<p>Barriers and enablers to the implementation of perioperative hypothermia prevention practices from the perspectives of the multidisciplinary team: a qualitative study using the Theoretical Domains Framework</p>

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O R I G I N A L R E S E A R C H

Barriers and enablers to the implementation of

perioperative hypothermia prevention practices

from the perspectives of the multidisciplinary

team: a qualitative study using the Theoretical

Domains Framework

This article was published in the following Dove Press journal: Journal of Multidisciplinary Healthcare

Judy Munday1,2

Alana Delaforce1,3

Gillian Forbes4

Samantha Keogh1

1_{School of Nursing and Institute of}

Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia;

2_{Department of Health and Nursing}

Science, University of Agder, Grimstad, Norway;3_{Clinical Governance Unit,}

Mater Health, South Brisbane, QLD 4101, Australia;4_{Department of Clinical,}

Educational and Health Psychology, UCL Centre for Behaviour Change, London WC1E 6BT, UK

Purpose: Inadvertent perioperative hypothermia is a signiﬁcant problem for surgical patients globally, and is associated with many detrimental side-effects. Despite the avail-ability of rigorously developed international evidence-based guidelines for prevention, a high incidence of this complication persists. This qualitative study aims to identify and examine the domains which act as barriers and enablers to perioperative hypothermia prevention practices, from the perspectives of the key healthcare professionals involved with periopera-tive temperature management.

Methods: A qualitative study employing semi-structured interviews was utilized. A purposive sample of key stakeholders involved in perioperative temperature management, including perioperative nurses, anesthetists, surgeons, and perioperative managers, were recruited via email. The interview guide was developed in reference to the Theoretical

Domains Framework. All interviews were recorded, de-identiﬁed, transcribed, and coded.

Belief statements were generated within each domain, and a frequency score generated for each belief. Finally, the domains were mapped to the COM-B model of the Behavior Change Wheel to develop recommendations for future interventions.

Results:Twelve participants were included including eight nurses, two surgeons, and

two anesthetists. Eleven key theoretical domains that inﬂuence the uptake of

periopera-tive hypothermia practices were identiﬁed: knowledge; skills; social/professional role

and identity; beliefs about capabilities; optimism; beliefs about consequences; reinfor-cement; goals; memory, attention, and decision processes; environmental context and

resources; social inﬂuence. Suggested intervention strategies include training, reminder

systems, audit, and feedback, organizational support to resolve lack of control of ambient temperature, as well as provision of accurate temperature measurement devices.

Conclusion: Future interventions to address the key behavioral domains and improve perioperative hypothermia prevention need to be evaluated in the context of feasibility, effectiveness, safety, acceptability, and cost by the target users. All suggested intervention strategies need to take a team-based, multi-modal approach, as this is most likely to facilitate improvements in perioperative hypothermia prevention.

Keywords: perioperative hypothermia, temperature management, Theoretical Domains Framework, multidisciplinary, COM-B, behaviour change wheel

Correspondence: Judy Munday

School of Nursing and Institute of Health and Biomedical Innovation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD 4059, Australia Tel +61 73 138 8209

Email judy.munday@qut.edu.au

Open Access Full Text Article

Journal of Multidisciplinary Healthcare downloaded from https://www.dovepress.com/ by 118.70.13.36 on 24-Aug-2020

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blem for surgical patients globally,1and is associated with a range of adverse side-effects, including increased blood

loss,2increased wound infection rates,3decreased immune

function,4 shivering, prolonged duration of medications

including muscle relaxants, increased Post Anesthetic

Care Unit (PACU) stay and overall hospital stay,3 and

patient discomfort. This leads to an impact on the efﬁ

-ciency of perioperative services, and increased costs to the

healthcare system.5 Perioperative hypothermia is

preven-table, however an incidence of perioperative hypothermia

between 50–54% is reported in general adult surgical

patients,6,7and up to 80% in obstetric patients under spinal

anesthesia.8This is unacceptable given the available high

level evidence base consisting of rigorously developed,

and regularly reviewed international evidence-based

guidelines which recommend the utilization of

multi-faceted interventions to manage and prevent the

condition.1,9,10 Most recently, in Australia, the Australian

College of Perioperative Nurses (ACORN) have published guidance on the prevention of perioperative hypothermia: the Standard on the Management of Hypothermia in the

Perioperative Environment.11This recommends the

identi-ﬁcation of high risk patients, regular and consistent

tem-perature monitoring at all stages of the perioperative pathway, the use of active warming measures, guidance on ambient temperature levels, and, importantly, clear communication regarding thermal care between all mem-bers of the perioperative team at all stages, and with patients and their carers. However, despite an abundance

of primary research, synthesized evidence, and

guidelines1,9,10,12,13to promote the prevention of

inadver-tent perioperative hypothermia, a signiﬁcant variation in

practice remains, and high rates of perioperative hypother-mia persist.

Safe perioperative care, including thermal care,

requires collaboration between, and is the responsibility

of, all members of the perioperative team–medical,

non-nursing, and nursing - with management support also vital.

Yet, the perioperative department has been – up until

recently – under-investigated in relation to barriers and

enablers to implementation of best practice guidelines.14

As well as recent guidelines,11a collaboratively developed

intervention bundle, based on evidence-based

recommen-dations, has also been published in Australia,15but did not

result in a reduction of the incidence of perioperative

of care that aligns with evidence-based recommendations and bundles for perioperative hypothermia prevention may require understanding the barriers and enablers to chan-ging behavior of multidisciplinary teams, and across multi-ple phases of the perioperative pathway. In addition, the level of change required to comply with guidelines and improve thermal care will depend upon the baseline level of thermal care already provided by healthcare facilities, as well as the level of adoption. Therefore, a pragmatic decision was made to identify the barriers and enablers to

implementation using the Theoretical Domains

Framework (TDF).17 A recent investigation utilized the

TDF to identify factors that Canadian anesthetists

per-ceived to inﬂuence perioperative temperature

measure-ment (one component of perioperative hypothermia

prevention).16 However, our study acknowledges the

input that the wider perioperative team have in providing adequate thermal care, and investigates the wider domain of care that encompasses perioperative hypothermia pre-vention, rather than just temperature measurement alone.

The TDF is an overarching framework integrating

a range of behavior change theories,17,18 and has been

used to examine uptake of evidence in a variety of clinical

settings.16,19–22As extensively described in the literature,

the framework includes 14 domains: 1) knowledge, 2) skills, 3) social/professional role and identify, 4) beliefs about capabilities, 5) optimism, 6) beliefs about conse-quences, 7) reinforcement, 8) intentions, 9) goals, 10) memory, attention, and decision processes, 11)

environ-mental context and resources, 12) social inﬂuences, 13)

emotion, and 14) behavioral regulation.18

The TDF, as part of the Behavior Change Wheel (BCW), guides a process for developing interventions

and policy that speciﬁcally target deﬁcits in three

identi-ﬁed essential behavior change conditions: capability,

opportunity, and motivation (referred to as the COM-B

system).23This taxonomy has been applied to inform the

development of interventions and policies to improve

delivery of healthcare in a variety of clinical settings.20

The TDF domains underpin the components of the COM-B system. In our study, the application of both the TDF and COM-B model assists us to develop intervention

stra-tegies to specifically target clinician-identified deficits in

capability, opportunity, and motivation that inﬂuence

peri-operative hypothermia prevention. Therefore, this

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and enablers that inﬂuence the uptake of temperature management practices to prevent perioperative hypother-mia, from the perspectives of the key stakeholders involved with perioperative hypothermia prevention. Furthermore, the study aims to utilize the BCW to develop potential interventions to improve the implementation of perioperative hypothermia prevention.

Methods

Aim

This study aimed to investigate the barriers and enablers

that inﬂuence the uptake of perioperative temperature

management from multiple perspectives, namely, perio-perative nurses, non-nursing or medical perioperio-perative staff, anesthetic staff, surgical staff, and perioperative managers. Second, the study aimed to develop a potential intervention to improve implementation of perioperative hypothermia prevention practices.

Design

A qualitative study design employing semi-structured

interviews based on the TDF17 was used to explore

enablers and barriers that inﬂuence perioperative

tempera-ture management amongst perioperative clinical staff. In addition, the COM-B model was utilized to assist in the

development of potential intervention strategies to

improve perioperative hypothermia prevention.23

Setting, sample, and recruitment

Participants were recruited at a metropolitan, tertiary hospital in Brisbane, Australia. A purposive sample of key stake-holders involved in perioperative temperature management, including perioperative nurses, non-nursing or medical peri-operative staff, anesthetic staff, surgical staff, and periopera-tive managers, were invited to participate via email. The study was also advertised via poster in the perioperative department. Informed consent was sought from individuals interested in participating. Low-risk ethical approval was obtained, prior to commencement, from the hospital human research ethics committee (HREC), and administrative approval was gained from the university HREC.

Data collection

Individual semi-structured interviews were conducted

utilizing an interview guide based on the TDF,17 with

the intention of exploring the healthcare professional’s

practices. The interviews were conducted in a quiet interview room within the perioperative department, and at a time that suited the participant. Each question was developed to address each of the 14 theoretical domains, based on the literature and with input from a panel of experts (qualitative researcher, anesthetist, surgeon, perioperative nurse). However, unprompted issues were also explored during the interviews. Two researchers conducted all interviews (JM, AD), which

were recorded, transcribed, and de-identiﬁed.

Demographic data, including position, gender, number of years of experience, and duration of interview were collected at interview. Data saturation was assessed

using the approach proposed by Francis et al,24whereby

no further interviews were conducted once no new infor-mation was observed to emerge.

Data analysis

After transcription, two independent coders (JM, AD) analysed the textual data and assigned them into the 14 TDF domains. After data from two initial interviews was coded in this way, the coding was reviewed to establish a coding strategy for use with all remaining interview data. Discrepancies between reviewers were resolved via discussion. Second, thematic analysis was utilized to generate belief statements across the domains. The third coder (SK) reviewed the data analysis at this stage, followed by an expert in utilizing the TDF (GF).

The identiﬁcation of key domains likely to inﬂuence the

implementation of perioperative hypothermia prevention was determined as per the three-pronged process utilized

by Patey et al:19,25the frequency of beliefs across the 12

interviews; the presence of conﬂicting beliefs within

domains; perceived strength of the belief inﬂuencing

the relevant behavior.19,25 Finally, the TDF domains

were mapped to the capability (C), opportunity (O),

and motivation (M) components, which form the “hub”

of the BCW.23 Within each component, further

sub-components were considered (Capability: psychological,

physical; Opportunity: social, physical; Motivation:

reﬂective, automatic (see Table 3),23 with the

corre-sponding intervention function, Behavior Change

Theory (BCT) taxonomy and individual BCT, to develop

suggested intervention strategy examples.26 This study is

reported in adherence to the Consolidated Criteria for

Reporting Qualitative Research (COREQ) checklist.27

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scout nurses, two post-anesthetic care unit nurses, one clinical nurse facilitator, one nurse manager, two anesthe-tists, two surgeons) took part in this study. This corre-sponded to eight females and four males across the

multidisciplinary groups. Participant’s years of experience

in their relevant perioperative specialty ranged from 2 to 30 years. The duration of interviews ranged from 9.52 to 28.15 minutes (median duration=18.3 minutes). Data saturation was assessed as occurring after 12 interviews.

Key domains

Eleven theoretical domains were identiﬁed as relevant

to the implementation of perioperative hypothermia prevention across interviews with the multidisciplinary participants: knowledge; skills; social/professional role and identity; beliefs about capabilities; optimism;

beliefs about consequences; reinforcement; goals;

memory, attention, and decision processes;

environ-mental context and resources; and social inﬂuence

(see Table 1).

It was evident that both nursing and medical partici-pants were unsure as to the existence of guidelines for prevention of perioperative hypothermia (Knowledge). Some participants expressed that they did not know of any, whilst others expressed a belief that they must be in existence, although they could not identify them. The existence of the UK-based National Institute for Health and Care Excellence guidelines was recognized, but whether Australian guidelines were in existence was

a source of confusion.1Although prevention of the

condi-tion was recognized as important (Goals), a general lack of knowledge regarding the condition was evident and recog-nized by the individual participants, both in relation to their own knowledge, but also that of their colleagues (Knowledge). Whilst anesthetists in this study were

con-ﬁdent in their knowledge of the condition, surgeons

inter-viewed were noted to be less so. Nurses with greater years of experience in the speciality expressed a greater knowl-edge of the condition. Nursing participants noted that those who felt they had formal knowledge of the condi-tion, including the characteristics and preventative strate-gies, had acquired this via extra study, attendance at conference workshops, and/or further education. The need for further education on the condition was widely cited across the participant groups, expressed both as

(Knowledge).

The practice of monitoring the patient was consistently

identiﬁed as being highly important in perioperative

hypothermia prevention, by all stakeholders (Skills). This included ensuring a baseline temperature was recorded. While no concerns over possessing the skill to monitor temperature were expressed, and the availability of devices to monitor temperature was not reported as a barrier, con-cerns were reported over the accuracy of available devices (Environmental Context and Resources), especially by anesthetic and PACU nursing participants. Furthermore, the inability to control ambient temperature was acknowl-edged across participant groups as being an environmental factor that impacts upon the ability to manage periopera-tive hypothermia. Although it was felt that that concrete resources, in terms of devices and monitors, were

avail-able, it was identiﬁed that checklists, documentation, and

guidelines would facilitate the implementation of practices to prevent perioperative hypothermia.

Discrepancies were evident in participants’perceptions

of whom is ultimately responsible for perioperative

hypothermia prevention. Whilst participants widely

expressed they believed this was a team effort, and that all healthcare practitioners involved in the care of the perioperative patients should take responsibility for pre-vention, the central position of the anesthetist in tempera-ture-related decision-making was emphasized (Social/ Professional Role and Identity). This was particularly so in relation to intraoperative monitoring, where it was felt that the anesthetist is in charge of this, so other team members have less of a role at this stage. In particular, the lesser involvement of scrub scout nurses was high-lighted by both scrub scout nurses themselves, as well as the participating anesthetists. A perceived inability or les-sened capacity to contribute to hypothermia prevention was evident in the beliefs of scrub scout nurses in this respect (Professional Role and Identity).

To some degree, the prevention of perioperative

hypothermia was identiﬁed as being achievable.

However, it was also recognized that barriers persist in prevention, and that prevention is hindered by factors

out-side of the perioperative healthcare practitioners’ control

(Beliefs about capabilities). In this regard, it was

recog-nized that the patients’health status and outcomes

(includ-ing temperature) at each stage of the perioperative

pathway are inﬂuenced by the preceding stage.

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T able 1 TDF domains lik ely to in fl uence the implementation of perioperativ e h ypothermia pr e vention practices *denotes belief statements congruent with Boet et al. 16 TDF domain Speci fi c belief Example quotations Fr equency out of 12 Knowledge I am/am not awar e that guidelines exist for the management of inadv ertent h ypothermia* I am not awar e of an y of fi cial guidelines I must sa y, I don ’ t think I am awar e of any guidelines per se , whether the y be fr om the Australian College of Anesthetists or Surgeons or A CORN, I am sur e the y exist, but yeah. (A2) Not particularly an y speci fi c guidelines, I just know practices that impr ov e the outcome and that ’ s what I do but I ha ven ’ t seen an y written guidelines that ha ve to be done e ver y time. Are ther e such things? (SS5) Guidelines .. . I don ’ t .. . I am not awar e of an y Australian guidelines, ther e ’ s some British guidelines called NICE guidelines which ar e fairly strict. Ther e is some auditing guidelines fr om the Australian anesthetic college , but the y ’ re not actually guidelines on how to manage perioperativ e h ypothermia, the y ar e really just how to audit it. (A11) 11 I/w e ha ve a lack of knowledge re gar ding the condition Umm .. . it ’ s wher e their temperature dr ops, um and I know it can cause death, lik e w ell I know that ’ s malignant h yper thermia, is that the same or differe nt? Oka y, I don ’ t really know a lot then. (PN1) Again, it ’ s just getting to a number for discharge, I don ’ t think that the backgr ound knowledge of the actual importance of it being a certain range is ther e so I w ould just sa y that, because that was me yo u know when I still didn ’ t know all the ins and outs of it. (PN12) 9 Education w ould assist me/us to incr ease our knowledge and awar eness of managing perioperative h ypothermia Uh, pr obably education. Y ou know for the surgical side because I think that w e don ’ t get a lot of that in the training, w e know it ’ s important but what steps, what checklists, w e, I don ’ t think, w ell I ha ve n ’ t. (S9) Information, just .. . Information, yeah knowledge , what w orks best, what ’ s the most eco-nomical, what ’ s re adily available and .. . just what assists and then how patient outcomes at the end of the pr ocess, if you come out cold, is their sta y in hospital another da y, is their pain relief har der to deal with, is ther e, I ’ d lik e to just know those sorts of information so that I can use that information when I ’ m educating staff, ne w staff as w ell as older staff. (SS5) 11 I know and understand the parameters for perioperativ e h ypothermia Right, w ell, I guess perioperative h ypothermia refers to the patient ’ s body temperature being less than 36 degr ees Celsius. P erioperative means it ma y be pr e-op , intra-op ,or post-op . (A11) 2 I understand how to monitor and pr e vent perioperativ e h ypothermia W arming blank ets, hot dogs, warm clouds .. . Bair Hugger , all of those sort of inter ventions that w e usually put in. K eeping the patient warm befor ehand and on transport. (SS4) 3 ( Continued

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T able 1 (Continued). TDF domain Speci ﬁ c belief Example quotations Fr equency out of Skills The ability to monitor temperatur e is important in pr e venting perioperative h ypothermia T o pr e vent it? To constantly be monitoring your patient, being awar e of what their tem-peratur e is in theater . (PN1) And I think another thing that is ver y important is actually taking the pr eop temperature so that w e know the baseline, wher e it is sitting. P eople sit in differ ent temperatur es .. . some high and some low , w e cannot re gulate e ver ything, and w e could end up with an e ven w orse scenario or outcome. (AN3) So , knowing how to tak e someone ’ s temperatur e, knowing how to use the de vices to keep them warm, that ’ s about it really , I think. I can ’ t think of any thing else. (A11) 8 I feel I ha ve the skills necessar y to manage and pr ev ent perio-perative h ypothermia My ability to perform the skills I w ould rate as high, m y diligence and attendance to it is pr obably not quite as good as it should be at times. (A2) I ’ ds ay I ’ ve got basic skills .. . (PN1) 3 Social/Pr ofessional Role and Identity I belie ve it is the responsibility of e ve ry one in the operating room (including surgeons and nurses) to manage the patient ’ s temperature* Ev er y practitioner that sees the patient along their entir e sta y (is responsible for monitoring, managing and pr ev enting perioperative h ypothermia). (PN12) Uh I will just tak e you know , the usual, team effor t appr oach. (S9) So , I think it is a multi-disciplinar y responsibility , so it is surgeons, anesthetists, unit managers, educators, staff, all of those, yes. (8CF) 10 It is pr edominantly the anesthetists ‘ re sponsibility to manage the patient ’ s temperatur e* W ell, intraoperatively it ’ s the anesthetist, ov erall that ’ s a har der question to answ er because the anesthetist has no contr ol ov er man y things outside the operating theater but I think at the end of the da y it ’ s our role to k eep all ph ysiological variables as normal as w e can and that ’ s one of them. (A2) W ell I th ink the anesthe ti st has th e pr im ar y rol e , th e m ai n rol e. Bec au se w e n ee d to h av e a le ad er sh ip rol e in th e ate r to sta rt o ff w ith .O b vi ou sl y if th e p er io p e ra tiv e n u rs e s an d an e sth e ti c tec h n ic ia n s h av e a p roa cti ve att it u de to it , it h e lps us b ut I w ou ld b e ta k ing th e re sp on si b ilit y fo r the o u tc om e s of th e pa ti en ts so ,if th e y b ec am e h yp o th e rmi c o r h ad a com p lica tio n ,I w ou ld ta ke th at per sonal ly as m y re spo n sibi lit y. (A11) W e ll th e an e sth e ti st is th e on e in the the at e r th at is lo o ki n g af ter th at b e ca us e th e y h av e th e m on ito rs th e re an d th e y ar e abl e to te ll u s, an d th e y ’ re mo n it o rin g th e p ati e nt s ’ vi ta ls and the y ca n see th at . The y ’ ve al so go t the te m p erat u re p ro b e s, so th e y ar e b asi cal ly ta ki n g on th at re spon -si b ilit y an d w e ca n o nl y as sis t th e m at th at ti me , b u t on ce in re co ve ry it ’ s th e an es th e ti c, th e re cov e ry n u rs e s an d th e te am th at h av e to mo n it o r an d kee p th e p at ie n ts w ar m. (SS 5 ) 10 It is not a scrub scout nurses ‘ re sponsibility to manage the patients ‘ temperature That ’ s not part of m y role as a scrub/scout, I mean it is but its ’ not m y primar y sort of thing, that is usually anesthetics or the anesthetist and stuff, but .. . I mean I still ha ve a basic understanding of what w e need to do , lik e k eep them cov er ed and all of that sort of stuff fr om uni e ven though I ha ven ’ t had dire ct training in it. Does that mak e sense? (SS4) 1 ( Continued

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T able 1 (Continued). TDF domain Speci fi c belief Example quotations Fr equency out of 12 It is/is not m y role to manage the patients ‘ temperature My role is a bit of a, yo u know , you ha ve .. . pr etty primar y. I am dealing with m y patient face to face and so I feel as if I am responsible for their warmth and their car e until the y ar e handed ov er to the surgeon and the anesthetist in the theater . But I certain ly will tak e them on as m y responsibility fr om the time I pick them up until I get them into the anesthetic room and then into theater , so it is a primar y car er at that time. (SS5) Um, yeah I can sort of passively delegate that pr etty w ell, thank you. (S9) 6 Beliefs about capabilities It is easy/challenging to manage m y patient ’ s temperature* Y eah, it ’ s easy , doable, achie vable. (PN1) I w ould sa y it is easy for me to implement practices that w ould minimize h ypothermia. Ther e ar e times when during the pr ocedur e ther e is ve ry little that you can do and then you need to spend some time to impr ove it at the end of the surgical pr ocedur e. (A2) W ell, ther e ’ s certain surgical or cases that ar e more challenging than others for example pr olonged lapar oscopic cases can be ver y har d to k eep the patient ’ s temperatur e up and major plastics cases lik e tram fl aps. (A11) 12 My ability to manage the patients ‘ temperatur e effectiv ely is limited by factors be yond m y contr ol* W ell ther e ’ s, sometimes if I ’ m scrubbed or if I ’ m .. . sometimes if I ’ m not going to be able to .. . lik e I can ’ t .. . (SS4) Right, so , some things ar e easy , some things ar e dif fi cult. So , the things that I ha ve dir ect contr ol ov er ar e easy to do . So I can quite easily warm a patient in the induction ba y and I can warm a patient in theater , so , and I can, and in re cov er y too , if I suggest to the recover y nurse that w e need to warm this patient then the y will do it, ther e is no barrier ther e. The main .. . pr obably the only time I don ’ t ha ve much contr ol is in the pr eoperativ e ar ea wher e the nurses ar e admitting the patients and taking their obs and then letting them sit and wait for their surger y. (A11) 9 I do/do not feel con fi dent in m y ability to manage patient ’ s temperature* I w ouldn ’ t sa y I am an expert at it (monitoring, managing & pr e ve nting perioperativ e h ypothermia). (PN1) 2 Optimism W e ar e managing perioperativ e h ypothermia effectiv ely Most of the time w e ar e doing pr etty w ell and the staff, with scrub/scout, re cov er y and holding ba y, e ver yone, anesthetic .. . quite w ell. (AN3) I think as a department w e ’ re pr etty good, lik e a team. (SN4) 8 Beliefs about consequences If perioperativ e h ypothermia is not managed, this can re sult in adve rse health outcomes* Patient outcomes, poor patient outcomes, post op car e and their recover y (will happen if w e do not monitor , manage and pr e vent perioperativ e h ypothermia). (PN1) Adv erse outcomes, patient outcomes. It ’ s as simple as that. (CN7) .. . it contributes to all manner of adve rse patient outcomes ranging fr om altere d coagulation to impair ed w ound healing, patient discomfort, shive ring, acidosis, e ve ntually if you let people get cold enough, arrh ythmias and e ven death. (A2) 12 ( Continued

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T able 1 (Continued). TDF domain Speci fi c belief Example quotations Fr equency out of I/w e do not know the impact of our efforts in pr e venting perioperative h ypothermia* I don ’ t really ha ve an y, it is a bit har d in re cov er y because yo u don ’ t see them. I don ’ t know what the long-term consequences really ar e, but I w ould sa y I guess it w ould ha ve something to do with their long-term recover y, how the y recover . (PN1) I think just in general the management of h ypothermia is impr oving, in m y opinion, um, and that ma ybe .. . feedback to the staff w ould be helpful, yeah lik e if it was, I don ’ t know patients, lik e pr e-op , intra-op and post-op temperatur es w er e recor ded for a da y and then the y came back to a staff member and said he y your patients w er e re ally warm what did you do or your patients w er e re ally cold, that w ould help change and implement better practice. That ’ s about it. Y eah, because once the patients out of the theater you ver y rare ly ev er see them again so you ar e not awar e if the y ar e cold or if the y ’ ve had a D VT or when the y ’ ve gone home. So yeah w e ‘ re so isolated that I think acknowledgement of your care w ould help people I guess. (Pr ompt) I think that w ould apply to e ve ry one, lik e ev er y ar ea yeah, ma ybe not so much with the pediatrics but with adults and obstetrics I think it w ould be notew orth y. (AN6) 3 Reinfor cement A war eness of the adve rse outcomes associated with periopera-tive h ypothermia acts as an incentiv e to manage the condition. Data. I think, if you pr esent staff, especially w ell-educated staff, which w e should all be, her e, if you pr esent staff sa ying this is the data that sa ys if you k eep this patient ’ s temperature at this le ve l the outcomes this .. . his statistically signi fi cant outcomes ar e going to be this. For me, that ’ s what I w ould think is an incentiv e. (CN7) Or ma ybe feedback w ould be good. So , for example, w e alwa ys hear about cold patients but ma ybe if you hear about all the patients that ar e warm ma ybe that w ould be helpful, yeah, um, yeah that ’ s about all I can think of. (AN6) .. . some feedback in terms of, you know , how it is going ov er time and if it is getting better or w orse and I think that is really helpful for people. Whether you strictly incentivise it or not .. . is I think questionable, but just tr ying to k eep e ver yone in the team on boar d. (S10) 8 Goals P erioperative h ypothermia pr e ve ntion practices ar e (v er y) importan t Y eah w ell, I know I feel it ’ s .. . importan t and a high priority , that ’ s wh y I ha ve it ther e set up ready to go . (PN1) Oh, it ’ s pr obably on the top fi ve, ye p . (CF8) Um, yeah, it ’ s an important concept I think, it ’ s when w e um, particularly when w e ar e operating for long periods w e need to pa y attention to k eeping the patient normothermic, so ma ybe 37 degr ees or abov e, um, yep . (S9) 8 Other goals ar e mor e importan t than pr e venting perioperativ e h ypothermia .. . I guess one time which mak es it dif fi cult is in emergencies, yeah so lik e um, both in obstetrics and in adults lik e, the last thing you actually get to is the warming and I think that ’ s just in the hierar ch y of needs ye ah, and you ’ re pla ying catch up . (AN6) Y eah, I w ould ha ve said it gets a relativ ely low priority for most anesthetists and theater teams. Ther e ’ s is a couple of anesthetists her e who ar e really big about it but others who ar e less so and the rest of us ar e pr obably some wher e in the middle. (A2) 7 ( Continued

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T able 1 (Continued). TDF domain Speci fi c belief Example quotations Fr equency out of 12 Memor y, atten-tion, and decision pr ocesses My attention to perioperativ e h ypothermia pr e vention could sometimes be impr ov ed T o be honest, if an ything when it is re ally , really busy . Y eah, if you ’ ve got other issues going on lik e pain and nausea, that w ould kind of, I feel, tak es m y priority awa y fr om, yeah, looking at their temperatur e and managing that, so I guess, that w ould be it. (PN1) So I think it is a priority but ther e ar e so man y other things going on with a complex case that it ’ s easy to miss. (S9) 8 I re mind others to implement h ypothermia pr e ve ntion Sometimes pr etty good, sometimes really don ’ t, don ’ t ha ve an y per ception that the patient ma y be cold, or exposed or any thing lik e that, ye ah, and that ’ s alright, that ’ s just education as w ell, all w e need to do is just bring their attention to it, just sa y did you , you know , do you see this patient ’ s got a lot skin ther e w e ar e waiting for the scrub team to wash their hands, I think w e could cov er them up for a bit longer , k eep them, you know , it ’ s just particip ation, communication, and participation amongst the team members. I don ’ t think it ’ s an y particular barriers, it ’ s just education .. . thoughtfulness. (SN4) 4 I/others ha ve pr ocesses or rituals in place to remind me to implement practices to pr e vent or manage perioperative h ypothermia I ha ve m y tra y, m y bedside tra y, set up with m y thermometer closest to the patient with a pen and piece of paper re ady to go and that kind of triggers me to do it and recor d it straight awa y when the patient comes out. (PN1) Um, so I guess rituals w ould be fr om the start when I get the patient I alwa ys get them a warm blank et, I giv e it to them to hold, um, as w e walk down to the induction room, and then when w e ar e in the induction room I ‘ ll get them onto the tr olle y, the blank et goes on and then the dr essing gown goes ov er it and then for monitoring, I alwa ys put the temperatur e pr obe um, ther e ’ s a little um, tra y on the anesthetic machine wher e all the airwa y de vices ar e and I ha ve one underneath with the top blue par t showing so it ’ s lik e a trigger for me to see it to get it, yeah. (AN6) 7 Pa ying attention to k eeping the patient cov er ed is ver y importan t Ok, um, so , fi rst of all is k eeping the patient warm and cov er ed, um, not necessarily alwa ys by a warm blank et, lik e in the induction room, but just so the y don ’ t um, radiate the heat, then w e intraoperatively , yo u know , ha ve bair huggers, warm fl uids, um, for a lot of joints um if the bottom of the patient is exposed w e wrap their head in a blank et or a tow el, yeah, and using our monitoring as w ell obviously . (AN6) 2 En vir onmental context and re sour ces The availability/non-a vailability of resour ces affects m y practice in pr e ve nting h ypothermia* The resour ces ar e all ther e ready to go and readily available. (PN1) The y ar e .. . the y ar e available her e. W ell, I see ev er ything that is possible, ma ybe ther e ’ s something else that w e can be doing – I don ’ t know . But e ver ything that I know of, is available to us her e. (SN5) 11 ( Continued

(10)

T able 1 (Continued). TDF domain Speci fi c belief Example quotations F requency out of A vailability/non-a vailability of checklists and documentation affects m y ability to re cor d temperatur e and pr e vent h ypothermia If the y ’ re concerned about it the y should ha ve a .. . something on the pr e-op checklist, if the y want us to initiate something pr eoperativ ely .. .because that ’ s basically our one piece of paper pr e-op – and then during will ha ve to be up to the anesthetist, and then post-op , I think it ’ s w ell done but if ther e ’ s impr ov ement ther e then it should be identi fi ed and fi x ed on the PA CU post-op form. (CN7) Again, some guidelines as to how to manage that and then some sort of established monitoring pr ocess and then someone who owns that, tak es responsibility for that w ould be really helpful. (S10) 7 Contr ol of ambient temperature impacts upon our management of perioperativ e h ypothermia Fix the air con, mak e it mor e adjustable, which the y ar e doing now , but w e ha ve not seen the result of that yet. (AN3) W ell I guess as I eluded to befor e, the individual contr ol of operating theater temperature is unr eliable and m y understanding is that ’ s not limited to her e – that that ’ s a result of the wa y the buildings ar e engineer ed, but a smarte r building design with better ability to contr ol the temperatur e mor e pr ecisely w ould be useful par ticularly in a place that does pediatric anesthesia as w ell. Y es .. . can ’ t think of an y other en vir onmental .. . w e could just open the windows on a da y lik e toda y! Oh, that ’ s right – w e don ’ t ha ve windows. (A2) 6 The en vir onmental la yo ut and organization assists/impedes m y ability to pr ev ent perioperativ e h ypothermia So , intraoperatively and postoperativ ely ther e is good suppor t. Pr eoperativ ely I don ’ t think it is existing, and I think the pr oblem is that it is har d to come up with rock solid effort and space. Look her e it is, because lots of hospitals do their little pilots and you get differ ent results fr om differ ent hospitals, some sa y ya y and others sa y no . Because our la yout is not that easy , people just sit and watch morning TV , while the y wait. (CF8) 5 Ther e is a lack of communication in the w orkplace re gar ding perioperative h ypothermia I think generally people ar e pr etty good with it, I think it is just that ther e ’ s not a lot of communication about it. I think that ’ s the biggest thing. I don ’ t think it is necessarily ignor ed by an yone, it ’ s just that ther e ’ s not really a lot of communication .. . (SN4) 1 I ha ve concerns regardin g the accuracy of the temperature monitoring de vices that ar e available to us .. . temperature monitoring and w ould pr obably better in re cov er y if w e had monitors that monitor .. . thermometers that w er e accurate, ve ry inaccurate sometimes and the y call them random number generators fr om time to time, so that ’ s a little bit tricky . (SN5) 3 ( Continued

(11)

over the actions taken in the preceding stage that may result in patients in their care already having experienced temperature decline. For example, an anesthetic nursing staff participant noted that the practices of preoperative staff (including whether patients lost heat in the waiting

area) inﬂuenced whether the patient was hypothermic in

the anesthetic phase of care. The impact of surgical factors

that directly inﬂuence temperature decline and which may,

or may not, be controlled for were also highlighted, in particular by the anesthetic medical participants (Beliefs about capabilities). Nonetheless, and conversely, a sense of optimism prevailed in that participants believed the depart-ment was doing well in the prevention of perioperative hypothermia, and that colleagues were motivated to pre-vent the condition (Optimism).

The recognition that perioperative hypothermia would result in adverse patient outcomes was widespread across the participants, however anesthetic medical staff were

most able to speciﬁcally identify associated outcomes. It

was evident that some nursing participants understood that the condition was detrimental, yet were unable to

commu-nicate further as to the speciﬁc, adverse associated

out-comes. It was also expressed that both medical and nursing participants felt that the outcomes extended beyond the realm of care that they were directly associated with, and that they were not aware of the adverse outcomes as they did not see them in their phase of care (Beliefs about consequences). This also meant that they did not see the positive aspects of the preventative care that they may have enacted. It was felt that reporting of the adverse consequences associated with perioperative hypothermia would act as an incentive for healthcare professionals to

improve their preventative practices–as would reporting

of the positive outcomes that might arise from proactive preventative care (Reinforcement).

Although it was widely agreed that perioperative hypothermia prevention is important, it was also clear

that other goals were seen as more important in the“

hier-archy of needs” – acknowledging the acute nature of

surgical care – and, therefore, hypothermia prevention

practices can shift down the list of priorities within the perioperative department (Goals). Whilst it is important, all participant groups noted that other clinical issues can affect the attention that is paid to keeping patients warm and implementing temperature monitoring (Memory, Attention, and Decision Processes), acknowledging that their individual attention to prevention can sometimes be

T

able

1

(Continued).

TDF

domain

Speci

ﬁ

c

belief

Example

quotations

Fr

equency

out

of

12

Social

in

ﬂ

uence

Other

team

members

support/impede

m

y

temperature

man-agement

practices

Ther

e

is

some

resistance

fr

om

surgeons

to

some

warming

methods

so

some,

especially

orthopedic

surgeons,

the

y

w

orr

y

about

incr

easing

infection

rates

so

the

y

don

’

t

lik

e

using

a

de

vice

lik

e

the

W

arm

Cloud.

Most

surgeons

don

’

t

lik

e

us

turning

the

for

ced

air

warmers

on

befor

e

the

y

ha

ve

ﬁ

nished

pr

epping

and

draping

which

can

tak

e

a

long

time

and

the

pr

epping

is

one

of

the

things

that

can

mak

e

the

patient

cold

ve

ry

quickly

.

So

,

ther

e

’

s

a

couple

of

barriers

ther

e

,

but

otherwise

it

is

pr

etty

straight

forwar

d.

(A11)

So

,

ah,

I

guess

either

awar

eness

to

start

off

with,

I

think

it

’

s

a

team

effor

t,

so

you

know

a

lot

of

times

surgeons,

w

e

pr

obably

don

’

t

think

about

it

as

much

as

w

e

should

but

you

do

see

nursing

staff

a

lot

mor

e

active,

anesthetists

a

lot

mor

e

activ

e

in

that

part.

(S9)

Oh,

I

think

people

are

ver

y

suppor

tive

once

you

initiate

it

and

there

’

s

some

anesthetist

par

ticularly

advocative

of

preoper

ative

wa

rming

.

(CN7)

12

Abbre

viations:

D

VT

,

deep

vein

thr

ombosis;

PA

CU

,

P

ost-Anesthetic

Car

e

Unit;

TDF

,

Theor

etical

Domains

Netw

ork.

(12)

improved. The existence of individual rituals or routines to serve as a reminder to implement preventative practices (such as the application of a warming blanket, or monitor-ing of temperature) were reported, particularly by anes-thetic and PACU nurses. Some participants also felt they regularly reminded colleagues to enact practices to prevent heat loss, including reminders of the importance of keep-ing patients covered as much as possible.

All participants highlighted the impact that other team members had on either supporting or impeding their

peri-operative hypothermia prevention practices (Social

Inﬂuences). The assertion that most colleagues are

suppor-tive appears to align with the optimism expressed by some

participants, however others expressed a conﬂicting belief

that resistance to implementation of preventative practice (particularly warming) was experienced. Reluctance of surgeons in relation to application of forced air warming, particularly in the orthopedic speciality, was reported by

anesthetists, however not by surgeons themselves.

Nonetheless, the importance of social inﬂuence was

evi-dent across all stakeholder groups.

Domains reported as less relevant

Three domains were assessed as less relevant; intention; emotion; and behavioral regulation (see Table 2). Intention to implement perioperative hypothermia prevention prac-tices was evident in four of the 12 interviews, and in these

interviews individual intention to implement, as well as

the perception of team members’intention, was reported.

Across the multidisciplinary team, it was reported that strong emotions were not associated with perioperative hypothermia prevention, however one nursing participant expressed a strong motivation (Emotion). The perceived

need to regulate behavior was not identiﬁed across the

interviews (Behavioral Regulation): in those interviews where beliefs relevant to this domain were evident, a need for planning to implement prevention practices was expressed.

Mapping to COM-B model and

identi

ﬁ

cation of potential intervention

strategies

The strategies likely to improve the implementation of

perioperative hypothermia prevention identiﬁed via

map-ping to the COM-B model and BCTs are audit and

feed-back, reminders and prompts, education (including

information delivered by a“high status”healthcare

profes-sional), the use of an identiﬁed “champion” to drive

improvements, care pathways, and monthly agreed goal

setting (see Table S3). The restriction intervention label

has no corresponding BCT. The identiﬁed issues regarding

the accuracy of available temperature monitoring devices in the department appears to correspond to this category as

domain out of 12

Intention I/we intend to implement practices to prevent perio-perative hypothermia

Oh, it’s something I try and think about every time I anesthetize a patient. (A2)

4

Emotion I do not feel any strong emotion regarding prevention of perioperative hypothermia

Not really. I don’t have any emotion attached to that. (S9) 1

I feel positive towards using interventions to prevent perioperative hypothermia

Totally. Yeah, I am all for it. So, like my motivation is tops, yeah. But, I haven’t really done a proper formal sort of analysis but I think all staff would agree that it is an important thing and would be on top of that as well. (CF8)

1

Behavioral regulation

We need to monitor and plan to implement perio-perative hypothermia prevention practices

. . . I think we all need to be so much more mindful of positioning and you know, Bair Huggers and warmﬂuids and so forth. (S10)

4

If temperature management practice were standar-dized within the hospital, I would be more likely to manage perioperative hypothermia

If there was some sort of, same sort of thing applied, you know if it was like, when the patient comes in, make sure they have a warm blanket on during the procedure, make sure . . . I don’t know, if they have a temp probe catheter and all that sort of stuff, monitoring that like there was . . . which I mean, I guess . . . (SN4)

4

(13)

T

able

3

COM-B

model

and

TDF

domains:

suggested

inter

vention

strategies

to

impr

ov

e

perioperativ

e

h

ypothermia

pr

e

vention

TDF

domain

COM-B

Inter

ve

ntion

function

BCT

taxonom

y

Individual

BCT

Strategy

example

Knowledge

C

(Psychological)

Education

Goals

and

planning

Feedback

and

moni-toring Associations

●

Information

about

consequences

●

Feedback

on

beha

vior

and

outcome

of

beha

vior

●

Pr

ompts/cues

●

Self-monitoring

●

Audit

and

feedback

of

k

e

y

pr

e

vention

activities

(temperatur

monitoring,

warming

–

behavior

)

and

rates

of

h

ypothermia

(

outcomes

)

●

Reminders

of

pr

e

ve

ntion

activities

in

all

k

e

y

clinical

ar

computerized

reminders

Memor

y,

attention,

and

decision

pr

ocesses

C

(Psychological)

T

raining

Shaping

knowledge

●

Demonstration

of

beha

vior

●

Feedback

on

beha

vior

and

outcome

of

beha

vior

●

Self-monitoring

●

Beha

vioral

practice/rehearsal

●

Education:

when

to

monitor

;

how

to

monitor

;

when

and

to

warm;

how

to

document

●

Education:

scenarios

that

allow

for

practice

and

feedback

En

vir

onmental

re

structuring

Associations Antecedents

●

Adding

objects

to

the

en

vir

onment

●

Pr

ompts/cues

●

Restructuring

of

ph

ysical

en

vir

onment

●

Reminders

(see

abov

e)

●

Ensur

e

monitoring

is

visibly

obvious

with

re

minders

Enablement

Goals

and

planning

Feedback

and

moni-toring Antecedents

●

Social

suppor

t

(unspeci

ﬁ

ed

and/or

practical)

●

Goal-setting

(beha

vior

and/or

outcome)

●

Adding

objects

to

the

en

vir

onment

●

Pr

oblem-solving

●

Action

planning

●

Self-monitoring

of

beha

vior

●

Restructuring

of

ph

ysical

en

vir

onment

●

Re

vie

w

beha

vior

and

outcome

goal(s)

●

Identi

ﬁ

ed

champion

to

monitor

and

pr

ovide

encouragement

●

Monthly

agr

eed

goals

(based

on

audit

and

feedback)

●

Reminders

and

equipment

(see

abov

e)

●

Pr

ovide

h

ypothermia

pr

e

ve

ntion

pathwa

y

Skills

C

(Ph

ysical)

T

raining

Shaping

knowledge

Feedback

and

monitoring

●

Demonstration

of

beha

vior

●

Feedback

on

beha

vior

and

outcome

of

beha

vior

●

Self-monitoring

●

Beha

vioral

practice/rehearsal

●

Education

(see

abov

e)

●

Audit

and

feedback

(see

abov

e)

(

Continued

(14)

T

able

3

(Continued).

TDF

domain

COM-B

Inter

ve

ntion

function

BCT

taxonom

y

Individual

BCT

Strategy

example

Social/Pr

ofessional

Role

and

Identity

M(

re

ﬂ

ectiv

e)

Education

Shaping

knowledge

Feedback

and

●

Information

about

consequences

●

Feedback

on

beha

vior

and

outcome

of

beha

vior

●

Pr

ompts/cues

●

Self-monitoring

●

Mak

e

information

available

about

consequences

of

not

itoring,

warming,

and

outcomes

of

condition

●

Pr

ompts

(see

abov

e)

●

Audit

and

feedback

(see

abov

e)

P

ersuasion

Comparison

of

out-comes Natural

conse-quences Feedback

and

monitoring

●

Cr

edible

sour

ce

●

Information

about

social,

en

vir

onmental

and

health

consequences

●

Feedback

on

beha

vior

and

outcome

of

beha

vior

●“

High

status

”

pr

ofessional

to

pr

ovide

information/education

importance

of

pr

e

vention

●

Patients

’

perspectiv

e

of

condition

(and

consequences)

●

Audit

and

feedback

(see

abov

e)

Modeling

Comparison

of

beha

vior

●

Demonstration

of

beha

vior

●

Pr

ovide

demonstration

of

pr

e

vention

pathwa

y

(ie,

ﬁ

lm/poster)

Beliefs

about

capabilities

M(

re

ﬂ

ectiv

e)

Education

Shaping

knowledge

Natural

and

●

Information

about

consequences

●

Feedback

on

beha

vior

and

outcome

of

beha

vior

●

Pr

ompts/cues

●

Self-monitoring

●

Mak

e

information

available

about

consequences

of

not

itoring,

warming

and

outcomes

of

condition

(as

abov

e)

●

Pr

ompts

(see

abov

e)

●

Audit

and

feedback

(see

abov

e)

P

ersuasion

Comparison

of

out-comes Natural

and

monitoring

●

Cr

edible

sour

ce

●

Information

about

social,

en

vir

onmental,

and

health

consequences

●

Feedback

on

beha

vior

and

outcome

of

beha

vior

●

High

status

’

pr

ofessional

to

pr

ovide

information

(as

abov

●

Patients

’

perspectiv

e

of

condition

(and

consequences)

●

Audit

and

feedback

(see

abov

e)

Modeling

Comparison

of

beha

vior

●

Demonstration

of

beha

vior

●

Pr

ovide

demonstration

of

pr

e

vention

pathwa

y

(ie,

ﬁ

lm/poster)

Enablement

Social

support

Goals

and

planning

Antecedents Goals

and

planning

Feedback

and

monitoring

●

Social

suppor

t

(unspeci

ﬁ

ed

and/or

practical)

●

Goal-setting

(beha

vior

and/or

outcome)

●

Adding

objects

to

the

en

vir

onment

●

Pr

oblem-solving

●

Action

planning

●

Self-monitoring

of

beha

vior

●

Restructuring

of

ph

ysical

en

vir

onment

●

Re

vie

w

beha

vior

and

outcome

goal(s)

●

Identi

ﬁ

ed

champion

to

monitor

and

pr

ovide

encouragement

●

Monthly

agr

eed

goals

(based

on

audit

and

feedback)

●

Reminders

and

equipment

(see

abov

e)

●

Pr

ovide

h

ypothermia

pr

e

ve

ntion

pathwa

y

(

Continued

(15)

T

able

3

(Continued).

TDF

domain

COM-B

Inter

ve

ntion

function

BCT

taxonom

y

Individual

BCT

Strategy

example

Optimism

M

(r

e

ﬂ

ectiv

e)

Education

Shaping

knowledge

Feedback

and

●

Information

about

consequences

●

Feedback

on

beha

vior

and

outcome

of

beha

vior

●

Pr

ompts/cues

●

Self-monitoring

●

Mak

e

information

available

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abov

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●

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ompts

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abov

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ovide

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ﬁ

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(

Continued

(16)

T

able

3

(Continued).

TDF

domain

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ﬁ

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vir

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oblem-solving

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vior

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outcome

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●

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ﬁ

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to

monitor

and

pr

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agr

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on

audit

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feedback)

●

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equipment

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ovide

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ypothermia

pr

e

ve

ntion

pathwa

y

(

Continued