1

Introduction

Among health-care providers, nurses spend the most time with patients and are responsible for maintaining and improving their health. With their specialized knowledge, high clinical skills, and decision-making abilities, they are able to provide comprehensive and targeted care to patients, which can reduce complications and consequently promote health. One of the important areas of nursing care is caring for patients who are undergoing traction treatment due to fractures.

Unlike developed countries, traumatic injuries are the second leading cause of mortality in developing countries such as Iran and the most common cause of limb fractures, creating significant challenges for survivors and their families. According to studies conducted in Iran, accidents are the most common cause of limb fractures (39.6 %), especially among young people, while in individuals over 65 years old, falls (30.2 %) are the most common cause of limb fractures. ^, Therefore, fractures are more common among the elderly and those involved in accidents, and it is predicted that by 2050, the annual number of hip fractures among the elderly worldwide will nearly double.

Patients with limb fractures often experience severe pain and swelling at the injury site due to the disruption of bone integrity, which may lead to further complications and risks if not promptly and effectively managed. Although surgery is the standard treatment for limb fractures, in some cases, such as the unavailability of an operating room, the patient’s condition, or the need to stabilize the patient, surgery may be delayed. In such cases, traction is used as a temporary measure before surgery. Although the use of traction, especially in developed countries like the United States, has declined, its use remains more prevalent in developing countries. ^, While precise statistics on the use of skin traction in Iran are not available, given the high prevalence of traumatic injuries and related fractures, it appears that this method remains common for limb fractures in Iran. ^{, ,}

Traction, as an non-surgical treatment method, uses pulling force to immobilize fractures, relieve muscle spasms, and alleviate pain, and can be vital for patients. Among these, skin traction, which is used for a shorter period before orthopedic surgery, reduces muscle spasms and has fewer complications. Given the importance of this intervention in improving patient outcomes, specialized care for these patients is essential, and the success of their treatment depends on the nurses’ skills in managing skin traction and its potential complications.

Nurses play a crucial role in preventing injury, reducing complications of immobility caused by orthopedic devices such as skin traction, and promoting patient rehabilitation. In other words, they must possess a high level of competence to provide standard care to patients with skin traction. However, research has shown that nurses’ knowledge and practice in caring for patients with traction fall short of desired standards. For example, according to a study by Mohammad et al., nurses’ knowledge about traction, related care, and its complications was insufficient, and the majority of nurses demonstrated poor performance in post-traction care. Similarly, Wahba et al. found that more than half of the nurses lacked adequate skills in caring for patients with traction.

Providing high-quality patient care, based on Benner’s theory (from Novice to Expert) requires the acquisition of competency and skill in nurses. According to this theory, which can serve as a framework for evaluating skills, nurses progress over time and with experience from the novice stage (requiring precise instructions) to the expert stage (capable of complex decision-making and evidence-based care). They will be able to apply acquired knowledge in real- clinical situations.

Therefore, maintaining and enhancing nursing performance, which includes both direct and indirect nursing care, particularly for patients with specific conditions, directly impacts their recovery. Studies have shown that nurses performance and awareness can be influenced by various factors, including work environment or individual characteristics. For example, nursing performance improves with age and experience, and nurses with more experience tend to make better care decisions for patients.

As mentioned, despite the importance of proper nursing interventions for these patients, inadequate care of skin traction can lead to complications such as pressure ulcers. According to a study by Birch et al., the average rate of complications in patients with skin traction is 11 %. All these complications can be reduced by increasing nurses’ knowledge and practice in caring for patients with skin traction. In other words, if nurses have sufficient competence and their knowledge and practice are evidence-based and aligned with care standards, patient recovery can be achieved.

Given the importance of effective care for patients with skin traction and the critical role of nurses in emergency and surgical departments in managing these patients, as well as the lack of comprehensive studies in this area, there is a need for further research to comprehensively examine the knowledge and practice of nurses working in these departments regarding the care of patients with skin traction. Additionally, despite the association between individual characteristics and nurses’ awareness and performance, no study has been conducted on the relationship between demographic variables and the knowledge and practice of nurses in these departments regarding the care of patients with skin traction. Therefore, based on Patricia Benner’s theory, this study aimed to determine the knowledge and practice of nurses in skin traction care for orthopedic trauma patients with fractures and associated factors.

2

Methods

This descriptive correlational study was conducted in northwestern of XX, in the hospitals of XX University of Medical Sciences in 2023. The study population comprised all nurses working in the surgical and emergency departments of these hospitals. After obtaining a research permit from the Vice Chancellor for Research and ethical approval from the research ethics committee, the researcher proceeded to the research setting. Given the inaccessibility of the entire study population due to factors such as leave or unwillingness to participate, a convenience sampling method was employed.

To determine the sample size, Cochran’s sample size formula was used, resulting in the determination of 220 nurses. The inclusion criteria were informed consent to participate in the study, having at least a bachelor’s degree, and having at least six months of work experience in the relevant departments. After determining the sample size, the researcher visited the targeted hospital departments of XX University of Medical Sciences during different days of the week and various shifts (morning, afternoon, and night). Upon visiting the research environment in various work shifts, the purpose of the study, the method of work, and how to fill out the questionnaire were explained to the nurses of the respective shift. Those who consented and met the inclusion criteria were included in the study after providing informed consent. The questionnaires were completed individually at the workplace. For assessing knowledge, nurses completed the questionnaires, and for assessing practice, the researcher completed the questionnaires through indirect observation, using unique codes for each participant. Completion of each knowledge and practice questionnaire took approximately 15–30 min during the various shifts. In some research samples, due to time constraints, the nurse’s knowledge questionnaire was completed online. In this case, an online access link to the electronic questionnaire was sent to the nurse’s mobile phone via one of the messaging applications and then completed by the nurse during the same work shift. Sampling from nurses in the surgical and emergency departments continued across various work shifts until reaching the desired sample size over five months.

This study was designed based on the SQUIRE guidelines for quality improvement studies in healthcare.

The data collection tool in this research was a three-part questionnaire: The first part included demographic questions such as age, gender, marital status, education level, workplace department, work experience, and participation in related training courses and workshops. The second part was a tool for assessing nurses’ knowledge about caring for patients with skin traction, which included 17 questions in 4 sections: general knowledge about traction (3 questions), knowledge about skin traction (3 questions), knowledge about caring for patients with skin traction (8 questions), and knowledge about complications of skin traction (3 questions).

The scoring method was based on the proportion of correct answers, and a higher score indicated greater knowledge about caring for patients with skin traction. Thus, the overall knowledge of nurses and each section regarding traction was evaluated. Overall, a score of 75 % or higher indicated good knowledge, 50 % to 74 % indicated average knowledge, and less than 50 % indicated poor knowledge about skin traction. The psychometric properties of this tool had previously been confirmed, with a Cronbach’s alpha coefficient of 0.87.

The third part, an observational checklist assessing nurses’ practice in caring for patients with skin traction, comprised 65 questions divided into four sections: nursing interventions before skin traction application (11 questions), nursing interventions during skin traction application (27 questions), nursing interventions after skin traction application (19 questions), and follow-up of patients under skin traction (8 questions). ^, All questions in this tool had three options and were scored using the Likert scale. The total score was then calculated, ranging from 0 to 130. In this tool, the ratio of correct answers was also estimated. A higher score indicates a higher level of practice. Generally, nurses’ practice in caring for patients with skin traction were categorized into three levels: good, average, and poor. If the practice score was above 75 % (98–130), it indicated good practice; a practice score between 50–74 % (65–97) indicated average practice; and a practice score below 50 % (0–64) indicated poor practice. The Cronbach’s alpha coefficient for this tool had previously been assessed and confirmed at 0.74.

To assess the validity and reliability of these tools, considering they had not been psychometrically evaluated in XX, the tools were initially translated. To ensure proper translation, they were retranslated into Persian by a specialist. After the translator confirmed the translation, it was accepted. Subsequently, the tools were provided to 10 expert faculty members in this field for thorough review to ensure there were no semantic discrepancies. Then, the content and face validity indices, as well as internal consistency reliability, were examined. For determining face validity, the tools were given to specialists to provide their opinions and suggestions regarding the appearance of the questions. For ensuring content validity in both tools, the content validity index was used to assess the relevance of the questions separately. The obtained validity index for the relevance of the questions was 0.73 for the nurses’ knowledge tool and 0.78 for the nurses’ practice tool. Additionally, the internal consistency reliability of the nurses’ knowledge and practice tools was assessed using the Cronbach’s alpha coefficient, which was 0.72 for the nurses’ knowledge tool and 0.75 for the nurses’ practice tool, both of which were confirmed.

Obtaining ethical approval from the Research Ethics Committee of XX University of Medical Sciences, obtaining an introduction letter from the Deputy of Research and Technology of XX University of Medical Sciences, visiting the research environment, explaining the study’s purpose, obtaining informed consent from participating nurses, participation upon willingness, and assuring participants that collected data would remain confidential were among the ethical considerations addressed in this research.

In this study, data were analyzed using SPSS software version 23. Descriptive statistics, including frequency, percentage, mean, and standard deviation, were used to describe the data. Given that the data distribution was normal based on the Kolmogorov-Smirnov statistical test, Pearson correlation, independent t -test, and one-way ANOVA were used to evaluate the relationships between variables. In all the statistical tests used, p < .05 was significant.

3

Result

A total of 220 nurses from emergency and surgical departments participated in this study. The mean age of participants was 35.45 ± 8.62 years, ranging from 21 to 55 years. Approximately half of the nurses were female (50.9 %) and married (65.5 %). In terms of education, 72.7 % of participants reported having a bachelor’s degree. Most participating nurses were from the emergency department, and 32.8 % were from the surgical departments. The employment status of the participating nurses varied, with most (60.9 %) being university employees. Over half of the participants (55 %) had less than 10 years of work experience. Overall, the majority of participants had not attended training courses related to the care of patients with skin traction (81.8 %) ( Table 1 ).

Regarding nurses’ knowledge about caring for patients with skin traction, Table 2 shows that most nurses (91.8 %) scored poorly in the general information section about traction, providing incorrect answers regarding the reasons for using traction, the duration of traction use, and the weights used in traction. In the section on knowledge of caring for patients with skin traction, most nurses (85.4 %) obtained moderate to good scores. For example, most nurses correctly answered questions about the frequency of assessing the neurovascular status (79.1 %) and the reason for doing so (69.1 %), the patient’s position in bed (87.3 %), how to change patient position in bed (85.5 %), the timing of removing skin traction weights (79.1 %), and the timing of getting out of bed (55.5 %). However, some knowledge gaps were identified. Although a small percentage of nurses (9.1 %) scored poorly in the section on complications of skin traction, most nurses (92.7 %) were unaware of the long-term complications of using skin traction.

Table 2

Frequency distribution, mean, and standard deviation of nurses’ knowledge regarding skin traction care.

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