Nurses’ knowledge about venous leg ulcer care:a literature review

M. Ylönen1 RN, MNSc, PhD(c), M. Stolt2 PhD, H. Leino-Kilpi3,4 RN, PhD, &R. Suhonen5 RN, PhD

1 Doctoral Student, 2 Podiatrist, 3 Professor, 5 Professor, Department of Nursing Science, University of Turku, 4 NurseDirector, Turku University Hospital, Turku, Finland

YLÖNEN M., STOLT M., LEINO-KILPI H. & SUHONEN R. (2013) Nurses’ knowledge about venous legulcer care: a literature review. International Nursing Review 61, 194–202

Introduction: There is an increasing prevalence of venous leg ulcers coinciding with increasing older people

populations. They are therefore important health problems, which restrict daily activities and incur high costs.

Background: Efficient and comprehensive nursing care for people with venous leg ulcers requires knowledge

of causes, presentations and characteristics, the effects that venous leg ulcers have on individuals and nursing

care with evidence-based treatment.

Aim: To identify the gaps between nurses’ demonstrated knowledge of venous leg ulcers and the related

nursing care treatment with evidence-based nursing care.

Method: A computerized search using MEDLINE, CINAHL the COCHRANE LIBRARY was conducted.

Results: The initial search yielded 174 citations from which 16 relevant articles were included in this

review. Four themes in venous leg ulcer nursing care emerged demonstrating nurses’ knowledge gaps:

assessment, physiology and the healing process, nursing care and dressings, and compression

treatment.

Conclusion: This review suggests that there is a lack of knowledge related to venous leg ulcer physiology, the

healing process and how this influences care and treatment. Nurses may not be using the evidence base

sufficiently well to support ulcer healing and patient well-being.

Implications for nursing and health policy: There is a need for a positive work culture development and

ongoing educational programmes aimed at improving nurses’ knowledge of venous leg ulcer treatment and

care, which address the themes within the results of this review.

Keywords: Knowledge, Literature Review, Nurse, Nursing, Venous Leg Ulcer

IntroductionA venous leg ulcer (VLU) is the result of venous insufficiencyassociated with venous hypertension. A VLU is defined as anopen wound on the ankle or lower leg of venous origin.

(Wound, Ostomy and Continence Nurse Society (WOCN)2011) Leg ulcers are encountered all over the world butonly few studies give details about VLU prevalence becausemany VLUs are not diagnosed properly. Those studiesthat discuss VLU prevalence have shown that approximately1% of the adult population has a history of a healed or openVLU and this number seems to be stable over time. (Nelzén2007).

Correspondence address: Minna Ylönen, Sunilantie 16, 23100 Mynämäki, Finland.Tel: +358-400667809; Fax: +35823338400; E-mail: minna.ylonen@utu.fi

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Literature Review

© 2014 International Council of Nurses 194

Affected patients with VLU consider their main problems tobe pain, difficulties with washing, bathing and moving, odourand slippage of dressings and bandages (Fagervik-Morton &Price 2009). Good VLU nursing care includes the correct man-agement of these issues and takes account of patients’ needs inorder to maximize their quality of life (European WoundManagement Association (EWMA) 2008). Where optimalnursing care of people with VLUs occurs, outcomes areimproved. For example, in Europe, the care of foot and legulcers accounts for 2–4% of healthcare budgets (Gottrup et al.2010) and in the USA, the estimated cost for treating forpatients with VLU exceeds $2 billion a year (Valencia et al.2001).

BackgroundThe knowledge base used in VLU nursing care requires anunderstanding of the physiology of venous insufficiency, whichhelps in the management of people with VLUs. When a VLUoccurs, effective nursing care should be based on a full assess-ment, ongoing evaluation and treatment, which include theunderlying causes, the control of factors that affect healing andthe use of appropriate dressings and healing products (WOCN2011).

Assessment and evaluation take account of the ulcer loca-tion, size, the condition and colour of the ulcer bed, the levelof exudate, odour, levels of pain and the effects the ulcer hason the individual. Assessment also includes a consideration ofthe condition of the surrounding skin and leg (WOCN 2011).Part of the leg assessment is the palpation of the pedal pulseswhich should take place before decisions are made on treat-ment. If the palpation is difficult, a calculation of the AnkleBrachial Pressure Index (ABPI), the ratio of the blood pressurein the ankles to that in the arms, is necessary (Graham et al.2001; Vowden & Vowden 2001). The nutritional requirementsof the body change during periods of VLU healing and extraproteins are required. A nutritional assessment, including acalculation of the body mass index (height over weight) istherefore part of the assessment (The Wound Healing Society2007; World Union of Wound Healing Societies (WUWHS)2008).

Monitoring the ulcer area, size and depth, over time providesa baseline for the ongoing evaluation of the VLU (Edwards et al.2005; Ribu et al. 2003; WOCN 2011). Infection can delayVLU healing and nurses must know how to recognize theclinical signs of infection. These signs are a burning sensation,erythema, oedema, malodour, an increase in exudate volume,pain around the ulcer site and the expansion of the ulcer(EWMA 2005; Gottrup et al. 2010; The Wound Healing Society2007).

There are two goals of VLU treatment. Firstly, to reduce thesize of the ulcer by creating a moist wound healing environmentand to protect the ulcer from further deterioration (The WoundHealing Society 2007). This protection includes considering thenutritional intake of proteins and where necessary weight lossprogrammes (The Wound Healing Society 2007; WOCN 2011).

The second goal is to treat the effects of the VLU such as painand excess exudate by using appropriate dressings (Palfreymanet al. 2006; The Wound Healing Society 2007; WOCN 2011).Pain is one of the major problems encountered by patients withVLUs (Fagervik-Morton & Price 2009). Nursing care must beperformed so that pain is minimized, especially during ulcerdressing changes (WUWHS 2004).

The preferred treatment for a VLU is compression therapy(Dealey 2001; WUWHS 2008), which reduces the effects ofvenous insufficiency. When regular compression is imple-mented correctly, most VLUs heal within 2 months but if com-pression is used incorrectly, it can delay healing and cause painand trauma (WOCN 2011; WUWHS 2008). High compressionsystems are better than low compression systems (O’Meara et al.2012; WOCN 2011).

Identifying nurses’ knowledge gaps in VLU nursing care isneeded to facilitate and improve healthcare practice, whichmust take account of the patients’ life situation within the rel-evant evidence base.

AimTo identify the knowledge gaps between the VLU evidence baseand nurses’ theories in use about VLU treatment and nursingcare.

MethodA review of the literature, which integrated separate study find-ings into a comprehensive and logical entity (Kirkevold 1997),was carried out.

A computerized search strategy identified relevant studiesfrom three electronic databases: MEDLINE from 1966 to theend of 2012, CINAHL from 1982 to the end of 2012 andCOCHRANE LIBRARY from 1972 to the end of 2012. Thesearch terms used were ‘leg ulcer’ and ‘nursing’ and ‘knowledge’and ‘leg ulcer’ and ‘nurse’ and ‘knowledge’. The initial searchyielded 174 citations; 84 from MEDLINE, 74 from CINAHL and16 from the COCHRANE LIBRARY. The search was completedwith keywords ‘leg ulcer’ and ‘nurses’ and ‘knowledge’ whichrevealed no new citations.

To be included in the review, a study had to (1) be publishedin a scientific journal, (2) be empirically based (includingreviews), (3) describe nurses’ knowledge in VLU nursing careand (4) use the English language. The exclusion criteria for this

Nurses’ knowledge about venous leg ulcer care 195

© 2014 International Council of Nurses

review stated that each study should not (1) describe patients’knowledge in VLU nursing care; (2) describe student nurses’knowledge in VLU nursing care, (3) describe physicians’ knowl-edge in VLU nursing care and (4) be an editorial, expertopinion, case report or clinical care description. In some of thestudies also, patients and nursing students participated in thestudy, but their results are not included in the review results.

The initial 174 citations found were reduced to 141 byremoving duplicates. These 141 citations were screened againstthe inclusion and exclusion criteria at the title and abstract levelby two researchers (MY and MS) working independently.Finally, the researchers discussed their independent choices andby consensus, 28 studies remained. After reading the full texts ofthese 28 studies, 12 were excluded because there was either nodescription about nurses’ knowledge in VLU nursing care oronly the patients’ perspectives of care were described. This left15 empirically based articles and one review, 16 in all (Fig. 1).

Information from each of the 16 studies was collectedregarding the authors, year and country of study, participants,data-collection time and instruments/questionnaires used(Table 1).

Quality appraisal of the studiesThe focus of the quality appraisal of each article chosen wasconcerned with the methodological strengths and weaknessesand a consideration of the worth of the paper in terms of thegaps in nurses knowledge according to the evidence base.During this data analysis, the rigour of the process was managedby using appropriate appraisal instruments: CONSORT,COREQ, PRISMA or STROBE and two researchers who workedindependently and discussed their findings to consensus.

Of the 16 studies, three (experimental studies with interven-tion and control groups) were analysed using the CONSORTappraisal tool (Begg et al. 1996; Schultz et al. 2010). The one

Fig. 1 The retrieval process.

196 M. Ylönen et al.

© 2014 International Council of Nurses

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Nurses’ knowledge about venous leg ulcer care 197

© 2014 International Council of Nurses

literature review was analysed using the PRISMA appraisal tool(Moher et al. 2009) and 11 other studies were analysed usingthe STROBE appraisal tool (von Elm et al. 2007). The one quali-tative study was analysed using the COREQ appraisal tool (Tonget al. 2007; Table 1).

Although the experimental studies were able to be analysed interms of an introduction, the description of eligibility criteria ofparticipants, the baseline data description for each group and adescription of outcomes, there was marked variation within theother CONSORT statement criteria. Supporting InformationTable S1 provides the results.

All of the STROBE evaluated articles met at least 14 of the 22STROBE statement criteria. The most poorly managed criteriawere the description of funding sources, the description ofpotential sources of bias, such as selection, performance ordetection bias and discussions about generalizability. Addition-ally, the title did not always provide enough information aboutthe study design. Supporting Information Table S2 provides theresults.

One of the articles evaluated using PRISMA, met the criteriain terms of the rationale for the review in the context of what isalready known and the summary of evidence and conclusionsonly. Presenting a synthesis of the results was a main part of thearticle. One qualitative article did not meet all of the COREQcriteria as personal characteristics were not completelydescribed and it was not clear who were the researchers andwho conducted the interviews.

Overall, the amount of research in the field of VLU nursingcare knowledge was limited as only 16 studies met the inclusioncriteria for this review. Additionally, there seemed to be somemissing information in the results presented in the articles. Forexample, sometimes there were no descriptions of the contextand methods of selection of participants. Also, the timing of thedata collection and how the sample size was determined wererarely mentioned.

There were many questionnaires used to measure nurses’knowledge about VLU nursing care, and in almost every study(Ameen et al. 2005; Graham et al. 2001; Jones & Nelson 1997;Smith-Strøm & Thornes 2008; Taverner et al. 2011; Weller &Evans 2012; Wong 2003), a new questionnaire was developed.Information about the names of the questionnaires wasmissing. The development of the questionnaires was based onliterature reviews and sometimes expert analyses, although adescription of their expertise was often lacking. Some research-ers (Barrett et al. 2009; Dealey 2001; Haram et al. 2003; VanHecke et al. 2009) used questionnaires from previous studies,but there was only a limited evaluation of the validity andreliability of these questionnaires presented in the articles(Table 1).

ResultsIn the studies reviewed, if a particular practice was not basedwithin evidence-based guidelines, a gap in knowledge was rec-orded. These gaps, theoretical and practical, were identified bydifferent methods in the different studies: questionnaires, obser-vation, interviews and patient-based documentation. Theresults gave rise to four themes, namely, VLU assessment, VLUphysiology and the healing process, local VLU nursing care,dressings and compression treatment (Table 2).

Knowledge gaps in VLU assessment

Some nurses demonstrated a lack of knowledge in VLU clinicalassessment by failing to inspect the VLU and the surroundingskin on both legs thoroughly (Clarke-Moloney et al. 2008;Dealey 2001; Graham et al. 2001; Ribu et al. 2003; Weller &Evans 2012). This assessment included the inability to palpatethe pedal pulses and measure the ABPI using Doppler ultra-sound equipment (Clarke-Moloney et al. 2008; Dealey 2001;Ribu et al. 2003; Walsh & Gethin 2009; Weller & Evans 2012).

Nurses also demonstrated a lack of knowledge about the paincaused by a VLU and its treatment. Although most patientsexperience pain related to their VLUs, treatment and dressingchanges (McMullen 2004; Ribu et al. 2003; Van Hecke et al.2009), many nurses assume that only arterial ulcers are painful(McMullen 2004). This lack of knowledge about VLU painmeans that patients may not receive adequate pain relief(Haram et al. 2003; McMullen 2004; Smith-Strøm & Thornes2008; Taverner et al. 2011; Van Hecke et al. 2009).

Nurses used several different documentation systems toassess their patients, including evaluation reports, electronicdocumentation, wound records and nursing care plans. Withinthese documents, VLU nursing care assessment was poorlymanaged (Dealey 2001; Ribu et al. 2003; Smith-Strøm &Thornes 2008). VLU assessment charts were rarely used andnurses rarely wrote reports about the state of the VLU or theVLU treatment. Only a few nurses made drawings of VLUs andphotography was not used. Associated with this communicationof information, few nurses always measured the area of the VLUin a systematic way to demonstrate VLU changes (Ribu et al.2003; Smith-Strøm & Thornes 2008). As part of the assessment,patients did not always have their ulcers diagnosed definitively(Graham et al. 2001; Haram et al. 2003; Smith-Strøm &Thornes 2008) and many patients were diagnosed as having‘mechanical damage’ (Haram et al. 2003, p. 291) and ‘otherunknown diagnoses’ (Haram et al. 2003, p. 291).

Knowledge gaps in VLU physiology and the healing process

Failures in accurate assessment of VLUs may have been due to alack of understanding of VLU physiology (Ameen et al. 2005;

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Bell 1994; Smith-Strøm & Thornes 2008). In the review, theblood supply to the leg and mobility were not considered sig-nificant factors in ulcer healing. Nurses had difficulties in iden-tifying factors that enhance or delay the healing process such asnutrition, mobility, poor bandaging and oedema (Bell 1994).Also, nurses did not seem to recognize the stages of VLU healingespecially the identification of sloughy and infected VLUs. Thisfailure of recognition was also shown by nurses who wereuncertain whether they were observing fibrin or necrosis whenVLUs were yellow (Ribu et al. 2003). This failure to recognizethe stages of healing may have led to nurses’ poor differentia-tion between infected and healing ulcers (Bell 1994; Ribu et al.2003).

Knowledge gaps in VLU nursing care and dressings

This section considers information in the review about handcleansing before a VLU procedure, cleansing and dressing theVLU. At the start of any nursing procedure hands should becleansed (WHO 2006). In the reviewed articles, nurses demon-strated a knowledge gap in hand-cleansing routines before andduring VLU nursing care (Dealey 2001; Ribu et al. 2003). Whencleansing ulcers after assessment, nurses should use tap water tocleanse the VLU if the water source is reliably clean (TheWound Healing Society 2007). Although most of the nursescleansed VLUs routinely, sometimes, this was done infrequently(Barrett et al. 2009). Normal saline was the preferred cleansingagent, but chlorhexidine use was common (Barrett et al. 2009;Dealey 2001; Haram et al. 2003; Ribu et al. 2003). Additionally,

nurses often swabbed the VLU bed with gauze, which has beenreported to leave fibres of cotton in the VLU leading to potentialinfection (Ribu et al. 2003).

There were gaps in knowledge about the use of VLU dress-ings (Ameen et al. 2005; Barrett et al. 2009; Dealey 2001; Ribuet al. 2003). The dressing type is dependent on the individualpatient and the state of the VLU (WOCN 2011; WUWHS2004).

Nurses used mostly dry dressings but common dressingsincluded gauze impregnated with silver (Clarke-Moloney et al.2008; Haram et al. 2003; Ribu et al. 2003), iodine and hydrogel(Haram et al. 2003; Ribu et al. 2003). Sometimes, some incom-patible product combinations were used, such as paraffin andsilver or two iodine-based dressings (Barrett et al. 2009). Thislack of knowledge was demonstrated when, in the reviewedarticles, nurses usually decided a treatment before the underly-ing causes of the VLUs were known and before a diagnosishad been made (Graham et al. 2001; Haram et al. 2003). Nursesalso changed treatments without consulting a dermatologist(Graham et al. 2001; Haram et al. 2003; Smith-Strøm &Thornes 2008).

The frequency of dressing changes varied from once a weekto 6 days a week, although with sufficient knowledge aboutVLUs, it is possible to dress many VLUs weekly(Clarke-Moloney et al. 2008; Haram et al. 2003). Dressingchanges lasted from between 20 min and 1 h, which is signifi-cant considering the amount of pain the patient may sufferduring dressing changes (Ribu et al. 2003).

Table 2 Themes and sub-themes of nurses’ VLU nursing care knowledge gaps

Theme Sub-theme References

Knowledge gaps in VLU

physiology and healing process

Diagnosis, VLU healing Bell 1994; Graham et al. 2001; Haram et al. 2003; Ribu

et al. 2003; Smith-Strøm & Thornes 2008

Knowledge gaps in VLU

assessment

Inspection of the ulcer and surrounding skin, inspection

of both legs, palpating pedal pulses and ABPI, pain

assessment, documentation, drawing from the VLU,

photography, ulcer area measurement

Dealey 2001; Graham et al. 2001; Haram et al. 2003; Ribu

et al. 2003; McMullen 2004; Clarke-Moloney et al. 2008;

Smith-Strøm & Thornes 2008; Van Hecke et al. 2009;

Walsh & Gethin 2009; Taverner et al. 2011; Weller &

Evans 2012

Knowledge gaps in local VLU

nursing care and dressings

Hand washing routines, Ulcer cleansing, VLU bed swab,

frequency of dressing changes, different kind of

dressings, taking care of the surrounding skin

Dealey 2001; Graham et al. 2001; Haram et al. 2003;

Ameen et al. 2005; Clarke-Moloney et al. 2008;

Smith-Strøm & Thornes 2008; Barrett et al. 2009;

Van Hecke et al. 2009

Knowledge gaps in compression

treatment

When and how to use compression, effectiveness of

various types of compression

Bell 1994; Jones & Nelson 1997; Dealey 2001; Graham et al.

2001; Haram et al. 2003; Ribu et al. 2003; Ameen et al.

2005; Clarke-Moloney et al. 2008; Smith-Strøm &

Thornes 2008; Barrett et al. 2009; Van Hecke et al. 2009;

Weller & Evans 2012

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Knowledge gaps in compression treatment

A lack of knowledge about compression treatment was apparentin many of the reviewed studies (Ameen et al. 2005; Barrettet al. 2009; Bell 1994; Clarke-Moloney et al. 2008; Dealey 2001;Graham et al. 2001; Haram et al. 2003; Jones & Nelson 1997;Ribu et al. 2003; Smith-Strøm & Thornes 2008; Van Hecke et al.2009; Weller & Evans 2012).

Specifically, nurses did not seem to know which patientsneeded compression treatment and when compression was nec-essary. In some studies, compression treatment was not used onany patients with VLUs (Barrett et al. 2009; Dealey 2001; Haramet al. 2003). Where compression bandaging was used, nurseshad a poor knowledge of the effectiveness of different types ofcompression bandaging, and the principles of graduated com-pression (Barrett et al. 2009; Graham et al. 2001; Ribu et al.2003). In one study, nurses used single-layered compressionmost often (Van Hecke et al. 2009), but in another study(Barrett et al. 2009), a four-layer compression system was pre-ferred. However, when compression was used and the pressureexerted measured, the pressure was sometimes incorrect due tothe lost elasticity of the bandage (Ribu et al. 2003). This lack ofunderstanding may have arisen because sometimes nursesapplied compression treatment without any training (Barrettet al. 2009).

DiscussionThe most important result in this review was nurses’ lack ofknowledge of the evidence base, which is a cause for concern if,because of this, patients receive poor nursing care and treat-ment. Knowledge about the physiology and underlying causesof VLU is the basis of VLU nursing care, and it was found to belacking, for example, about the palpation of pedal pulses andthe measurement of the ABPI. Lack of this knowledge affectsthe ability of the nurses to vary VLU treatments appropriatelyand may lead to poor use of the evidence base and the derivedguidelines and recommendations.

Overall, this review demonstrates that the nursing care ofpeople with a VLU is not conducted in accordance with the evi-dence base. Assessment of VLUs should include pain assess-ments and patients should receive sufficient pain relief whenneeded. Additionally, a clean moist wound environment, whichhas neither excess exudate nor is completely dry, is importantfor VLUs healing (WOCN 2011; WUWHS 2004). Cleansingmethods and dressings should be chosen to support the moistwound environment. Managing this moist wound environmentrequires that nurses understand the stages of wound healing, theactions of cleansing solutions, the purpose of dressings and howthese work together to promote healing. Knowledge about com-pression of the VLU to promote healing and the skills to effect

compression usefully are essential to increase the opportunitiesfor VLU healing and the prevention of further trauma to theleg. In this review, nurses’ knowledge of compression treatmentwas not in line with current evidence-based guidelines andrecommendations.

Five limitations are acknowledged. Firstly, the three databasesused (MEDLINE, CINAHL and COCHRANE LIBRARY) werechosen because they are mostly concerned with the healthcaretreatments and nursing care (Brazier & Begley 1996; Subiranaet al. 2005). A hand search of non-electronic materials wasomitted and may have led to some useful literature beingmissed. The topic of this review was VLU but instead of using itas a keyword, leg ulcer was used in order to identify all relevantstudies.

Secondly, the computerized searches covered a long period(1966 to end of 2012) and some of the data used in this reviewdates back to 1994. The nursing care, treatment and nurses’knowledge of VLUs have changed markedly since that time.Thirdly, there may have been research studies in languages otherthan English that are worthy of analysis. Fourthly, the validity ofthe study was reduced because the sample sizes in the studieswere often small making it difficult to generalize the findings.Finally, it is acknowledged that most of the studies (13) in thisreview were conducted in Europe with three outside of Europe.The themes inside and outside of Europe seem to be equivalentbut this needs further research.

Implications for nursing and health policyThe treatment and care options for people with a VLU must bechosen based on a sound knowledge of the patients about theirlifestyles and the way VLUs are formed and healed. This knowl-edge includes the underlying causes of VLUs, their accurateassessment, the physiological basis of VLU healing and the useof dressings and compression bandaging. In addition, nursesshould have knowledge of VLU-related guidelines and recom-mendations derived from the evidence base. If nurses do nothave the evidence-based knowledge, it can affect ulcer healingadversely leading to increased patient suffering, pain and dis-comfort and delayed healing. From an organizational perspec-tive, delayed healing will increase the costs of care.

Nurses’ knowledge gaps about the VLUs evidence base are aprofessional concern, which must be addressed if care and treat-ment of people with a VLU is to be improved. Nurses have aresponsibility to set the patient in the centre of appropriatenursing care and treatment, which is more difficult if the evi-dence base is not able to be used within treatment and nursingcare.

In order to assist this work, there is a need to develop a spe-cific work-based culture based on an increase in interest and

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expertise in the management of VLUs. Heads of nursing staffmust consider VLU nursing care as an important part ofpatient-centred care so that expertise in nurses can be improvedand supported.

There are international and national evidence-based recom-mendations about VLUs nursing care (EWMA 2005, 2008; TheWound Healing Society 2007; WOCN 2011; WUWHS 2004,2008), and nurses should have the ability to access and appraisethe research findings and recommendations wherever possible.The development of these abilities, including education andaccess to supporting resources, should be a priority for bothnurses and their managers. Educational interventions could bedirected towards the application of published international andnational guidelines. Educational efforts could also be based onthe organization’s own research findings. In this way, it wouldbe possible to produce and provide relevant up-to-date infor-mation for nursing professionals and help to develop a cultureof VLU expertise.

The use of the Internet for access to learning and teachingwould be useful, but this may not be available, or is intermit-tent, in many parts of the world. Where the Internet is notreadily available, the training and employment of expert nursesin wound and ulcer management is important. These expertnurses could work as consultants to other nurses and membersof the staff to improve VLU treatment and care. In Europe, theseexpert nurses are called tissue viability nurses (Bethell 2006).

ConclusionBased on the review results, nurses may not be using the evi-dence base sufficiently well to support ulcer healing and patientwell-being. The knowledge gaps were identified in VLU assess-ment, VLU physiology and the healing process, local VLUnursing care, dressings and compression treatment. Therefore,there is the need to increase knowledge about VLUs and theirnursing care and treatment in basic nursing care education andcontinuing education. Furthermore, the knowledge gaps identi-fied in the review, together with existing international andnational guidelines, can be used in further studies. For example,an instrument can be developed based on the review results toidentify theoretical and practical knowledge and knowledgegaps in VLU nursing care.

AcknowledgementNo grants were obtained in relation to this study. We acknowl-edge the assistance with the language checking of the manu-script by Dr Norman Rickard PhD, RN.

Author contributionsStudy design: MY, HL-K, RS; data collection: MY, data analysis:MY, MS and manuscript preparation: MY, MS, HL-K, RS.

Conflict of interestThe authors state that they do not have any conflict of interest.

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Supporting informationAdditional Supporting Information may be found in the onlineversion of this article at the publisher’s web-site

Table S1 Evaluation of experimental studies according toCONSORT criteria

Table S2 Evaluation of non-experimental studies accordingto STROBE statement criteria

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