orthopedic nurses in mainland China. Overall knowledge of osteoporosis was moderate-to-low among orthopedic nurses. Compared to other studies (Bilal et al., 2017; 3
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The impact of educational level on knowledge has been previously examined (Etemadifar et al., 2013; Riaz et al., 2008). And individuals with a higher level of education achieved better knowledge scores in osteoporosis (Etemadifar et al., 2013; Riaz et al., 2008). Furthermore, highly educated orthopedic nurses might prevent patient mortality (Aiken et al., 2003). Therefore single orthopedic nurses with a lower educational level should be targeted for osteoporosis training.
Sayed-Hassan and Bashour, 2013) using OKAT or similar instruments, the knowledge level of orthopedic nurses was higher than that of the lay population. However, the knowledge level of the participants in this study was lower than other specialty nurses (Fourie et al., 2015) and registered nurses (Zhang and Chandran, 2011). In this study, the idenitied areas of insufficient knowledge may influence whether or not orthoapedic patients are provided with adequate (primary and secondary) fracture prevention and lifestyle information. These results were similar to those of previous studies (Sayed-Hassan et al., 2013; Zhang and Chandran, 2011). In the dimension of understanding symptoms and risks of osteoporosis, a vast majority of the orthopedic nurses were aware that osteoporosis leads to an increased risk of bone fracture. However, there was a poor knowledge that osteoporosis usually causes symptoms (e.g, pain) before an onset of fracture. Similar findings were confirmed by Sayed-hassan (Sayed-Hassan et al., 2013) and Zhang et al. (2012). This shows an important deficit of knowledge of osteoporosis among orthopedic nurses in this study. Knowledge of risk factors for osteoporosis was moderate among orthopedic nurses. These results were also found among nursing students (Sayed-Hassan et al., 2013) and orthopedic nurses (Fourie et al., 2015). In this dimension, most nurses did not grasp the knowledge of bone metabolism after menopause and during adolescence/youth. It also demonstrated a knowledge deficit of osteoporosis and associated risk factors such as ethnicity and gender. The findings show a poor knowledge of positive dietary requirements of calcium intake, physical activities and health lifestyle in the prevention of osteoporosis. As prevention is closely related to patient rehabilitation and re-fracture prevention, this is an important area of deficit. Therefore it is strongly recommend that nurses working in orthopedic type settings in China should have a stronger knowledge in this area, that not only improves awareness but can strengthen nursing practice and improve patient education/awareness. Orthopedic departments may offer training in basic theoretical knowledge (including bone metabolism, osteoporosis symptoms & preventive factors), implementations and evaluating health education at regular intervals so as to improve the care proficiency of orthopedic nurses.
Development and learning channels of osteoporosis training program The major learning sources of osteoporosis for orthopedic nurses were basic curriculum of their nursing schools and working experiences. Only 93 nurses (17.5%) received any formal training and this was contrary to the finding of Chen's study (Chen et al., 2005). There are different possible explanations. Firstly, osteoporosis curriculum has been established only at universities for Bachelor degree students in Hunan Province. Secondly, no formal provincial continuing osteoporosis training program currently targets orthopedic nurses. This could partially explain why most orthopedic nurses continued their education from working experiences. Hence, it is imperative to provide osteoporosis education for nursing students and develop a continuing education program for orthopedic nurses. Finally, textbooks and journal articles were cited as two supplemental channels of knowledge. This is somewhat similar to a previous study of Middle East nurses (Vered et al., 2008). And mass media also played an important role in the delivery of knowledge to health providers (Chen et al., 2005). So public healthcare departments or hospitals should encourage nurses to enroll into advanced degree studies and offer better patient care especially for those working in specialty areas such as orthopedics. Limitations The first limitation of this research is its cross-sectional design so that the authors made no attempt to elucidate the cause and effect relationships among variables. The second limitation is the use of OKAT questionnaire in this study. OKAT was originally was developed for assessing knowledge among a non-professional population and not among healthcare providers. Though previously used for testing the knowledge of nursing students (Zhang et al., 2012; Sayed-Hassan et al., 2013), it is the first time of assessing the nurses’ knowledge level. In addition, the questionnaire did not allow for subjects to elaborate on their views and answers. The final limitation lies in the fact that this survey was conducted in 2014. There is potential that these levels of knowledge have changed over time, since data collection, but the authors believe that there is still value in presenting this data for consideration in this specific population. . Further research in this area is recomnded.
Related factors of osteoporosis knowledge among orthopedic nurses In the present study, age, marital status and education level of orthopedic nurses were associated with a greater knowledge of osteoporosis. Riaz et al. (2008) reported that younger women (25–35 years) had a poor osteoporosis knowledge as compared to relatively older females in the groups of 36–45 years and > 45 years In this study, orthopedic nurses aged ≤25 years had the lowest scores in osteoporosis knowledge when compared to other groups. The possible explanation could be that older participants (all female) were potentially more susceptible to osteoporosis and concerned about their health in comparison to youth. The other explanation could be that the older and more experienced nurses are better aware of this disease. According to the World Health Organization (WHO, 2003), peak bone mass is achieved at skeletal maturity (around 30 years). Thus the younger group (≤25 years) may be at a low risk. Hence osteoporosis training for younger nurses should be strengthened for improving osteoporosis knowledge. Married status was also associated with the knowledge of orthopedic nurses. Also married status was positively associated with individual health awareness (Margelisch et al., 2015; Miller-Martinez et al., 2014; Neuman and Werner, 2015). A study in the United States revealed that never marrying, experiencing a divorce, widowhood or separation were associated with worse bone health in males (MillerMartinez et al., 2014). It may be related to the role of social supports in influencing patient choices of hospitals and their self-management (Neuman and Werner, 2015). Furthermore, most participants in this study who were older were also more likely to be married and this also correlated with an increase in osteoporosis knowledge.
Conclusions The knowledge of osteoporosis was identified at a moderate-to-low level among orthopedic nurses in Hunan Province during data collection. Also considerable gaps exist in the knowledge of the four dimensions. Orthopedic nurses in this population need to improve their osteoporosis knowledge in symptoms/signs, risk factors and preventative factors, especially treatment availability of nursing care/education. Married orthopedic nurses who were aged 36–45 years and with a Bachelor degree or above tended to grasp a better osteoporosis knowledge. In our study, primary learning resources of orthopedic nurses were traditional curricula in nursing schools and working experiences. Few of them attended formal continuing education courses. Thus professional associations, hospitals and/or departments of orthopedics should develop an osteoporosis program to provide continuing educational opportunities. And multi-channels including traditional face-to-face lectures and internet learning should be exploring for delivering the contents. Future studies shall focus upon developing and 4
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evaluating the programs of osteoporosis education.
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Conflicts of interest This study has no any financial and personal relationships with other people or organizations. Ethics in publishing ● "The study was granted an exemption by the institutional review board” ● The research conforms to the provisions of the Declaration of Helsinik in 1995; All participants gave informed consent for the research, and that their anonymity was preserved. Role of the funding source The study was sponsored by Xiangya Hospital and Orthopedic Nursing Branch of Hunan Medical Association. The authors also would like to acknowledge financial supports from Health & Family Planning Commission of Hunan Province (B2014-015). Acknowledgements The study was sponsored by the Xiangya Hospital and the Orthopedic Nursing Branch of Hunan Medical Association. The authors also would like to acknowledge financial support from the Health and Family Planning Commission of Hunan Province (B2014-015). Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ijotn.2019.100714. References Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., Silber, J.M., et al., 2003. Educational levels of hospital nurses and surgical patient mortality. J. Am. Med. Assoc. 290 (12), 1617–1623. Atik, O.S., 2015. Has the awareness of orthopedic surgeons on osteoporosis been increased in the past decade? Joint Dis. Relat. Surg. 26 (2), 63. Bilal, M., Haseeb, A., Merchant, A.Z., Rehman, A., Arshad, M.H., Malik, M., Rehman, A.H.U., Rani, P., Farhan, E., Rehman, T.S., Shamsi, U.S., Aminah, S., 2017. Knowledge, beliefs and practices regarding osteoporosis among female medical school entrants in Pakistan. Asia Pac. Fam. Med. 16, 6. Beaudoin, C., Bessette, L., Jean, S., Ste-Marie, L.G., Brown, J.P., 2014. The impact of educational interventions on modifiable risk factors for osteoporosis after a fragility fracture. Osteoporos. Int. 25 (7), 1821–1830. Bessette, L., Davison, K.S., Jean, S., Roy, S., Ste-Marie, L.G., Brown, J.P., 2011. The impact of two educational interventions on osteoporosis diagnosis and treatment after fragility fracture: a population-based randomized controlled trial. Osteoporos. Int. 22 (12), 2963–2972. Chan, M.F., Kwong, W.S., Zang, Y.L., Wan, P.Y., 2007. Evaluation of an osteoporosis preventioneducation programme for young adults. J. Adv. Nurs. 57 (3), 270–285. Chen, I.J., Yu, S., Wang, T.F., Cheng, S.P., Huang, L.H., 2005. Knowledge about osteoporosis and its related factors among public health nurses in Taiwan. Osteoporos. Int. 16 (12), 2142–2148. Claesson, A., Toth-Pal, E., Piispanen, P., Salminen, H., 2015. District nurses' perceptions
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