Running Head: PERIOPERATIVE IMPLEMENTATION An...

Running Head: PERIOPERATIVE IMPLEMENTATION

An Investigation of Evidence‐Based Clinical Practice Guideline

Implementation to Promote Perioperative Patient Normothermia

Brandon G. Bennett

Doctor of Nursing Practice Program Capstone

Simmons College

© 2012, Brandon G. Bennett

Simmons College Doctor of Nursing Practice Program Capstone Manuscript Approval Form

Name: Brandon G. Bennett Title of Project: An Investigation of Evidence‐Based Clinical Practice Guideline Implementation to Promote Perioperative Patient Normothermia Date: April 14, 2012 _________Capstone Manuscript is approved _________Capstone Manuscript is approved with the following revisions: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________Capstone Manuscript is not approved Committee Signatures: ____________________________________________________________________________________________________Rebecca Koeniger‐Donohue, PhD, APRN‐BC, WHNP‐BC, FAANP _____________________________________________________________________________________________________ Patricia Rissmiller, DNSc, PNP‐BC _____________________________________________________________________________________________________ Susan Letvak, PhD, RN

PERIOPERATIVE IMPLEMENTATION iii

Abstract

There is a lack of knowledge about perioperative registered nurses’ management of unplanned perioperative hypothermia and utilization of evidence‐based clinical practice guidelines EBCPGs . The focus of this practice inquiry is to examine knowledge translation and implementation of EBCPGs. Specifically, this study investigates guideline implementation for the prevention of unplanned perioperative hypothermia, identifies barriers to implementation, and examines staff attitudes about guideline implementation.

The study population consists of perioperative Association of Operating Room Nurses AORN® members working with adult patient populations. The study determined interventions that are used to manage perioperative thermal regulation and evaluated these measures to determine if they were consistent with the selected evidence‐based clinical practice guideline.

The study questions included: 1. What is the level of knowledge among perioperative nurses related to

EBCPGs for the prevention of unplanned perioperative hypothermia? 2. What are the barriers to perioperative nurses’ implementation of EBCPGs

related to management of perioperative normothermia? 3. What nursing interventions are used for thermal regulation and management

in the perioperative setting? 4. What is the relationship between reported interventions and an identified

EBCPG? The study used a descriptive, non‐experimental, exploratory survey design. The

data collection used an electronic web‐based questionnaire to capture information from nurses who have opportunity to recognize EBCPGs and provide practice‐based information on correlated interventions.

Study results indicated knowledge translation into practice across a group of perioperative registered nurses. Study findings also support implementation of EBCPGs intended to prevent unplanned perioperative hypothermia. Practices by a number of respondents indicate consistent behaviors of “use always” and a large number of utilized interventions. There does not appear to be a significant difference when evaluating educational preparation or job roles, though this was a highly educated and clinically experienced sample.

Further study of the concerns described related to BARRIERS to research implementation is recommended with a more heterogeneous sample who are not AORN members and potentially with different education and experience. Additional research incorporating patient outcomes is recommended based on this study’s findings.

PERIOPERATIVE IMPLEMENTATION iv

Acknowledgments

This project was possible due to the amazing collegial support of students, co‐workers, and a myriad of professionals. My journey in healthcare began in my earliest years with a National Science High School Student Foundation scholarship, coaching and mentoring by an academic‐neurosurgeon, and interactions with the entire surgical team at Indiana University‐Purdue University Hospital. Progressing through college and then through undergraduate nursing education, I continued a passion of helping and caring for others. I was honored by my undergraduate capstone elective section being in perioperative nursing and in the Operating Rooms at Rhode Island Hospital. It was an incredible opportunity and an honor to be a graduate student at Rush University College of Nursing.

The Association of Operating Room Nurses AORN recognized my academic

efforts in 1984 as the “first doctoral student to propose clinical research in perioperative nursing.” The AORN Nursing Research committee at the request of Linda Groah, CEO and Executive Director, reviewed this capstone proposal and subsequently authorized access to the entire AORN membership – an honor and privilege from a supportive organization and professional resource that I have appreciated for many years.

Lastly, the experiences of doctoral education at Simmons College have been foundational, while uplifting. Many discussion posts, papers, bibliographies, and academic encounters have helped me be confident that I have been amongst the “best of the best.” I thank and acknowledge the doctoral students and faculty at Simmons, particularly Rebecca Koeniger‐Donohue who guided me consistently and steadily as my advisor and committee chairperson. Susan Neary, Pat White, Alice Sapienza, Patricia Rissmiller, Susan Duty, and other faculty served as subject matter experts and provided academic guidance and stimulation throughout the program. Susan Letvak has contributed expert review and additional perspective on the project and this manuscript in its final reviews. Furthermore, as well as co‐workers and colleagues from the myriad of healthcare settings during these years, I thank the many patients and professionals with whom I have interacted. The journey has provided me with an amazing foundation for professional practice.

Dedication

To all humankind that I have opportunities to touch and serve, I quote Etienne de Grellet (1773-1855), “I shall pass this way but once; any good that I can do or any kindness I can show to any human being; let me do it now. Let me not defer nor neglect it, for I shall not pass this way again.”

To Sam with whom I have found endless possibilities of joy and love, I thank you for your consistent, persistent, and unfaltering love and support.

PERIOPERATIVE IMPLEMENTATION v

Table of Contents

Abstract ................................................................................................................................................................ iii

Acknowledgments ........................................................................................................................................... iv

Dedication ........................................................................................................................................................... iv

Table of Contents............................................................................................................................................... v

List of Figures ................................................................................................................................................. viii

List of Tables ................................................................................................................................................... viii

The Clinical Problem ..................................................................................................................................... 12

Description of the Problem ................................................................................................................... 12

Background .............................................................................................................................................. 13

Purpose of Study ........................................................................................................................................ 15

Research Questions ....................................................................................................................................... 15

Specific Aims of the Study .......................................................................................................................... 16

Significance of the Problem .............................................................................................................. 16

Policy Implications ............................................................................................................................... 17

Review of the Literature ............................................................................................................................. 19

Pathophysiology – Medical Science ............................................................................................... 21

Adverse Effects of Hypothermia ..................................................................................................... 22

Regulatory Activity ............................................................................................................................... 23

Nursing Knowledge and Science .................................................................................................... 24

Knowledge Translation ...................................................................................................................... 27

Nursing Interventions ............................................................................................................................. 28

Gaps in the Literature .............................................................................................................................. 30

PERIOPERATIVE IMPLEMENTATION vi

Conceptual Model ........................................................................................................................................... 31

Methods .............................................................................................................................................................. 33

Design ............................................................................................................................................................. 33

Description of the Sample ...................................................................................................................... 34

Human Subjects Protection .............................................................................................................. 34

Sampling Method and Recruitment Plan .................................................................................... 35

Data Collection ................................................................................................................................................ 36

Survey Instrument .................................................................................................................................... 36

Tool Validation ............................................................................................................................................ 39

Data Analysis ............................................................................................................................................... 41

NPQ Scoring ............................................................................................................................................. 41

Hooper’s Tool Scoring ......................................................................................................................... 43

Demographics ............................................................................................................................................. 43

Research Questions Analysis ................................................................................................................ 45

Research Findings ..................................................................................................................................... 48

Research Question #1 ......................................................................................................................... 48




Data Cleaning ............................................................................................................................................... 57

Qualitative Data Analysis ....................................................................................................................... 57

Qualitative Narrative Themes .......................................................................................................... 58

Discussion .......................................................................................................................................................... 59

PERIOPERATIVE IMPLEMENTATION vii

Limitations .................................................................................................................................................... 62

Conclusion ......................................................................................................................................................... 62

Recommendations for Future Research .......................................................................................... 64

Appendices ........................................................................................................................................................ 66

Appendix A Tables and Graphs ............................................................................................................ 66

Appendix B ASPAN Algorithms ........................................................................................................... 84

Appendix C Hooper Data Collection Tool ........................................................................................ 88

Appendix D Survey Questionnaire ..................................................................................................... 90

Appendix E Face Validity Questionnaire ....................................................................................... 103

Appendix F Content Analysis Checklist .......................................................................................... 107

Appendix G AORN Research Committee Support ...................................................................... 126

Appendix H Simmons College IRB Approval ............................................................................... 128

Appendix I AORN Approval to use Membership Database .................................................... 130

Appendix J AORN Informz.net Invitation Content ..................................................................... 132

Appendix K Demographics .................................................................................................................. 134

Appendix L BARRIERS Narrative Data ........................................................................................... 145

References ....................................................................................................................................................... 153

Bibliography ................................................................................................................................................... 166

PERIOPERATIVE IMPLEMENTATION viii

List of Figures

Figure 1 Conner's conceptual model for research‐utilization evaluation ............................ 31

Figure 2 Survey respondent’s Education by percentage ............................................................. 46

Figure 3 Survey respondents’ Role by percentage ......................................................................... 47

Figure 4 TIAB Scores by Education Group ......................................................................................... 48

Figure 5 TIAB Scores by Job Role Group ............................................................................................. 50

Figure 6 BARRIERS Means Scores by Factors .................................................................................. 52

Figure 7 M Frequency of Intervention ............................................................................................ 54

Figure 8 M Intervention Used ............................................................................................................. 55

Figure 9 M Number of Interventions Used per Patient based on EBCPG ........................ 56

List of Tables

Table 1 Cronbach's Alphas ........................................................................................................................ 41

Table 2 Stage of Adoption .......................................................................................................................... 43

Table A1 “What is your highest level of education degree ?” ................................................. 67

Table A2 “What is your current title role ?” ................................................................................... 67

Table A3 “Please indicate your gender.” ............................................................................................. 68

Table A4 “What is your age?” ................................................................................................................... 68

Table A5 Education Categories for Analysis...................................................................................... 68

Table A6 Role Categories for Analysis ................................................................................................. 69

Table A7 AORN Recommended Practice Use: Descriptive Statistics ...................................... 69

Table A8 AORN Recommended Practice Descriptive Statistics: Infrequently or

Frequently ......................................................................................................................................................... 69

Table A9 ASPAN Clinical Practice Guideline Use: Descriptive Statistics ............................... 70

PERIOPERATIVE IMPLEMENTATION ix

Table A10 ASPAN Clinical Practice Guidelines Descriptive Statistics: Infrequently or

Frequently ......................................................................................................................................................... 70

Table A11 TIAB Score ................................................................................................................................. 70

Table A12 TIAB Descriptives: Education ............................................................................................ 71

Table A13 Mann‐Whitney Analysis: Education ............................................................................... 71

Table A14 TIAB Descriptives: Role ....................................................................................................... 71

Table A15 Mann‐Whitney Analysis: Role ........................................................................................... 71

Table A16 BARRIERS: Descriptive Statistics ..................................................................................... 72

Table A17 Correlations: Factor 1 through Factor 4 ....................................................................... 72

Table A18 Descriptive Statistics: BARRIERS Factors ‐ Education ........................................... 73

Table A19 Box’s Test of Equality of Covariance Matrices ........................................................... 73

Table A20 Multivariate Tests: Factors to Education ..................................................................... 74

Table A21 Descriptive Statistics: BARRIERS to Role ..................................................................... 75

Table A22 Box’s Test of Equality of Covariance Matrices: Roles .............................................. 75

Table A23 Multivariate Tests: Factors to Role ................................................................................. 76

Table A24 ANOVA: Factor 1: Adopter by Role ................................................................................. 76

Table A25 Mean Adopter Score by Role .............................................................................................. 76

Table A26 ANOVA: Factor 2: Organization by Role ........................................................................ 77

Table A27 Mean Organization Score by Role .................................................................................... 77

Table A28 ANOVA: Factor 3: Innovation by Role ............................................................................ 77

Table A29 Mean Innovation Score by Role ........................................................................................ 78

Table A30 ANOVA: Factor 4: Communication by Role .................................................................. 78

Table A31 Mean Communication Score by Role .............................................................................. 78

PERIOPERATIVE IMPLEMENTATION x

Table A32 Hooper’s Intervention Descriptive Statistics .............................................................. 79

Table A33 Descriptive Statistics: All Responses to Hooper’s Tool .......................................... 79

Table A34 Correlations Hooper with AORN Recommended Practice .................................... 79

Table A35 Correlations Hooper with ASPAN Clinical Practice Guideline ............................ 80

Table A36 Correlations Hooper with Other Evidence Based Clinical Practice Guideline

................................................................................................................................................................................ 80

Table A37 Number of Interventions Used by EBCPG: Descriptive Statistics ...................... 80

Table A38 Interventions: Descriptive Statistics .............................................................................. 81

Table A39 Number of Interventions Reported per respondent : Descriptive Statistics

................................................................................................................................................................................ 81

Table A40 Number of Interventions Identified ................................................................................ 81

Table A41 Number of Interventions Reported per respondent ........................................... 82

Table A42 Correlation: Number of Interventions to AORN Recommended Practice ...... 82

Table A43 Correlation: Number of Interventions to ASPAN Clinical Practice Guideline82

Table A44 Qualitative Categories: EBCPG .......................................................................................... 83

Table A45 Comments: Distribution by coded categories ............................................................ 83

Table K1 In what type of setting do you primarily work? ......................................................... 135

Table K2 If you work in a hospital setting which term best describes your primary

place of employment .................................................................................................................................. 135

Table K3 Which term best describes the ownership of your primary place of

employment? .................................................................................................................................................. 135

Table K4 How would you describe the location of your workplace? ................................... 136

Table K5 In what region of the country are you currently employed? select one ...... 136

PERIOPERATIVE IMPLEMENTATION xi

Table K6 If not currently employed in the United States, please select the country

where you are employed. select one ............................................................................................... 136

Table K7 What is the total number of ORs in your facility? ...................................................... 137

Table K8 What is your current title?................................................................................................... 138

Table K9 What percentage of your work week are you providing direct patient care?

.............................................................................................................................................................................. 138

Table K10 Which of the following areas are you responsible for or in which do you

PRIMARILY work? select all that apply .......................................................................................... 139

Table K11 Please indicate your affiliation with your primary workplace. ........................ 139

Table K12 What is your highest level of education? .................................................................... 140

Table K13 How many years has it been since you achieved the level of education

mentioned above? ........................................................................................................................................ 140

Table K14 Which of the following certifications do you have? select all that apply .. 141

Table K15 How many years have you been employed as a Perioperative Nurse? ......... 142

Table K16 What shift do you usually work? .................................................................................... 143

Table K17 How many years have you been an AORN member? ............................................ 144

Table K18 Please indicate your gender. ............................................................................................ 144

Table K19 What is your age? .................................................................................................................. 144

PERIOPERATIVE IMPLEMENTATION 12

The Clinical Problem

Description of the Problem

Inadvertent perioperative hypothermia IPH is a common patient problem in

perioperative clinical settings as described by a number of researchers over the past 20

years Frank et al., 1992; Karalapillai et al., 2009; Kurz, Sessler, & Lenhardt, 1996;

Sessler, 2001, 2008; Wagner, 2010 . Inadvertent perioperative hypothermia is defined

as unplanned hypothermia that occurs as a consequence of treatment that promotes

heat loss e.g., application of solutions to large portions of unprotected skin, exposure of

major organs and cavities, air currents, and anesthesia during the perioperative

continuum of care Wagner, 2006 . Inadvertent perioperative hypothermia is currently

described as unplanned perioperative hypothermia UPH Hooper, 2010 .

There is a wide range of reported occurrences with research reporting from

17% to 90% of adult patients experience unplanned perioperative hypothermia.

Fallacaro et al. 1986 stated that between 80% and 90% of patients studied have

decreases in core temperature; Hegarty et al. 2009 stated that between 60% and 90%

of perioperative patients become hypothermic; and Lynch, Dixon, and Leary 2010

stated between 50% and 90% of perioperative patients become hypothermic. Despite

the seemingly high prevalence of perioperative hypothermia and the nearly

unavoidable physiologic causes attributed to anesthesia, unplanned perioperative

hypothermia is controllable Sessler, 2001, 2008; Wagner, 2006 .

A number of professional healthcare organizations have identified the increased

risk to patients when unplanned perioperative hypothermia is not adequately managed.

The American Society of Perianesthesia Nurses ASPAN , the Association of


periOperative Registered Nurses AORN , the American Society of Anesthesiologists

ASA , and the American Association of Nurse Anesthetists AANA have developed and

disseminated policy, recommended practices, and EBCPGs. Even though these

professional organizations have developed and disseminated EBCPGs or recommended

practices RP AORN, 1988, 2009, 2010a, 2012; Hooper et al., 2009, 2010 the problem

of hypothermia continues and inconsistent understanding of implementation persists.

Several sources Hooper, 2006; Hooper et al, 2009; NICE, 2008 have noted that

guidelines are not consistently implemented in practice. Hooper 2006 suggested that

further research by a number of guideline‐related and professional task forces have

identified areas needed to further the translation of EBCPGs into practice.

This study investigated: the level of knowledge among perioperative nurses

related to EBCPGs for the prevention of unplanned perioperative hypothermia, barriers

to perioperative nurses’ implementation of EBCPGs related to management of

perioperative normothermia, nursing interventions used for thermal regulation and

management in the perioperative setting, and the relationship between reported

interventions and an identified EBCPG.

Background

The evolution of perioperative practice guidelines and standards was first noted

in 1988 when AORN included standards related to patient temperature in its

publication of “Proposed Recommended Practices: Safe Care and Identification of

Potential Hazards in the OR Environment” AORN, 1988 . In February 1998 the

American Society of PeriAnesthesia Nurses ASPAN hosted the first Consensus

Conference on Perioperative Normothermia which resulted in the definition of


hypothermia and normothermia and the formation of a panel of experts who published

the first peer reviewed guideline in 2001 ASPAN, 2001; Jeran, 2001 . Beyea 2002

noted that the elements of the guideline were incorporated into AORN’s Perioperative

Nursing Data Set PNDS to facilitate and document intraoperative perioperative

nursing care. The clear goal for perioperative nurses to ensure perioperative

normothermia for patients was clarified by both definition and nursing practice

expectations in the early versions of Standards, Recommended Practices and Guidelines

and PNDS Beyea, 2002 . Continued adverse outcomes and increased evidence,

however, led to the AORN publication “Recommended Practices for the Prevention of

Unplanned Perioperative Hypothermia” AORN, 2010a which updated the previous

version.

There is a paucity of studies documenting aspects of implementation of clinical

practice guidelines for the prevention of unplanned perioperative hypothermia.

Further, there is limited research on the factors that influence either successful

implementation, barriers to implementation, or related practice changes in the

perioperative setting. Wagner 2010 suggested implementation barriers might be

grouped into the following categories: a available resources – devices and personnel;

b local services, policies and protocols; c circumstances and wishes of the patient

and surgical team members; d clinical experience of the practitioner; and e

knowledge of more recent research findings.

V. D. Hooper personal communication, December 22, 2010 corroborated that

despite EBCPGs being disseminated through the Journal of PeriAnesthesia Nursing i.e.,

ASPAN’s journal , presentations at Association conferences, and other means,


significant opportunities remain to improve understanding of barriers to successful

implementation.

Purpose of Study

The purpose of this practice inquiry study was to determine implementation

frequency rates, as well as barriers to implementation of EBCPGs for the prevention of

perioperative hypothermia. The study population included perioperative registered

nurses who were members of the AORN and who were working with adult patient

populations. The interventions used to manage perioperative thermal regulation were

identified and evaluated to determine if these measures were consistent with the

selected EBCPG. This study analyzes perioperative nurses’ responses related to

implementation of EBCPGs in the practice setting.

This study’s focus was to evaluate nursing staff implementation of at least one of

the following recognized EBCPGs:

AORN Recommended Practice on the Prevention of Inadvertent Perioperative

Hypothermia AORN, 2010a ,

Evidence‐Based Clinical Practice Guideline CPG for the Promotion of

Perioperative Normothermia: Second Edition Hooper et al., 2010 , and

Clinical Practice Guideline: Management of Inadvertent Perioperative

Hypothermia in Adults NICE, 2008 .

Research Questions

The study questions included:

1. What is the level of knowledge among perioperative nurses related to EBCPGs

for the prevention of unplanned perioperative hypothermia?


2. What are the barriers to perioperative nurses’ implementation of EBCPGs

related to management of perioperative normothermia?

3. What nursing interventions are used for thermal regulation and management in

the perioperative setting?

4. What is the relationship between reported interventions and identified EBCPGs?

Specific Aims of the Study

This clinical inquiry study specifically determined how knowledge was

translated into perioperative nursing practice by determining the level of knowledge

among perioperative nurses as it related to the use of EBCPGs for the management of

unplanned perioperative hypothermia. In addition, this study identified barriers to the

implementation of EBCPGs in order to inform future work with implementation

strategies. An assessment of the relationship between various nursing interventions

with published EBCPGs was done to support and improve understanding of the

translation of evidence‐based knowledge into practice.

Significance of the Problem

Advanced practice registered nurses APRNs are leaders in the synthesis and

rapid translation of a wide array of knowledge from the sciences into the rigorous

practice of patient care DeBourgh, 2001 . Implementation of evidence‐based care

through research‐based clinical practice guidelines is a key aspect of advanced practice

nursing. The impact on patients, families, and organizations is extensive and the need

for consistent success in thermal management is an ongoing quality initiative that

requires the advanced skills of practicing nursing experts IOM, 2011; U.S. Department

of Health and Human Services, 2010a .


The need to implement EBCPGs is well understood and is addressed by

organizations e.g., AORN, ASPAN, and NICE that have developed and disseminated

EBCPGs AORN, 2012; Hooper et al., 2009, 2010; NICE, 2008 . However, the difficulties

of translating evidence into practice, as well as various other barriers to

implementation, continue to delay broad‐scale adoption CIHR, 2005 . Although the

science of hypothermia is well documented, translation of evidence‐based practice into

perioperative nursing practice has not been consistently accomplished.

Implementing EBCPGs in perioperative environments requires leadership,

vision, knowledge, and skill to support and ensure that the necessary culture change is

initiated. Addressing the need of nurses to move through change requires a leader with

preparation in systems and organizational practice. The ability to project and attain

improvement in health outcomes as well as improved quality and patient safety is also

essential. Furthermore, Kitson 2000, p. 459 suggested that the ability of a team to

understand “what to do, how to do it, and who should do it” directly affects the

outcomes of evidence‐based practice. The sophistication of DNPs’ academic

preparation enables them to assess, identify, communicate, and propose system

changes needed to impact systems and patient outcomes AACN, 2006 .

Policy Implications

Although there are several prominent national organizations that have

developed EBCPGs there continues to be a lack of consistent implementation of these

EBCPGs Holtzclaw, 2008 . Each organization has begun significant, yet, essentially

passive dissemination of these guidelines. There continues to be limited understanding

of local policy development or enforcement Wagner, 2010 . The significant


consequence of hypothermia to patients continues to necessitate focus and regulatory

monitoring. This is demonstrated through the progression of regulatory monitors from

the Surgical Infection Project SIP into the “NQF‐endorsed voluntary consensus

standards for hospital care: Measure information form SCIP‐Inf‐10” U.S. Department of

Health and Human Services, 2010a . Current requirements include mandatory

reporting of all inpatient surgical patients who have an anesthetic that continues for

60 minutes or longer.

Health care reform, through the Patient Protection and Affordable Care Act of

2010, targets improving quality and efficiency, and, suggests that checklists will be a

requirement to ensure adherence to EBCPGs. Current practices do not include patient

temperature findings as a component of the “universal protocol” or other “time‐out”

communication; however, as checklists are increasingly required, the patient’s

temperature is anticipated to be included.

In addition, there may be a future emphasis through pay‐for‐performance on

health outcomes and patient care results. Current regulatory requirements already

require reporting of patients’ perioperative temperature findings. Although it is

unclear what elements will be included in pay‐for‐performance measures, thermal

regulation would be a reasonable expectation. Paradis, Wood, and Cramer 2009

suggest that inclusion of quality and safety measures based on evidence will be a

measure for transformed healthcare systems that will be measured in the percentage of

compliance with implementation of EBCPGs within perioperative settings.


Review of the Literature

The literature review was conducted using CINHAL® and MEDLINE® as the

primary online search engines. Additional search was completed using specialty

organization journals: a AANA Journal from the American Association of Nurse

Anesthetists AANA , b Anesthesiology from the American Society of

Anesthesiologists ASA , c AORN Journal from the Association of PeriOperative

Registered Nurses AORN , d Journal of PeriAnesthesia Nursing from the American

Society of PeriAnesthesia Nurses ASPAN , and e Journal of the American College of

Surgeons from the American College of Surgeons ACS . The keywords or search words

included singularly and in combination were as follows: a clinical practice guidelines,

b core temperature, c cutaneous warming, d evidence‐based practice, e forced

air warming, f hypothermia, g knowledge translation, h morbidity,

i normothermia, j perioperative, k surgical care improvement, l temperature

regulation, m thermal comfort, and n warming.

Searches were restricted to peer reviewed journals, although inclusion of

specialty organizations’ journals required some exceptions since some of these are not

peer reviewed yet they serve as a valuable source of specialty practice information.

More than 100 articles were reviewed and nearly 95 articles were included, ranging in

publication dates from 1971 to 2011. The excluded articles addressed “intended” or

“therapeutic” hypothermia in addition to those involving pediatric populations

Galante, 2007 .

Findings using these searches were supplemented with additional materials

identified through judicious review of authors’ references. For example, Holtzclaw’s


review 2008 included 236 references, many of which were identified through

separate and independent searches in preparing this study. Hooper et al. 2009, 2010

included 151 reference sources and Sudsawad 2007 contributed an additional 78

references. A limited comparison of available research was done using additional

online media including Google Scholar™ and Wikipedia. Critical review of each of these

articles was performed prior to the article being included in this study.

The reviewed studies represented a variety of professional sources and

researcher skills. The physiologic cause and effect of unplanned perioperative

hypothermia yielded the focus in non‐nursing studies. The majority of these

researchers were from the academic and clinical practice of anesthesiology. Other

medical contributions supported physiology related to both environmental exposure

and induced physiologic changes through anesthetic interventions. Reviewed studies of

knowledge translation were from several sources and incorporated literature

developed internationally.

After reviewing these various articles, findings were categorized into several

groupings. These are a pathophysiology ‐ medical science, which include studies

predominantly related to pathophysiology; b regulatory, which include policy and

national perspectives and regulatory reporting expectations i.e., the Surgical Infection

Project SIP or the Surgical Care Improvement Project SCIP ; c nursing knowledge

and science including evidence‐based practice and clinical practice guidelines;

d knowledge translation; and e others. All studies addressed the clinical problem of

unplanned perioperative hypothermia. Some studies specifically related to the

problems of knowledge translation and EBCPG implementation. All of the reviewed


materials contributed to both broadening and enriching the researcher’s understanding

of the clinical problem of unplanned perioperative hypothermia and the problem of

implementing EBCPGs.

Pathophysiology – Medical Science

Perioperative hypothermia results in vasoconstriction at the dermal level.

This, in conjunction with reduced blood flow to the surgical site, lowers tissue oxygen

tension and impairs the immune function of neutrophils. Mild hypothermia, defined as

only 1 to 2 °C below normal in a wide range of patient populations, has been associated

with adverse consequences in randomized clinical trials. The perioperative patient’s

ability to maintain thermal regulation is affected by anesthetic interventions including

both general and regional or neuroaxial anesthetics Fallacaro, Fallacaro, & Radel,

1986; Fiedler, 2001; Galvão, Marck, Sawada, & Clark, 2009 .

Although the mechanisms are different, nearly all patients who receive

anesthesia experience core‐to‐peripheral heat redistribution. A variety of anesthetic

agents and the various methods through which they are administered are well

documented as contributing to hypothermia Bremmelgaard et al., 1989; Hofer et al.,

2005; Johansson, Lisander, & Ivarsson, 1999; Kurz, Goll, Marker & Greher, 1998; Kurz,

Sessler, & Lenhardt, 1996; Kurz et al., 1995; Lenhardt et al., 1997; Nesher et al., 2003;

Schmied, Kurz, Sessler, Kozek, & Reiter, 1996; Widman, Hammarqvist, & Selldén, 2002;

Winkler et al., 2000 . A few medications have been identified that can modify, mitigate,

limit, or treat the hypothermic event Frank et al., 1992; Leslie, Sessler, Bjorksten, &

Moayeri, 1995; Şahin & Aypar, 2002 .


The combination of environmental exposure and anesthetic administration is a

consistent, significant, and unavoidable cause of the shift of temperature from core‐to‐

peripheral tissue. The decrease in patient core or near‐core temperature can be more

significant with a exposure of body cavities e.g., thoracic and abdominal ,

b increased skin surface area, c and blood loss Fallacaro et al., 1986; Galvão et al.,

2009; Kurz, Sessler, & Lenhardt, 1996; Matsukawa et al., 1995; Roe, 1971 . This

decrease in temperature occurs in many patients over the first 30 minutes of anesthesia

administration De Witte & Sessler, 2002; Sessler, 2000, 2001, 2008 .

Adverse Effects of Hypothermia

Mild hypothermia has been associated in randomized trials with adverse

consequences. These include a prolonged drug action, b delayed recovery phase

and hospital discharge Kurz, Sessler, & Lenhardt, 1996; Lenhardt et al., 1997; Leslie,

Sessler, Bjorksten, & Moayeri, 1995 , c post‐anesthetic shivering and associated

thermal discomfort Kurz et al., 1995 , d increased susceptibility to infection

Bremmelgaard et al., 1989; Kurz, Sessler, & Lenhardt, 1996 , e impaired coagulation

and increased transfusion requirements Hofer et al., 2005; Johansson, Lisander, &

Ivarsson, 1999; Nesher et al., 2003; Schmied, Kurz, Sessler, Kozek, & Reiter, 1996;

Widman, Hammarqvist, & Selldén, 2002; Winkler et al., 2000 , and f cardiovascular

stress and cardiac complications Frank, Fleisher, et al., 1995; Frank, Higgins, et al.,

1995 .

The American Society of Anesthesiologists ASA includes research‐supported

information in their current quality initiatives education ASA, 2010 . A meta‐analysis

by Mahoney and Odom 1999 documented the correlation of outcomes and associated


costs measured in time and material expenses dollars for extended patient

hospitalizations. Wagner 2010 noted that negative impact on patient care extends

into organizational efficiency and expenses. Unplanned perioperative hypothermia has

led to involvement by national organizations and federal regulatory agencies. For

example, the U.S. Department of Health and Human Services 2010a tied successful

management of perioperative patients’ temperature regulation to quality and financial

reimbursement.

Regulatory Activity

Regulatory agencies responded to a better understanding of the clinical impact

of hypothermia on healthcare in both resources and finances by adding thermal

regulation as a reporting category to the measures for the Surgical Care Improvement

Project SCIP , which became effective in October of 2010 U.S. Department of Health

and Human Services, 2010a . SCIP’s aim is to reduce surgical complications and is an

extension of a prior initiative supported by the Centers for Medicare and Medicaid

Services CMS called the Surgical Infection Prevention Project SIPP . SCIP is

sponsored by the CMS in collaboration with the American Hospital Association AHA ,

Centers for Disease Control and Prevention CDC , Institute for Healthcare

Improvement IHI , Joint Commission on Accreditation of Healthcare Organizations

JCAHO , and others. CMS reporting criteria applied in 2010 includes all adult patients

who receive inpatient‐based surgical care with an intraoperative time of 60 minutes or

greater and who achieve a near‐core temperature measurement of 36 °C within 15

minutes of discontinuing anesthetic intervention or within 30 minutes after arrival in

postoperative care U.S. Department of Health and Human Services, 2010a .


Nursing Knowledge and Science

There are a variety of studies of nursing and medical interventions that are

intended to minimize or correct perioperative hypothermia Alfonsi, Nourredine,

Adam, Chauvin &Sessler, 2003; Bräuer et al., 2002; Galvão et al., 2009; Hamza et al,

2005; Janicki et al., 2002; Kadam, Moyes & Moran, 2009; Kurz et al., 1998; Lindwall,

Svensson, Söderström & Blomqvist, 1998; Lynch, Dixon, & Leary, 2010; Motamed et al.,

2000; Serour, Weissenberg, Boaz, Ezri, & Gorenstein, 2002; Sheng et al., 2002; Wagner,

Smith & Quan, 2010 . Holtzclaw 2008 provided an extensive analysis of the nursing

and medical management of accidental and unplanned hypothermia, concluding that

perioperative hypothermia can be addressed with a variety of nursing interventions.

Although several of these studies have strong recommendations, others do not have

conclusive findings.

Timing of the active warming intervention as it relates to the preoperative,

intraoperative, and postoperative phases of care is a developing research area Hooper

et al., 2009, 2010; Wagner, 2006, 2010 . A medical management analysis Buhre &

Rossaint, 2003 concluded that patients should be actively warmed before, during, and

after surgery to reduce negative outcomes. Information related to preoperative

warming as a preventive measure prior to patient intraoperative exposure is now

incorporated in many of the EBCPGs AORN, 2010a, 2012; Hooper et al., 2010; NICE,

2008 .

Nursing knowledge and scientific studies have been utilized to develop EBCPGs

that have been disseminated to support nursing professionals providing care for

patients who experience unplanned perioperative hypothermia AORN, 2010a, 2012;


Ferguson, 2008; Hooper et al., 2009, 2010; NICE, 2008 . These guidelines have been

developed by expert committees. Most guidelines have undergone several revisions

and are presented as strong EBCPGs.

Interprofessional leadership is demonstrated in the diverse representation in

the collaboration, development, and review of each of these EBCPGs. Educational

products incorporate the key objectives of maintaining perioperative normothermia by

a identifying the physiological aspects of normothermia, b recognition of patient

risk including surgical conditions, c identifying patient temperature measurement

methodologies, and d identifying preventive and corrective nursing interventions.

Each of the professional organizations that has created and disseminated

evidence‐based guidelines has a documented methodology to ensure consistent and

timely review and necessary revisions of the practice guidelines. ASPAN and AORN

publish their respective review cycles and provide draft documents for member and

public comment, thereby inviting and encouraging a broad base of review and

participation. Input from a variety of professionals contributes to the strength of the

science of these studies and guidelines.

In 2010, and again in 2012, the AORN updated the Recommended Practice for

the Prevention of Unplanned Perioperative Hypothermia AORN, 2010a, 2012 , which

was first published in 1988, as elements of the safe care guideline. AORN supports

nursing education on this content by offering a learning module: “Prevention of

Unplanned Perioperative Hypothermia” AORN, 2010b . Although AORN has taken a

leadership role in EBCPG development for perioperative patients, several other

organizations have also contributed to the development of EBCPGs.


For example, the Ontario PeriAnesthesia Nurses Association posted a Clinical

Practice Guideline: Thermoregulation Ferguson, 2008 which was developed as one of

the topics of concern identified by the Canadian Patient Safety Institute and part of the

“Safer Healthcare Now!” campaign. This guideline is similar to the AORN guideline but

has fewer references.

The American Society of PeriAnesthesia Nurses’ ASPAN EBCPG Hooper et al.,

2009, 2010 was developed by a strategic work team who refined the previous

guideline to include specific recommendations for problem prioritization, evaluation of

quality of evidence and strength, and development of quality ranking for practice

recommendations. Hooper et al. 2009 used a modified scale based on the American

College of Cardiology/American Heart Association ACC/AHA classifications to

delineate these rankings. This EBCPG provides ranking for the evidence upon which

the recommendations were created, rankings for each recommended practice guideline,

and rankings for each recommended intervention formatted as algorithms. There are

separate algorithms for preoperative, intraoperative, and postoperative phases of care

that include research‐based recommendations and a broad spectrum of commonly

available interventions Appendix B Figures 1, 2 and 3 .

In the United Kingdom, the National Institute for Health and Clinical Excellence

NICE formulated an exhaustive clinical guideline NICE, 2008 . “Clinical Practice

Guideline: Management of Inadvertent Perioperative Hypothermia in Adults” is an

evidence‐based guideline with supporting documentation of the need for improved care

and outcomes focused on ensuring normothermia in the perioperative patient

population.


Knowledge Translation

Knowledge translation KT is the scientific study of methods for closing the

knowledge‐to‐practice gap and the barriers and facilitators in this process. The

Canadian Institutes for Health Research CIHR website defines KT as “the exchange,

synthesis and ethically‐sound application of knowledge within a complex system of

interactions among researchers and users to accelerate the capture of the benefits of

research … through improved health, more effective services and products, and a

strengthened health care system” CIHR, 2005 .

Other definitions of KT have been developed. For example, in 2004 the

Knowledge Translation Program, Faculty of Medicine, University of Toronto 2004 ,

adapted the evolving CIHR definition of knowledge translation as "the effective and

timely incorporation of evidence‐based information into the practices of health

professionals in such a way as to effect optimal health care outcomes and maximize the

potential of the health system.” The World Health Organization 2005 also adapted

the CIHR’s definition and defined KT as "the synthesis, exchange, and application of

knowledge by relevant stakeholders to accelerate the benefits of global and local

innovation in strengthening health systems and improving peoples’ health."

There is limited and subtle difference recognized between the definitions of

Knowledge Translation and Research Utilization. This capstone study employs the

Canadian definition of knowledge translation as it relates more closely with

translational research.


Nursing Interventions

Available EBCPGs and current studies Holtzclaw, 2008; Wagner, 2010 do not

suggest that any single intervention is successful in preventing unplanned

perioperative hypothermia. Galvão et al. 2009 performed a systematic review of

nursing interventions that can be used to prevent hypothermia in the surgical patient

population and concluded that there was moderate evidence to support forced‐air

warming and carbon‐fiber reflective blankets. The most common patient intervention

continues to be forced‐air warming Holtzclaw, 2008 . Forced‐air warming is a therapy

provided by a temperature management unit where heated air is used to warm patients

through convection. The warming unit draws ambient room air through a filter and

warms the air to a specified temperature. The warmed air is delivered through a

flexible hose to a blanket or gown NICE, 2008 .

The carbon‐fiber reflective blanket conserves temperature due to the reflective

qualities of the tightly woven fabric, which is further enhanced when the fabric contains

very fine carbon fiber filaments. The inert nature of the tightly woven carbon fibers

creates a heat‐reflective and heat‐tolerant barrier that serves as a natural reflective

barrier to prevent patient conductive heat loss.

Galvão et al. 2009 also suggested that circulating water garments are more

effective at maintaining intraoperative temperature. The circulating water garment is

an active patient warming device which conducts heat to the front and/or back of the

body, and, by design, has better interface with body surfaces than traditional water

mattresses NICE, 2008 .


Additional measures to better control environmental impact on thermal

regulation have been studied and include a increasing ambient temperature in the

operative suite, b adjusting air exchanges and air flow patterns within the suite e.g.,

decreasing use of laminar flow ventilation systems , and c monitoring relative

humidity in the operative suite. These studies address the relative comfort of the

perioperative team members by ensuring that temperature management of the patient

becomes the priority over relative comfort of the surgical team Fallacaro et al., 1986 .

Long‐standing recommendations for environmental conditions, including air

exchanges, temperature, and relative humidity Fogg, D., Parker, N., & Shevlin, D., 2002

are being questioned as the impact on patient thermal regulation and outcomes are

better understood.

Perioperative nurses are responsible for advocating for patient outcomes, safety,

and quality of care. Although many interventions that address thermal management of

the perioperative patient would appear to be specifically managed by perioperative

nurses, nurses in perioperative settings must work collaboratively with anesthesia and

surgeons to ensure that the surgical field, patient positioning, and other safety aspects

of care are addressed. EBCPGs AORN, 2010a, 2012; Hooper et al., 2010; NICE, 2008

are available to guide the selection of the thermal regulation intervention, application of

the intervention, and adjustment of these devices during the intraoperative phase of

care.

Lynch et al. 2010 described a quality improvement project conducted at Riddle

Memorial Hospital, Media, Pennsylvania that evaluated a number of perioperative

warming interventions in an effort to improve quality and to change nursing practice.


Lynch et al. stated the project’s goals to be “ to achieve optimal results in patient

temperatures, meet governing regulatory agency requirements for patient safety

temperature , and minimize patient risks” 2010, p. 553 . The study described the use

of EBCPGs published by AORN 2010a for intraoperative care planning and the use of

guidelines published by ASPAN Hooper et al., 2009 for preoperative and

postoperative care. Although the study concluded that there are usable interventions

that successfully achieved desired outcomes, there is no discussion related to

implementation of change in nursing practice.

Gaps in the Literature

The literature reviewed presents comprehensive research findings related to the

cause and effect of unplanned perioperative hypothermia; EBCPGs that support

assessment, intervention and evaluation of the perioperative patient population; and

recommendations for a variety of thermal management interventions. Gaps in the

literature continue to focus on dissemination of the evidence‐based findings or

translation of research into practice. This gap is identified in several different studies

and clearly described by Hooper: “ The process for measuring compliance with and

adoption of the CPG for the Prevention of Perioperative Hypothermia has yet to be

developed” 2006, p. 177 . Hooper 2006 concluded that the extent of adoption of the

ASPAN clinical practice guideline needed further study. Hooper suggested a variety of

study approaches, including the impact of various interventions on patient outcomes,

the impact of phase‐specific i.e., intraoperative interventions on patient outcomes,

and the impact of staff education on implementation of each practice guideline. In

addition, further refinement and expansion of Hooper’s Medical Record Abstraction


MRA tool 2006 see Appendix C and a self‐report survey is reported as ongoing

and is associated with continued review and revision of the ASPAN clinical practice

guideline. This study addresses these gaps in the literature by informing the status of

implementation of EBCPGs, nurses’ attitudes related to barriers of implementing

research, and the relationship of nursing interventions to published guidelines.

Conceptual Model

Conner 1980 proposed a conceptual model that is useful in evaluating research

utilization. The model evaluates goals, inputs, processes, and outcomes.

Figure 1

Conner's conceptual model for research‐utilization evaluation

Source: Handbook of Criminal Justice Evaluation M. W. Klein & K. S. Teilmann, Eds. , Conner, R. F., The evaluation of research utilization, pp. 629–653.

According to Conner 1980 , the first step of evaluating research utilization is to

set up goals one would like to achieve because of the research‐utilization effort. In this

model, the primary inputs for a utilization effort are research findings. The research

findings need to be evaluated on two aspects: quality and importance. For the

processes monitoring, the model includes documenting who received the information

to be utilized, their opinions of the information and their judgment of subsequent use of

such information pattern , their reasons for use or nonuse of the information

Components of an

Evaluation Project *Aspects of

theutilization process

Goals

Inputs

* Qualityof results

* Importanceof results

Processes

* Pattern* Rationale* Stateof utilizers

Outcom

es

* Type* Level* Timing


rationale , and the organizational arrangement and personal state and situation of the

potential users state of utilizers . Outcomes are the central question of Conner’s

evaluation process and are defined as whether the results of the research are utilized.

Conner indicated that evaluation of outcomes must occur for the type, level, and timing

of the utilization process.

Conner concluded that there are five benefits to evaluating research utilization.

These include: a critical review of the process as it determines utilization, b

recognition focused on the dissemination‐utilization process as separate from the

actual research process, c attention focused on utilization goals, d additional

information on the process including barriers to implementation of research findings,

and e interaction between researchers and users of the research is increased.

Conner’s model is closely correlated with The Diffusion of Innovation framework

by Rogers 1983 . Rogers’ work is used to evaluate research utilization and knowledge

translation and describes the four stages of innovation adoption. These stages in order

are: 1 knowledge, 2 persuasion, 3 decision, and 4 implementation. These four

stages are similar to the five benefits of evaluating research utilization described by

Conner.

The Nursing Practice Questionnaire NPQ Brett, 1987 provides a tool directly

related to this project’s investigation of the translation of knowledge into perioperative

practice by measuring perioperative nursing practice related to thermal regulation of

patients. Brett’s NPQ measures use of specific research findings by adapting the work

of Rogers into seven questions: a have you read about this nursing practice, b have

you heard about this nursing practice, c have you observed this practice in use, d


have you learned about this practice from any other source, e if appropriate to the

practice setting, do you believe a nurse should use this nursing practice, f how often

do you use this nursing practice, and g are you aware of any policies concerning this

nursing practice in your workplace.

Barriers are defined as a real or perceived reason, situation, or circumstance that

impacts or directly influences nursing decision‐making related to implementing

EBCPGs. Barriers were measured using the elements on the survey adapted from the

BARRIERS scale Funk, et al. 1991 .

Methods

Design

The study used a descriptive, non‐experimental, exploratory survey design. The

survey tool that was developed for this study has a sufficiently large number of

questions and is better suited to an internet‐based questionnaire so a hybrid approach

was used i.e., the invitation to participate in the study was distributed by email and the

actual tool was located on the internet . Data were collected through an electronic

internet‐based survey. Wright 2005 suggests that there are significant benefits to

using internet‐based survey tools. Kittleson and Brown 2005 concluded that there is

minimal difference in response rates between respondents directed to an internet site

to complete a survey and those that receive an email containing the survey.

Kaplowitz et al. 2004 studied the differences between a mailed hard copy

questionnaire and a web‐based questionnaire. There was some reported age difference

in the groups studied; however, there was a comparable response rate.


Description of the Sample

This study sought to determine the practices of perioperative registered nurses

who participate in the thermoregulation of patients and who would recognize EBCPGs.

The sample was recruited from the membership of the AORN because the AORN

membership represents over 40 different perioperative practice areas and more than a

dozen specialties. Members work in a variety of settings including urban, suburban,

and rural hospitals; freestanding and hospital‐based ambulatory surgery centers; and

office‐based practices. In addition, the size of facilities where AORN members practice

varies from small to large.

Although AORN has members from nearly all countries, this study included only

those nurses residing and practicing in the United States in order to limit the influence

of international practices and policies. Survey questions included demographic as well

as work‐setting information modeled on the AORN 2012 Salary and Compensation

Survey Bacon, 2011 in order to support analysis and enhance the future ability to

generalize findings across a myriad of different perioperative settings.

The AORN recently described its membership as 40,000 members with an active

email list of over 37, 000 members. The response rate of this capstone study is 5.95%

N 893 with a net response rate of 3.58% n 537 included in the analysis of the

responses.

Human Subjects Protection

The Institutional Review Board IRB at Simmons College reviewed and

approved the project to ensure ethical study content and approach. Participating

survey respondents used an internet‐based survey tool and associated standard survey


collection methods. Electronic medical record and other health information systems

were not used for this study since the survey relates to knowledge translation and

nurses’ understanding of EBCPGs.

Sampling Method and Recruitment Plan

The project proposal and survey instrument were submitted to the AORN

Research Committee for review. Once approved by the AORN Research Committee see

Appendix G and the IRB at Simmons College see Appendix H , AORN released the

current membership list see Appendix I providing access through known email

addresses to the AORN membership. AORN member demographic and workplace

information was collected through the survey instrument.

All AORN member emails were processed using a random‐sample function in

Excel Microsoft Excel 2003 formula rand that created a randomized sample list

of eligible emails. AORN practice is that a survey is distributed to a sample of only five

thousand members; however, in this study three samples of five thousand each were

pulled from the population resulting in a total sample of 15 thousand members. This

was done as follows: 1 the first sample of five thousand was pulled from the

37 thousand emails in the total database, 2 the second sample of five thousand emails

was derived from the original 37 thousand less the first sample so from approximately

32 thousand available emails, and 3 the third sample of five thousand emails was

provided from within the remaining 27 thousand emails.

AORN uses an email application to distribute and invite members to participate

in surveys. This tool Informz.net was adapted to include the invitation text and the

internet hyperlink that directed invitees to the survey see Appendix J . AORN does not


allow any internet tracking. Although an invitation was directed to the email for each of

the members in the sample selected there was no ability to evaluate which members

responded to the survey.

The survey was initiated on September 30, 2011 and closed on November 30,

2011. The survey application was configured to allow participants to complete the

survey at any time. The application terminated all responses that indicated the member

only provided care to pediatric patients. In total, 893 viewed the survey for a view rate

of 5.95%. Of the 893 viewers, 25 surveys were terminated and another 331 were not

completed. This resulted in 537 completed surveys for a 60.1% completion rate and a

3.58% net response rate.

Data Collection

Survey Instrument

The tool developed for this capstone study i.e., “Perioperative Guideline

Implementation Survey” see Appendix D was adapted from three published tools

Brett, 1987; Funk, et al, 1991; Hooper, 2006 . Survey questions incorporate three

domains addressing a nursing practice NPQ , b clinical use of EBCPGs Hooper ,

and c nursing barriers to research implementation BARRIERS .

The first component was based on knowledge translation work done by Brett

1987 using the Nursing Practice Questionnaire NPQ . Brett based the NPQ on

Rogers’ stages of innovation adoption 1983 . This work provided seven questions

included here as Michel and Sneed 1995 describe them:

Have you read about this nursing practice?

Have you heard about this nursing practice?


Have you observed this practice in use?

Have you learned about this practice from any other source?

If appropriate to the practice setting, do you believe a nurse should use this

nursing practice?

How often do you use this nursing practice?

Are you aware of any policies concerning this nursing practice in your

workplace?

The second survey component was derived from a data collection instrument

developed by Vallire D. Hooper as published in the Journal of PeriAnesthesia Nursing in

2006 see Appendix C . These questions capture practice‐related attributes of

successful implementation, including partial or inconsistent use of EBCPGs. The

questions address each of the three primary phases of care i.e., preoperative,

intraoperative, and postoperative care :

How often do you document preoperative/arrival admission temperature?

Do you apply any interventions to manage thermal regulation?

At the time of admission, do you ask the patient to describe their thermal

comfort?

At the time of admission, do you document the patients’ description of their

thermal comfort?

The third component of the survey was adapted from the BARRIERS to Research

Utilization Scale developed in 1987 by the research team of Funk, Champagne,

Tornquist, and Wiese. This tool was developed and used to assess clinicians’,

administrators’, and academicians’ perceptions of barriers to the implementation of


research in practice. Initial development of this instrument included 1,948 registered

nurses of which nearly 50% were clinicians.

The BARRIERS tool addresses key respondents characteristics including: a

potential adopter characteristics, b characteristics of the organization, c

characteristics of the innovation, and d characteristics of the communication of the

research. Each of these characteristics has a set of questions based on the following

four factors:

Factor 1: Characteristics of the Adopter: The nurse’s research values, skills, and

awareness.

The nurse does not see the value of research for practice.

The nurse sees little benefit for self.

The nurse is unwilling to change/try new ideas.

There is not a documented need to change practice.

The nurse feels the benefits of changing practice will be minimal.

The nurse does not feel capable of evaluating the quality of the research.

The nurse is isolated from knowledgeable colleagues with whom to discuss the

research.

The nurse is unaware of the research.

Factor 2: Characteristics of the Organization: Setting, barriers and limitations.

Administration will not allow implementation.

Physicians will not cooperate with implementation.

There is insufficient time on the job to implement new ideas.

Other staff are not supportive of implementation.


The facilities are inadequate for implementation.

The nurse does not feel she/he has enough authority to change patient care

procedures.

The nurse does not have time to read research.

The nurse feels results are not generalizable to own setting.

Factor 3: Characteristics of the Innovation: Qualities of the research.

The research has methodological inadequacies.

The conclusions drawn from the research are not justified.

The research has not been replicated.

The literature reports conflicting results.

The nurse is uncertain whether to believe the results of the research.

Research reports/articles are not published fast enough.

Factor 4: Characteristics of the Communication: Presentation and accessibility of the

research.

Implications for practice are not made clear.

Research reports/articles are not readily available.

The research is not reported clearly and readably.

Statistical analyses are not understandable.

The relevant literature is not compiled in one place.

The research is not relevant to the nurse’s practice.

Tool Validation

Initial face validity was performed twice for this survey. The first validation was

done using a paper survey tool. Once perioperative nurses evaluated the tool it was


submitted to non‐perioperative nurses in order to understand face validity concerns.

The second validation was performed once the tool was developed using the internet

survey application FluidSurveys v3.0 .

Several face validity responses suggested wording changes. In the earliest

version of the survey, wording was adjusted in several of the Nurse Practice

Questionnaire Brett, 1987 items. Incidental face validity concerns focused on

wording in several BARRIERS items; however, the original wording of the BARRIERS

tool was retained. Several options for open‐ended text entries were included in the

final survey to encourage further description of interventions as well as demographics

e.g., job classifications .

Initial content validity was done using a paper survey tool. The survey tool was

shared with five expert perioperative professionals. Using the categories of a not

relevant 1 point , b somewhat relevant 2 points , c quite relevant 3 points , and

d highly relevant 4 points scores for each item were obtained. The values ranged

from 0.9 to 1.0 and the Content Validity Index CVI was 0.99 overall. This was

sufficiently high and suggests that the content has agreement that is not likely to be due

to chance.

The tools that were adapted to become the questionnaire have previously been

used and have established and reported measures for test‐retest NPQ and internal

consistency or reliability. Brett 1987 reported the NPQ test–retest reliability was

r .83. The overall internal consistency for this study Cronbach's alpha was .95,

whereas the coefficients of the individual innovation scales ranged from .79 to .86.

Since innovations are based on published nursing care standards, content validity was


assumed. The NPQ has been used in a number of studies Berta, 1995; Brett, 1987,

1989; Coyle & Sokop, 1990; Michel & Sneed, 1995; Rodgers, 2000 with demonstrated

strong psychometric results. Psychometric analyses have been performed and reported

in the literature on the BARRIERS tool. The factors, their corresponding items, and

Cronbach’s alphas are listed below for both BARRIERS and this study:

Table 1

Cronbach's Alphas

Overall

BARRIERS tool

”Perioperative Guideline Implementation Survey”

N αN α 276 .95

Factor 1: 8 items Adopter 1948 .80 427 .79Factor 2: 8 items Organization .80 452 .85Factor 3: 6 items Innovation .72 319 .86Factor 4: 6 items Communication .65 426 .81

Data Analysis

Data collection was complimented by use of an internet‐based survey

application. The FluidSurveys application provides real‐time data collection and

supports data export to a variety of software packages including Statistical Package for

Social Sciences SPSS . SPSS v19 was used to analyze data.

NPQ Scoring

Responses to the seven questions in the NPQ address the four stages of

innovation adoption identified in the Diffusion of Innovation Framework Rogers,

1983 . These stages are in sequence from lowest level of adoption to highest level of

adoption and are 1 knowledge awareness , 2 persuasion, 3 decision, and 4

implementation. The seven questions in the NPQ correlate to four practices that


measure 1 level of awareness, 2 attitude about the innovation, 3 achievement of

the implementation stage, and 4 knowledge of institutional processes. The

relationship of questions to practices is observed by:

Practice 1: Questions 1 through 4 measure the level of awareness of the

recommended practice,

Practice 2: Question 5 measures the nurse's attitude about the innovation,

Practice 3: Question 6 assesses the nurse's achievement of the implementation

stage, and

Practice 4: Question 7 measures the knowledge of institutional policies and/or

procedures concerning the innovation.

The NPQ tool was developed with a specific method for scoring and assignment

of points to be given for each question. Groups or “practices” of questions were totaled

and an overall score determined. This is the Total Innovation Adoption Behavior

TIAB score Squires, Moralejo, and LeFort, 2007 . Specifically, questions 1 through 4

were totaled with each positive response given a score value of 1. If any of the

responses are “yes” then the grouping – the practice ‐ was given a score value of 1.

Question 5 was similarly scored with a positive response or “yes” receiving a score

value of 1. Question 6 has three possible responses, 1 point was given for a

“sometimes” response and 2 points were given for an “always” response. The response

to question 7 was not used in the summed score result.

These 3 scores i.e., 1‐4, 5, and 6 were summed and the result was assigned.

The range of scores was between 0 and 4. The interpretation of the results of the

summed scores assigned to the various stages of adoption was as follows:


Table 2

Stage of Adoption

Stage Description ScoreStage 1 Unaware 0 – 0.49Stage 2 Aware 0.50 – 1.49Stage 3 Persuasion 1.50 – 2.49Stage 4 Used Sometimes 2.50 – 3.49Stage 5 Used Always 3.50 – 4.00

Hooper’s Tool Scoring

Hooper’s Tool data was collected using a Likert scale with the following scores:

a never – 0 points, b occasionally – 1 point, c sometimes – 2 points, d often – 3

points, and e always – 4 points.

BARRIERS Tool Scoring

The BARRIERS tool was scored using specific requirements developed by Funk

et al 1991 . Averages were determined for each item, eliminating those items with

“non‐response” or “no opinion” scores. If an individual responded “no opinion” for at

least half of the items on a scale a “missing value” for the scale was assigned since the

scale score may be unstable. The appropriate divisor for the mean was the number of

items with valid responses i.e., scores of 1‐4 not the total number of items on the

scale.

Demographics

There were 19 demographic questions included in the survey. The responses for

two questions served as the primary demographics included in analyses of the

responses for this study. These include education see Table A3 and current title i.e.,


role see Table A2 . Compiled demographics information obtained through this survey

represents the sample population see Appendix K .

A number of respondents indicated that the majority n 400, 73.1% worked

in acute care settings and that the majority of these primary employments were in

general/community hospitals n 341, 69.6% . Ownership of the facilities was mostly

non‐government/non‐profit n 312, 57.7% with a number identified as

private/investor‐owned/for‐profit n 145, 26.8% . The location of employments was

nearly equal between urban n 220, 40.6% and suburban n 211, 38.9% with a

smaller number reporting rural settings n 111, 20.5% . Region of the United States

was distributed with the largest number of responses from the East North Central

region WI, MI, IL, IN, OH n 93, 17.1% and the least from the East South Central

region KY, TN, MS, AL n 28, 5.1% .

The majority of respondents indicated that they spend 90% to 100% of their

workweek in direct patient care n 284, 53.3% and that they are considered

full‐time employees defined by working 32 or more hours per week n 457, 84.5% .

Most respondents usually work the day shift n 479, 89.9% . A large majority of

respondents indicated they have the Certified Nurse Operating Room CNOR

credential n 368, 67.2% .

Gender was reported with 93.0% n 489 female and 6.1% n 32 male see

Table A3 . Age was reported with the largest number of respondents aged 55‐64

n 208, 39.3% followed by age 45‐54 n 196, 37.1% and 35‐44 years

n 64, 12.1% see Table A4 .


Although the demographic questions were obtained from the AORN 2012 Salary

and Compensation Survey Bacon, 2011 the demographics data collected were not

compared to the AORN 2012 Salary and Compensation Survey Bacon, 2011 . This was

not done since the AORN survey included a large number i.e., approximately nine

thousand of non‐members that created a different population.

Research Questions Analysis

Several demographic variables as developed from the Bacon 2011 study had a

large number of categories. Raw data showed responses for all levels of education

preparation with response rates for Bachelor’s in Nursing preparation highest

n 214, 39.6% followed by Associate degree n 112, 20.7% and Masters in

Nursing n 74, 13.7% . However, the distribution did not have sufficient

representation in several areas e.g., Doctorate in Nursing to be useful during analyses

see Table A3 . Education categories were collapsed into a smaller set of categories

prior to analyses.

Therefore, the eight surveyed categories were collapsed prior to analysis. The

eight categories collapsed into the following three categories: a Diploma and

Associate degree prepared respondents represented 31.6% n 171 , b Bachelor’s

degree prepared respondents represented 46.4% n 251 , and c Master’s and

Doctoral prepared respondents represented 22.0% n 119 see Figure 2 see Table

A5 .


Figure 2

Survey respondent’s Education by percentage

Survey data showed responses at all levels of role with response rates for Staff

Nurse highest n 291, 53.4% followed by Nurse Manager/Supervisor/Coordinator/

Team Leader n 96, 17.6% and Educator/Staff Development n 57, 10.5% .

However, the distribution did not have sufficient representation in several areas e.g.,

Nurse Practitioner n 3 , to be useful during analyses see Table A2 .

Therefore, the eleven surveyed categories were collapsed into the following four

categories: a staff nurse which represented 53.4% n 291 ; b leadership and

management, which represented 25.5% n 139 ; c educator and CNS, which

represented 13.2% n 72 ; and d RN First Assistant and Nurse Practitioners, which

represented 7.9% n 43 see Figure 3 see Table A6 .

31.6%

46.4%

22.0%

0%

10%

20%

30%

40%

50%

60%


Figure 3

Survey respondents’ Role by percentage

Survey responses indicated a large number of respondents used the AORN

Recommended Practice either “Often” or “Always” see Table A7 . These five groups

were collapsed into two categories by placing those with either “Never,” “Occasionally,”

or “Sometimes” in a newly created category of “Infrequently” and those who responded

with either “Often” or “Always” in a newly created group of “Frequently” see Table A8 .

Survey responses indicated a large number of respondents used the ASPAN

Clinical Practice Guideline indicating either “Often” or “Always” see Table A9 . These

five groups were collapsed into two categories by placing those with either “Never,”

“Occasionally,” or “Sometimes” in a newly created category of “Infrequently” and those

who responded with either “Often” or “Always” in a newly created group of

“Frequently” see Table A10 .

53.4%

25.5%

13.2%7.9%

0%

10%

20%

30%

40%

50%

60%


Research Findings

Research Question #1

The first research question focused on determining the level of knowledge

among perioperative nurses related to EBCPGs for the prevention of unplanned

perioperative hypothermia. There were 694 completed responses for the seven

focused NPQ questions. The mean score was 3.52 with standard deviation of .828.

This suggests that the majority of respondents are in the 5th Stage of Adoption or “Used

Always” grouping see Table A11 .

Analyses were conducted to evaluate if the level of education influences the TIAB

score. Results demonstrated a minimal difference in the mean scores and a slight

increase from the overall mean score of 3.52. Educational preparation n 516 is a

slightly smaller sample with a slightly higher mean M 3.60 see Figure 4

see Table A12 .

Figure 4

TIAB Scores by Education Group

3.60 3.61 3.56

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00


Using Crosstabulation analysis, there are five cells that have expected counts

below five and therefore the conditions necessary for using Chi‐Square tests were not

met. Mann‐Whitney tests were run using all possible pairwise comparisons of the TIAB

scores and education levels. In order to consider the chance of a type I error, the

Bonferroni correction was applied. Given three comparisons, the comparison p .05

must have a significance of .0167 see Table A13 .

The first test compared the TIAB score of those with Diploma and Associate

education with those with a Baccalaureate degree. The significance level of .856

indicates that there is no significant difference. The next test compared the TIAB score

of those with Diploma and Associate education with those with a Master’s or Doctoral

degree. The significance level of .853 indicates that there is no significant difference.

The third test compared the TIAB score of those with a Baccalaureate degree and a

Master’s or Doctoral degree. The significance level of .973 indicates that there is no

significant difference.

The Master’s/Doctoral group had the lowest mean score M 3.56 and the

Bachelor’s group had the highest mean score M 3.61 . The Levene statistic for this

analysis is not significant p .225 .

Statistical analysis was conducted to evaluate the research question: “Is there a

job role difference in NPQ scores” using the TIAB score and the four role groups.

Results demonstrate a minimal difference in the mean scores with a slight increase

from the overall of 3.59 n 522 to the smaller education sample which had a mean of

3.60 n 516 see Figure 5 see Table A14 .


Figure 5

TIAB Scores by Job Role Group

Using Crosstabulation analysis, there were nine cells that have expected counts

below five and therefore the conditions necessary for using Chi‐Square tests were not

met. Mann‐Whitney tests were run using all possible pairwise comparisons of the TIAB

scores and roles. In order to consider the chance of a type I error, Bonferroni correction

was applied. Given four comparisons, the comparison p .05 must have a

significance of .0125.

Mann‐Whitney tests were run using all possible pairwise comparisons of the

TIAB scores and roles. The first Mann‐Whitney test compared the TIAB score of

Staff Nurses with Admin/Leader/Managers and has a significance level of .009. The

next test compared the TIAB score of Staff Nurses with CNS/Educ/Faculty and has a

significance level of .022. The third test compared the TIAB score of Staff Nurses with

Mid‐Level/Practitioners and has a significance level of .289. Admin/Leader/Managers

were compared with CNS/Educ/Faculty and have a significance level of .897.

3.51 3.67 3.73 3.61

0.000.501.001.502.002.503.003.504.00


A significance level of .560 was found when Admin/Leader/Managers were compared

with Mid‐Level/Practitioners. The significance level of .516 was observed when

CNS/Educ/Faculty were compared with Mid‐Level/Practitioners see Table A15 .

The only statistically significant differences between group means as determined

by Mann‐Whitney tests is the statistic between the Staff Nurse group and

Admin/Leader/Managers group p .0125 . In this sample, the Staff Nurse group has

the lowest mean score M 3.51 followed by Mid‐Level and Nurse Practitioners group

M 3.61 , Administrators and Managers group M 3.67 , and CNS and Educators

group M 3.73 .


The second research question focused on determining what the barriers are to

perioperative nurses’ implementation of EBCPGs related to management of

perioperative normothermia. Responses were analyzed for the 29 BARRIERS questions

using SPSS and following the BARRIERS study guidelines. Responses for

Factor 1: Adopter had the lowest mean scores M 1.7144 followed by the responses

for Factor 3: Innovation M 1.8536 . The next highest was the group identifying

Factor 4: Communication M 2.0690 and the highest scores were observed with

Factor 2: Organization M 2.2317 see Figure 6 see Table A16 .


Figure 6

BARRIERS Means Scores by Factors

Analyses of BARRIERS as they were identified within the groups by education

and role were completed. Using MANOVA, separate tests were done for education see

Tables A18, A19, A20 and for roles see Tables A21, A22, A23 . Since the MANOVA

was significant for roles, individual ANOVA tests were completed to identify any

differences. Since the MANOVA already indicates a significant difference, the

Bonferroni adjustment was not used.

Pillai‐Bartlett Trace Pillai’s Trace was used to review the MANOVA tests since

it is the most robust outcome measure. Pillai’s trace “is the sum of the explained

differences; therefore, a large value indicates significance” Munro, 2005, p. 183 .

Furthermore, since sample sizes are not the same across education groups, the Pillai’s

Trace criterion is more robust and preferred Tabachnick & Fidell, 1989, p. 399 .

Analysis of the BARRIERS Factors to Education by using covariance matrices

shows that the levels of education do not differ. Therefore, the MANOVA is appropriate.

1.71

2.23

1.852.07

1.0

1.5

2.0

2.5

3.0

3.5

4.0


Reviewing findings for education, the model was not significant using Pillai’s trace,

F 8,858 .545, p .823 see Table A20 . Therefore, none of the BARRIER factors

differed significantly by education. Therefore, ANOVAs were not run.

Reviewing findings for role, the model is significant using Pillai’s trace,

F 12,1296 2.554, p .002 see Table A23 . Therefore, at least one of the BARRIER

factors differed significantly by role. Therefore, ANOVAs were analyzed.

MANOVA analysis of the four BARRIERS factors revealed an overall difference in

the factors related to role. Follow‐up ANOVA tests see Tables A23‐A31 showed that

only Factor 2: Organization approached significance p .060 see Table A26 .

Therefore, although there appeared to be differences related to role the differences are

not significant.


The third research question explored what nursing interventions are used for

thermal regulation and management in the perioperative setting. The findings

demonstrate that staff always n 392, 59.3% apply interventions to manage patients’

thermal regulation, ask patients to describe their thermal comfort n 322, 49.0% ,

frequently do not document the patient’s description n 294, 44.9% , and are nearly

equally distributed when documenting patients’ temperatures between those who

never document n 238, 36.3% and those who always document n 251, 38.3%

see Table A32 .

Analyses were conducted evaluating the relationship between users of the three

varied EBCPGs i.e., AORN, ASPAN, and “other” . The descriptive statistics for all

responses varied with the strongest correlation observed with AORN Recommended


Practice, followed by the ASPAN Clinical Practice Guideline. A less significant finding

was observed for only one question in the “Other Clinical Practice Guideline.”

The Spearman rho’s for each level of measurement in Hooper’s tool indicates

significance p .01 for all four questions with the AORN Recommended Practice

see Figure 7 see Table A34 .

Figure 7

M Frequency of Intervention


significance p .01 for three of four questions with the ASPAN Recommended

Practice see Table A35 and the other question indicates significance p .05 as well.


significance p .05 for only one question with the Other EBCPG see Table A36 .

Using Crosstabulation analysis, there were 13 cells that have expected counts

below five and therefore the conditions necessary for using Chi‐Square test were not

met. Analysis was conducted evaluating the number of interventions attributed to each

2.12

3.423.11

1.47

1.01.52.02.53.03.54.04.55.0


of the three EBCPGs. These indicate the highest number of interventions per response

was from users of the AORN Recommended Practice M 3.58 , followed by the users

of the ASPAN Clinical Practice Guideline M 2.54 , and by the users of Other EBCPG

M 1.98 see Table A37 . The total number of interventions reported by all

respondents is indicated as a mean between 0 and 1 i.e., M .92 which indicates that

nearly all respondents utilized that specific intervention see Figure 8 see Table A38 .

Figure 8

M Intervention Used

A total of 2,939 interventions were identified by the respondents

see Table A39 . When the individual responses for the number of interventions

reported per respondent were analyzed, the range was from 0 to 9, M 4.42, and

SD 1.591. There were 13 interventions included in the analyses for this survey

question; however, only 10 were included by respondents see Table A40 .

3%14%

1%

89% 92%

9%20%

68%

4%

65%76%

0%10%20%30%40%50%60%70%80%90%

100%



In order to analyze the fourth research question that explored the relationship

between reported interventions and identified EBCPGs, the interventions specifically

named in the guideline were identified. These interventions included: a circulating

water blanket, b circulating water garment, c cotton blankets, d forced‐air

warming blanket, e gel pad surface warming, f humidified warmed oxygen,

g increased room temperature, h radiant heat, i resistive heating, j warmed IV

fluids, and k warmed irrigation fluids. Analyses were conducted for those eleven

interventions that were identified in the algorithms with the users of the AORN

Recommended Practice demonstrating a significant correlation r .126 p .01

see Figure 9 see Table A42 .

Figure 9

M Number of Interventions Used per Patient based on EBCPG

Users of the ASPAN Clinical Guideline did not have a positive correlation with

the identified interventions see Table A43 .

3.58

2.54

1.98

1.5

2.0

2.5

3.0

3.5

4.0

AORN ASPAN Other


Data Cleaning

The survey was compiled using FluidSurveys in order to ensure that clean

quantitative data were captured. The application structured results and allowed for

direct export to SPSS. This ensured that all quantitative responses were compiled

without data cleaning activities. Data cleaning was conducted on the narrative data to

ensure that the quantitative measures were captured accurately. If a narrative

response to an “other” question included a comment of “CRNFA”, then the narrative was

cleaned by placing a check‐mark for the variable of “CRNFA” while the narrative was

deleted. Scoring some elements required inclusion and exclusion considerations

see BARRIERS methods .

Qualitative Data Analysis

Content analysis was used to develop broad categories of the open‐ended

responses. These were collapsed into overarching broad themes. Qualitative data were

obtained through the inclusion of a number of open‐ended questions in the survey.

These are related to the BARRIERS survey as well as other elements that help better

clarify: a nursing interventions, b type of facility where respondent works,

c primary place of employment, d job title, e areas of responsibility or work,

f affiliation with work, g highest level of education, h certifications, i shift

usually worked, and j other general comments. BARRIERS narratives were not

individually analyzed; however, they are provided in Appendix L and serve to further

inform the findings of the survey.


Qualitative Narrative Themes

Although there were open‐ended questions included for a number of the survey

items, results for most did not offer content pertinent to the study. Only those that

addressed the research questions were analyzed.

Analysis for the question, “Please indicate which evidence‐based clinical practice

guideline if any you utilize to plan and deliver perioperative nursing care to prevent

unplanned perioperative hypothermia: a AORN Recommended Practice, b ASPAN

Clinical Practice Guideline, and c “Other evidence‐based clinical practice guideline”

captured a total of 53 entries. Categories were developed and data analyzed for

frequencies. Comments included use of locally developed policy n 12, 22.6% ; SCIP

n 8, 15.1% ; ASA/AANA n 6, 11.3% ; AAMI n 5, 9.4% ; APIC n 3, 5.7% ;

ACS, JCAHO, and ORNAC each n 2, 3.8% ; and ANA n 1, 1.9% . The distribution

includes 12 additional single entry comments see Table A44 . These included

comments not related to EBCPGs and did not reveal any additional information for this

study.

The survey captured 21 free‐text comments with three specific interventions

described in the other text field associated with the question, “Which of the following

thermal management interventions do you use in perioperative care of adults on a

regular basis? Please select all that apply…Other please specify .” There were two

responses indicating use of “thermal cap” or “thermal drapes.” The thermal cap and

thermal drape comments were specific. However, these have been coded as “carbon‐

fiber” since the products are usually constructed using carbon‐fiber material. Two

respondents indicated use of warmed CO2 for laparoscopic insufflation. There were


17 responses specifying the use of “forced‐air warming gowns” which were changed

during data cleaning to be “forced‐air warming blanket” since the intervention is

considered by many perioperative professionals as interchangeable during

intraoperative care.

A total of 75 comments were entered in the “Do you have any other comments

you would like to share with us?” field. These comments were coded into the five

following categories: a highest level of education n 11, 14.7% , b certifications

n 7, 9.3% , c nursing interventions n 3, 4.0% , d shift usually worked

n 1, 1.3% , and e general n 53, 70.7% . These general comments were further

coded into: a non‐specific n 39, 52.0% , b support of survey and study

n 6, 8.0% , c BARRIERS – difficulty with scale n 4, 5.3% , d NPQ

n 3, 4.0% , and e nursing team care of patients n 1, 1.3% see Table A45 .

Discussion

This project’s investigation of the translation of knowledge into practice by

measuring perioperative nursing practice related to thermal regulation of patients

began with the first research question, what is the level of knowledge among

perioperative nurses related to EBCPGs for the prevention of unplanned perioperative

hypothermia? The NPQ and analysis of TIAB scores provides one measure of adoption

of research into nursing practice. The analyses of the NPQ and findings i.e., TIAB

scores M 3.52 indicate that a number of respondents have progressed to the

5th stage of adoption or the most advanced level of adoption of EBCPGs. This stage is

described as the “used always” phase of implementing new knowledge in clinical

practice.


Implementing new knowledge is often associated with either an achieved level

of education or the role of the user. Analyses were conducted to explore if either

education or role might result in different implementation scores; however, this study

did not find significant differences. Although this lack of differences is surprising, it

supports that practice with EBCPGs has advanced and has minimal variation across

both educational levels and roles within organizations.

This lack of difference is potentially related to the efforts of practicing nurses,

educators, and administrators to adopt EBCPGs. The focus of educators in the clinical

setting has improved sharing of information during staff development opportunities.

Regulatory requirements have influenced practice settings as patient outcomes may

affect financial reimbursement. Other potential reasons for this lack of difference are

the adoption of standards by many organizations i.e., policies that require staff to

document the provision of thermal management interventions for all patients .

The second research question of this study identified barriers to the

implementation of research. Results from this study demonstrated that there was no

significant difference for any of the factors related to the educational preparation of the

respondents. However, analyses of roles suggested there was a difference in the

Factor 2: Organization means between the roles of Admin/Leader/Manager

M 2.1028 when compared to the roles of Mid‐level/Practitioner M 2.3367 .

Factor 2: Organization describes the organization’s setting, barriers, and limitations by

exploring questions about administration, physician cooperation, time available for

implementation of research, intra‐professional support, and empowerment of the

nurse.


Eizenberg 2010 initially determined that implementation of evidence‐based

nursing practice was correlated with both degree and role; however, after further

analysis this study determined that analyses were not statistically significant. Similarly,

the findings in this study suggest that there is no significant difference in educational

level or role of the professional. The suggestion of any barriers related to these EBCPGs

is focused on only Factor 2: Organization although this difference is not significant.

The third research question explored what nursing interventions are used for

thermal regulation and management in the perioperative setting. Analyses using

Hooper’s data collection tool showed strong correlation of AORN Recommended

Practice, followed by the ASPAN Clinical Practice Guideline. Statistical analyses

indicated significance with all four questions for AORN Recommended Practice

“frequently” identified users. Three of four questions had significant correlation with

the users who identified using the ASPAN Clinical Practice Guideline “frequently.” Users

of either the AORN or ASPAN EBCPGs replied consistently to the intervention questions.

Data analysis showed the respondents used 2,939 interventions. On average, the

group who used the AORN Recommended Practice frequently used more interventions

M 3.58 than those who used the ASPAN Clinical Practice Guideline M 2.54 and

than the group who followed another guideline M 1.98 . Data were analyzed to

explore how many of the 13 available interventions were used and the average

indicated that nearly all used at least one intervention M 4.42, SD 1.6 . The

findings in this study indicate use of multiple interventions for each patient. This

suggests that nurses are applying interventions to ensure that unplanned perioperative

hypothermia is prevented.


The last research question explored the relationship between reported

interventions and identified EBCPGs. This study showed that for those respondents

indicating that they followed AORN Recommended Practices a very high percent

applied interventions frequently 95% whereas those using the ASPAN Clinical

Practice Guideline applied interventions frequently but somewhat less consistently

76.1% . The correlation of interventions associated with the AORN EBCPG was

significant p .01 while the correlation with the ASPAN identified respondents was

not significant.

Limitations

One limitation of this study related to the sample population as it was a

convenience sample from AORN’s membership database. These subjects have potential

to understand the EBCPG e.g., AORN Recommended Practices , membership resources,

exposure to up to date publications, networking opportunities, and collegial interaction.

A second limitation is the online survey sampling since the AORN membership is

reported to be “over‐sampled.” Although the subjects are members of a professional

organization, there was no incentive provided to participate or complete the survey.

A third limitation was the minimal response rate. Only 5.95% N 893 opened

the survey with a net response rate completion rate of 3.58% n 537 . This may

have been related to the scope of the survey that required an extensive amount of time

to complete M 20.4 minutes .

Conclusion

Advanced practice nurses, nurse leaders, nurse educators, nurse researchers,

and practicing staff nurses must be engaged in the work of knowledge translation. This


study describes the multi‐factorial aspects of care utilized to prevent one undesirable

consequence of treatment for a specific patient population. Although this study has

limitations, future work must be based on the levels of implementation of EBCPGs.

Recognition that there are differences in EBCPGs can serve as another point to evaluate

the potential need and benefits of standardizing care across the perioperative and

perianesthesia continua.

Study results suggest that there has been knowledge translation into practice

across a group of perioperative registered nurses. The findings support consistent

implementation and adoption of EBCPGs intended to prevent unplanned perioperative

hypothermia. Practices by a number of respondents indicate consistent behaviors of

“use always” and a large number of interventions utilized.

There does not appear to be a significant difference when evaluating educational

preparation or job roles; however, additional study may inform leaders and educators

on differences. Similar to findings reported by Hutchinson and Johnston 2004 ,

analysis of the “extent of research utilization by nurses in the practice setting presents a

major challenge” p. 314 .

This study supports the following findings: a perioperative professionals have

read about, heard about, observed in practice, learned about from a resource, b

perioperative professionals believe the practice should be used, and c perioperative

professionals actually use EBCPGs. However, despite the findings of this study, and

conclusions by others that a number of interventions are available and used frequently

to prevent unplanned perioperative hypothermia, the problem continues without viable

standardized or consistent solutions.


Since the study has limitations, it would be difficult to make recommendations

for policy revision or development; however, the study findings based on the BARRIERS

tool suggest that respondents remain concerned about implementation related to

Factor 2: Organization. Efforts to explore the specific elements of concern from this

factor seem appropriate for future study. The study by Brown et al. 2010 also

suggests that the factor with the highest mean score is Factor 2: Organization and

recommends that further study of predictors should be undertaken. There are no

findings that address predictors that contributed to the high adoption rate.

Recommendations for Future Research

Recommendations for further research include studying a more heterogeneous

sample of the nursing population that would include perioperative nurses not prepared

at the bachelors or masters’ level. Additionally, study of a sample that is not members

of AORN should explore if membership in the professional organization and /or level of

education has significant influence on the study’s findings. Strategies to increase the

sample size might include employing an incentivized approach. Obtaining a sample of

the perioperative population that includes nurses with international practice

experience would provide another opportunity for study.

Further study should evaluate patients’ outcomes as they correlate to the actual

EBCPGs i.e., research applied to patient care. Research to understand the frequency

of unplanned perioperative hypothermia is warranted, as findings of this study do not

suggest a reason for the continued problem. Evaluation of the appropriateness of

interventions identified in the most current EBCPGs as they are implemented in patient

care should be included in research related to patient outcomes.


The scope of this capstone study did not include analysis of the entire spectrum

of data elements. Additional analyses could focus on evaluating the impact of

organizational setting, type of organizational structure and ownership, location, and

region of facility. Respondent‐specific data for analysis could also investigate the

number of years at the current educational level, number of years employed as a

perioperative nurse, and any influence the length of membership with AORN may have

on utilization of EBCPGs.

Further study of barriers should also investigate the relationship of EBCPGs with

local policy. Analysis of the data collected in this study could be expanded to explore

predictors of EBCPG utilization in contrast with reported barriers. Future study should

include the interprofessional team i.e., anesthesia and surgeon to understand the

interactions of team members as they relate to managing unplanned perioperative

hypothermia and achieve best outcomes of care.


Appendices

Appendix A

Tables and Graphs


Table A1

“What is your highest level of education degree ?”

Response N %Diploma 59 10.9%Associate degree 112 20.7%Bachelor’s in Nursing 214 39.6%Bachelor’s in another field

37 6.8%

Master’s in Nursing 74 13.7%Master’s in another field 39 7.2%Doctorate in Nursing 2 0.4%Doctorate in another field 0 0.0%Other 4 0.7%

Total Responses 541 100.0%

Table A2

“What is your current title role ?”

Response N %Staff Nurse 291 53.4% Hospital/Facility Administrator 4 0.7% Director/VP/Assistant Director Nursing 32 5.9% Nurse Manager/Supervisor/Coordinator/Team Leader/Business Manager

96 17.6%

Educator/Staff Development 57 10.5% Educator/Faculty 6 1.1% Clinical Nurse Specialist 9 1.6% RN First Assistant 40 7.3% Nurse Practitioner 3 0.6% Consultant 3 0.6% Other 4 0.7%



Table A3

“Please indicate your gender.”

Response N %Male 32 6.1%Female 489 93.0%Prefer Not to Answer 5 1.0%


Table A4

“What is your age?”

Response N %Under 18 0 0%18‐24 0 0%25‐34 28 5.3%35‐44 64 12.1%45‐54 196 37.1%55‐64 208 39.3%65 or Above 25 4.7%Prefer Not to Answer 8 1.5%


Table A5

Education Categories for Analysis

FrequencyValid Percent

Diploma/Associate 171 31.6Bachelor’s 251 46.4Master’s/Doctoral 119 22.0Total 541 100.0


Table A6

Role Categories for Analysis

Frequency ValidPercent

Staff Nurse 291 53.4Hospital/Facility Administrator/ Director/VP/Assistant Director Nursing/Nurse Manager/Supervisor/Coordinator/Team Leader/Business Manager/Consultant/Other

139 25.5

Educator/Staff Development/Faculty/Clinical Nurse Specialist

72 13.2

RN First Assistant/Nurse Practitioner 43 7.9Total 545 100.0

Table A7

AORN Recommended Practice Use: Descriptive Statistics

f %

Valid Percent

Valid Never 6 .7 1.3Occasionally 7 .8 1.5Sometimes 16 1.8 3.4Often 117 13.1 25.2Always 318 35.6 68.5Total 464 52.0 100.0

Missing Not Sure 15 1.7System 414 46.4Total 429 48.0

Total 893 100.0

Table A8

AORN Recommended Practice Descriptive Statistics: Infrequently or Frequently

f %

Valid Percent

Valid Infrequently 23 2.6 5.0Frequently 435 48.7 95.0Total 458 51.3 100.0

Missing System 435 48.7Total 893 100.0


Table A9

ASPAN Clinical Practice Guideline Use: Descriptive Statistics

f %

Valid Percent

Valid Never 32 3.6 16.4Occasionally 17 1.9 8.7Sometimes 22 2.5 11.3Often 62 6.9 31.8Always 62 6.9 31.8Total 195 21.8 100.0

Missing Not Sure 87 9.7System 611 68.4Total 698 78.2

Total 893 100.0

Table A10

ASPAN Clinical Practice Guidelines Descriptive Statistics: Infrequently or Frequently

f %

Valid Percent

Valid Infrequently 39 4.4 23.9Frequently 124 13.9 76.1Total 163 18.3 100.0


Table A11

TIAB Score

Frequency

Valid Percent

Valid 0 7 1.01 24 3.52 37 5.33 157 22.64 469 67.6

Total 694 100.0


Table A12

TIAB Descriptives: Education

Education N M SDDiploma/Associate 159 3.60 .712Bachelor’s 244 3.61 .691Master’s/Doctoral 113 3.56 .855Total 516 3.60 .735

Table A13

Mann‐Whitney Analysis: Education

Education M

Diploma/Associate

Bachelor’s Master’s/ Doctoral Total

Diploma/Associate .360 1 .856 .853 Bachelor’s .361 .856 1 .973 Master’s/Doctoral .356 .853 .973 1 Total .360 1

Table A14

TIAB Descriptives: Role

Role N M SDStaff Nurse 275 3.51 .780Admin/Leader/Manager 135 3.67 .721CNS/Educ/Faculty 71 3.73 .608Mid‐Level/Practitioner 41 3.61 .802Total 522 3.59 .749

Table A15

Mann‐Whitney Analysis: Role

Role M

StaffNurse

Admin/Leader/Manager

CNS/ Educ/ Faculty

Mid‐Level/ NP Total

Staff Nurse 3.51 1 .009 .022 .289 Admin/Leader/Manager 3.67 .009 1 .897 .560 CNS/Educ/Faculty 3.73 .022 .897 1 .516 Mid‐Level/Practitioner 3.61 .289 .560 .516 1 Total 1


Table A16

BARRIERS: Descriptive Statistics

BARRIERS N Minimum Maximum M SD Overall 546 1.00 3.90 1.9842 .57509 Factor 1 545 1.00 3.63 1.7144 .56515 Factor 2 548 1.00 4.00 2.2317 .71117 Factor 3 460 1.00 4.00 1.8536 .65315 Factor 4 554 1.00 4.00 2.0690 .71075 Valid N listwise 452

Table A17

Correlations: Factor 1 through Factor 4

Adopter Organization Innovation Communication

Adopter Pearson Correlation 1.00 .682 .695 .730

Organization Pearson Correlation .682 1 .625 .696

Innovation Pearson Correlation .695 .625 1 .782

Communication Pearson Correlation .730 .696 .782 1

Note: All correlations significant at p .01


Table A18

Descriptive Statistics: BARRIERS Factors ‐ Education

Education N M SD Factor 1: Adopter

Diploma/Associate 132 1.6886 .53881 Bachelor’s 192 1.6919 .58566 Master’s/Doctoral 110 1.6981 .56625 Total 434 1.6924 .56556

Factor 2: Organization


Factor 3: Innovation


Factor 4: Communication


Table A19

Box’s Test of Equality of Covariance Matrices

Box's M 22.437 F 1.106 df1 20 df2 469058.688 Sig. .334 Tests the null hypothesis that the observed covariance matrices of the dependent variables are equal across groups.a. Design: Intercept Education


Table A20

Multivariate Tests: Factors to Education

Effect Value F

Hypothesis df Error df Sig.

Noncent. Parameter

Observed Powerb

Intercept Pillai's Trace .916 1172.093a 4 428.000 .000 4688.371 1.000Wilks' Lambda .084 1172.093a 4 428.000 .000 4688.371 1.000Hotelling's Trace 10.954 1172.093a 4 428.000 .000 4688.371 1.000Roy's Largest Root

10.954 1172.093a 4 428.000 .000 4688.371 1.000

Education Pillai's Trace .010 .545 8 858.000 .823 4.361 .256Wilks' Lambda .990 .544a 8 856.000 .824 4.353 .256Hotelling's Trace .010 .543 8 854.000 .824 4.345 .255Roy's Largest Root

.007 .789c 4 429.000 .532 3.158 .253

a. Exact statistic b. Computed using alpha .05 c. The statistic is an upper bound on F that yields a lower bound on the significance level.d. Design: Intercept Education


Table A21

Descriptive Statistics: BARRIERS to Role

Role N M SD Factor 1: Adopter

Staff Nurse 207 1.7136 .61126Admin/Leader/Manager 130 1.6527 .50094CNS/Educ/Faculty 64 1.6244 .50644Mid‐Level/Practitioner 36 1.7505 .55888Total 437 1.6855 .56081







Table A22

Box’s Test of Equality of Covariance Matrices: Roles

Box's M 35.298 F 1.145 df1 30 df2 69179.850 Sig. .267 Tests the null hypothesis that the observed covariance matrices of the dependent variables are equal across groups. a. Design: Intercept Role


Table A23

Multivariate Tests: Factors to Role

Effect Value F

Hypothesis df Error df Sig.

Noncent. Parameter

Observed Powerb

Intercept Pillai's Trace .886 836.917a 4 430.000 .000 3347.668 1.000Wilks' Lambda .114 836.917a 4 430.000 .000 3347.668 1.000Hotelling's Trace

7.785 836.917a 4 430.000 .000 3347.668 1.000

Roy's Largest Root

7.785 836.917a 4 430.000 .000 3347.668 1.000

Role Pillai's Trace .069 2.554 12 1296.000 .002 30.649 .979Wilks' Lambda .932 2.564 12 1137.965 .002 27.092 .958Hotelling's Trace

.072 2.568 12 1286.000 .002 30.820 .979

Roy's Largest Root

.044 4.768c 4 432.000 .001 19.071 .953

a. Exact statistic b. Computed using alpha .05 c. The statistic is an upper bound on F that yields a lower bound on the significance level.d. Design: Intercept Role

Table A24

ANOVA: Factor 1: Adopter by Role

Unique Method SS df MS F Sig.

Factor 1: Adopter

Main Effects Role 1.153 3 .384 1.224 .300Model 1.153 3 .384 1.224 .300Residual 163.656 521 .314 Total 164.809 524 .315

a. Factor 1: Adopter by Role b. All effects entered simultaneously

Table A25

Mean Adopter Score by Role

Role N MStaff Nurse 273 1.7464Admin/Leader/Manager 139 1.6584CNS/Educ/Faculty 70 1.6360Mid‐Level/Practitioner 43 1.7409Total 525 1.7079


Table A26

ANOVA: Factor 2: Organization by Role



Main Effects Role 3.734 3 1.245 2.489 .060Model 3.734 3 1.245 2.489 .060Residual 259.103 518 .500 Total 262.837 521 .504

a. Factor 2: Organization by Roleb. All effects entered simultaneously

Table A27

Mean Organization Score by Role

Role N M Staff Nurse 272 2.2830 Admin/Leader/Manager 139 2.1028 CNS/Educ/Faculty 70 2.2977 Mid‐Level/Practitioner 41 2.3367 Total 522 2.2412

Table A28

ANOVA: Factor 3: Innovation by Role



Main Effects Role 1.882 3 .627 1.488 .217Model 1.882 3 .627 1.488 .217Residual 185.149 439 .422 Total 187.032 442 .423

a. Factor 3: Innovation by Roleb. All effects entered simultaneously


Table A29

Mean Innovation Score by Role


Table A30

ANOVA: Factor 4: Communication by Role



Main Effects

Role .156 3 .052 .102 .959

Model .156 3 .052 .102 .959Residual 258.700 505 .512 Total 258.857 508 .510

a. Factor 4: Communication by Roleb. All effects entered simultaneously

Table A31

Mean Communication Score by Role



Table A32

Hooper’s Intervention Descriptive Statistics

Never Occasionally Sometimes Often Always N MDocument temperature

238 36.3%

33 5.0%

45 6.9%

88 13.4%

251 38.3% 655 2.12

Intervene 18 2.7%

15 2.3%

30 4.5%

206 31.2%

392 59.3% 661 3.42

Describe comfort level

40 6.1%

35 5.3%

62 9.4%

198 30.1%

322 49.0% 657 3.11

Document patient's description

294 44.9%

74 11.3%

93 14.2%

71 10.8%

123 18.8% 655 1.47

Table A33

Descriptive Statistics: All Responses to Hooper’s Tool

N M SDHow often did you document patient temperature?

655 2.12 1.778

How often did you apply any interventions to manage the patient’s temperature?

661 3.42 .894

At the time of arrival of the patient, how often did you ask the patient to describe their thermal comfort?

657 3.11 1.156

At the time of arrival of the patient, how often did you document the patients’ description of their thermal comfort?

655 1.47 1.579

Valid N listwise 650 Note: Scores from 0 to 4.

Table A34

Correlations Hooper with AORN Recommended Practice

Spearman's rho N

How often did you document patient temperature? .188** 446How often did you apply any interventions to manage the patient’s temperature? .216** 451

At the time of arrival of the patient, how often did you ask the patient to describe their thermal comfort? .126** 448


.161** 447

**. Correlation is significant at the 0.01 level 2‐tailed .


Table A35

Correlations Hooper with ASPAN Clinical Practice Guideline

Spearman's rho N

How often did you document patient temperature? .324** 187How often did you apply any interventions to managethe patient’s temperature? .193** 187

At the time of arrival of the patient, how often did you ask the patient to describe their thermal comfort? .179* 187


.341** 187

**. Correlation is significant at the 0.01 level 2‐tailed .*. Correlation is significant at the 0.05 level 2‐tailed .

Table A36

Correlations Hooper with Other Evidence Based Clinical Practice Guideline

Spearman's rho N

How often did you document patient temperature? .022 264How often did you apply any interventions to manage the patient’s temperature? .126* 264

At the time of arrival of the patient, how often did you ask the patient to describe their thermal comfort? ‐.094 264


.067 262

*. Correlation is significant at the 0.05 level 2‐tailed .

Table A37

Number of Interventions Used by EBCPG: Descriptive Statistics

N M SD AORN Recommended Practice 464 3.58 .748 ASPAN Clinical Practice Guideline 195 2.54 1.433 Other evidence‐based clinical practice guideline 273 1.98 1.489 Valid N listwise 52


Table A38

Interventions: Descriptive Statistics

N M SDNone 665 .00 .039Carbon‐fiber blanket 665 .03 .175Circulating water blanket 665 .14 .352Circulating water garment 665 .01 .116Cotton blankets 665 .89 .309Forced‐air warming blanket 665 .92 .273Gel pad surface warming 665 .09 .280Humidified warmed oxygen 665 .20 .398Increased room temperature 665 .68 .466Radiant heat 665 .04 .201Resistive heating 665 .00 .055Warmed IV fluids 665 .65 .478Warmed irrigation fluids 665 .76 .428Valid N listwise 665

Table A39

Number of Interventions Reported per respondent : Descriptive Statistics

N Minimum Maximum Sum M SD Interventions 665 0 9 2939 4.42 1.591Valid N listwise 665

Table A40

Number of Interventions Identified

F %

Valid Percent

Valid 0 10 1.1 1.51 24 2.7 3.62 50 5.6 7.53 73 8.2 11.04 157 17.6 23.65 203 22.7 30.56 96 10.8 14.47 40 4.5 6.08 11 1.2 1.79 1 .1 .2Total 665 74.5 100.0



Table A41

Number of Interventions Reported per respondent

F %

Valid Percent

Valid 0 27 3.0 4.11 50 5.6 7.52 78 8.7 11.73 164 18.4 24.74 257 28.8 38.65 69 7.7 10.46 19 2.1 2.97 1 .1 .2Total 665 74.5 100.0


Table A42

Correlation: Number of Interventions to AORN Recommended Practice

AORN Recommended

Practice N Spearman's rho

Number of Interventions

Correlation Coefficient .126** 450 Sig. 2‐tailed .008

**. Correlation is significant at the 0.01 level 2‐tailed .

Table A43

Correlation: Number of Interventions to ASPAN Clinical Practice Guideline

ASPAN Clinical Practice Guideline N

Spearman's rho

Number of Interventions

Correlation Coefficient ‐.062 187 Sig. 2‐tailed .397


Table A44

Qualitative Categories: EBCPG

N %Locally developed policy and procedure 12 22.6%SCIP 8 15.1%ASA/AANA 6 11.3%AAMI 5 9.4%APIC 3 5.7%ACS 2 3.8%JCAHO 2 3.8%ORNAC 2 3.8%ANA 1 1.9%Other 12 22.6%Total 53 100.0%

Table A45

Comments: Distribution by coded categories

N %Highest level of education 11 14.7%Certifications 7 9.3%Nursing interventions 3 4.0%Shift usually worked 1 1.3%

Subtotal 22 29.3%General: Non‐specific 39 52.0%Support of survey and study 6 8.0%BARRIERs 4 5.3%NPQ 3 4.0%Hooper 1 1.3%

Subtotal 53 70.7%Total 75 100.0%


Appendix B

ASPAN Algorithms


Appendix C

Hooper Data Collection Tool


Appendix D

Survey Questionnaire


Introduction to Survey

Dear Perioperative Professional,

This Evidence‐based Practice Inquiry Survey is being conducted by Brandon

Bennett, MSN, RN, CNS, CNOR, NE‐BC for partial fulfillment of the requirements for the

degree of Doctorate in Nursing Practice DNP in the School of Nursing and Health

Sciences at Simmons College. The AORN Research Committee has reviewed the study

and provided approval to obtain potential subjects from the AORN membership. The

study asks perioperative nurses to provide input about many factors that influence

perioperative patient care of adult patients, including: facility settings, certifications,

education, experience, and more.

Participation in this survey is voluntary. Your survey responses will be strictly

confidential and data will be reported only in the aggregate. You may leave the survey

at any time or skip any questions. By completing the survey, you are agreeing to

participate in research.

If you have any questions about this survey, please contact the Principal

Investigator by email at [email protected]. If you would like to discuss

your rights as a research subject you may contact the Human Protections Administrator

at Simmons College, telephone number 617 521‐2415.

Results of this Evidence‐based Practice Inquiry Survey will be disseminated at a

future time. This survey will be available online until November 28, 2011. The

estimated time to complete the survey is 10 minutes. Thank you for your participation

and time.

Please start the survey now by selecting “Next.”


Questionnaire

Clinical Focus: In what phase of perioperative nursing do you currently practice? Please select the one best answer for each question.

Never Occasionally Sometimes Often Always

Preoperative / Admitting Area: Intraoperative: Postoperative / Recovery Area:

In what age‐specific area of perioperative nursing do you currently practice? Please select the one best answer for each question. No YesAdult only Pediatric only: Both adult and pediatric

Nursing Practice Questionnaire: The following questions ask about your nursing practice related to the AORN Recommended Practice “The Prevention of Unplanned Perioperative Hypothermia.”

No YesHave you heard about the AORN Recommended Practice, “The Prevention of Unplanned Perioperative Hypothermia”?

Have you read about this AORN Recommended Practice? Have you followed this AORN Recommended Practice? Have you learned about this AORN Recommended Practice (formal education offering, in‐service, or training experience)?

Do you believe a nurse should use this AORN Recommended Practice?

Are you aware if your organization has any policies concerning this AORN Recommended Practice?

Never Sometimes Always How often do you use this AORN Recommended Practice?


Please indicate which evidence‐based clinical practice guideline (if any) you utilize to plan and deliver perioperative nursing care to prevent unplanned perioperative hypothermia:

Never Occasionally Sometimes Often AlwaysAORN Recommended Practice ASPAN Clinical Practice Guideline Other evidence‐based clinical practice guideline: ______________________________

Interventions: Please describe a typical adult patient’s experience from a recent workday as you answer the following clinical focused questions. Indicate the frequency of your actions for each question by selecting one choice.

Never Occasionally Sometimes Often Always How often did you document patient temperature?




Which of the following thermal management interventions do you use in perioperative care of adults on a regular basis? Please select all that apply.

electNone Cotton blankets Carbon‐fiber blanket Forced‐air warming blanket Circulating water blanket Circulating water garment Increased room temperature Radiant heat Gel pad surface warming Resistive heating


Warmed IV fluids Warmed irrigation fluids Humidified warmed oxygen Other (please specify): ______________________________________

Barriers and Facilitators to Using Research and Implementing Evidencebased Clinical Practice Guidelines in Practice: Please rate the extent to which you think each of the following situations is a barrier to nurses’ use of research and evidence‐based clinical practice guidelines. If you currently hold a position in a clinical site and care for adult patients on a regular basis, please answer the questions in relation to your current work setting. If you do not currently practice in a clinical site or do not regularly care for adult patients, you may refer to your last clinical experience or provide your general perceptions. For each item, select the response that best represents your view. Thank you for sharing your views with us. To No

Extent To a Little Extent

To a Moderate Extent

To a Great Extent

Not Sure

Research reports/articles are not readily available

Implications for practice are not made clear

Statistical analyses are not understandable

The research is not relevant to my nursing practice

I am unaware of the research The facilities are inadequate for implementation

I do not have time to read research The research has not been replicated I feel the benefits of changing practice will be minimal

I am uncertain whether to believe the results of the research

The research has methodological inadequacies

The relevant literature is not compiled in one place

I do not feel I have enough authority to change patient care procedures


To No Extent

To a Little Extent


To a Great Extent

Not Sure

I feel results are not generalizable to my practice setting

I am isolated from knowledgeable colleagues with whom to discuss the research

I see little benefit for myself Research reports/articles are not published fast enough

Physicians will not cooperate with implementation

Administration will not allow implementation

I do not see the value of research for practice

There is not a documented need to change practice

The conclusions drawn from the research are not justified

The literature reports conflicting results

The research is not reported clearly and readably

Other staff are not supportive of implementation

I am unwilling to change/try new ideas The amount of research information is overwhelming

I do not feel capable of evaluating the quality of the research

There is insufficient time on the job to implement new ideas

Please list any additional barriers to research utilization.

To No Extent

To a Little Extent


To a Great Extent

Not Sure

The BARRIERS questionnaire was adapted from: Crane, J., Pelz, D., and Horsley, J.A. CURN Project Research Utilization Questionnaire. Ann Arbor, Michigan: Conduct and Utilization of Research in Nursing Project, School of Nursing. The University of Michigan, 1977.

© 1987, Funk, Champagne, Tornquist, & Wiese


Survey Respondent Demographics: Please tell us about your workplace. Your individual responses to this section will be kept COMPLETELY CONFIDENTIAL. Only group information will be reported. No individual data will be released. 1. In what type of setting do you primarily work? select one

A. Acute Care Hospital B. Ambulatory Surgery Center ‐‐ Hospital based C. Ambulatory Surgery Center ‐‐ Free standing D. Ambulatory Surgery Center ‐‐ Office based E. Industry F. School of Nursing G. Independent Consultant H. Other ___________________________________

2. If you work in a hospital setting, which term best describes your primary place of

employment? select one A. General/Community hospital B. Specialty Hospital/Facility C. University/Academic Medical Center D. Other ___________________________________

3. Which term best describes the ownership of your primary place of employment?

select one A. Government/Nonfederal e.g., County Hospital B. Government/Federal e.g., VA hospital C. Military D. Private, Investor‐owned/For profit E. Non‐Government/Nonprofit F. Other ___________________________________

4. How would you describe the location of your workplace? select one

A. Urban B. Suburban C. Rural

5. In what region of the country are you currently employed? select one

A. New England NH, VT, ME, CN, RI, MA B. Mid‐Atlantic NJ, DE, MD, PA, NY, Washington, DC C. South Atlantic WV, VA, NC, SC, GA, FL D. East North Central WI, MI, IL, IN, OH E. West North Central ND, SD, MN, NE, IA, KS, MO F. East South Central KY, TN, MS, AL G. West South Central OK, AR, TX, LA H. Mountain MT, ID, WY, NV, UT, CO, AZ, NM


I. Pacific AK, WA, OR, CA, HI J. Outside of United States please identify country in next question

If not currently employed in the United States, please select the country where you are employed. select one

Afghanistan Albania Algeria Andorra Angola Antarctica Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile

China Colombia Comoros Congo, Democratic Republic Congo, Republic of the Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Greenland Grenada Guatemala Guinea

Guinea‐Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall


Islands Mauritania Mauritius Mexico Micronesia Moldova Mongolia Morocco Monaco Mozambique Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Panama Papua New Guinea Paraguay Peru Philippines Poland

Portugal Qatar Romania Russia Rwanda Samoa San Marino Sao Tome Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland

Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe

6. What is the total number of ORs in your facility? Include CVOR, ASC, Ambulatory

OR, Hybrid Room, Inveterventional Suite e.g., Cardiac Catheterization Laboratory, Interventional Radiology Suite, GI Suite Endo rooms and Cysto rooms. select one A. 0B. 1 C. 2 D. 3 E. 4 F. 5 G. 6 H. 7 I. 8 J. 9 K. 10 L. 11

M. 12 N. 13 O. 14 P. 15 Q. 16 R. 17 S. 18 T. 19 U. 20 V. 21 W. 22

X. 23 Y. 24 Z. 25 AA. 26 BB. 27 CC. 28 DD. 29 EE. 30 FF. 31 GG. 32 HH. 33

II. 34 JJ. 35 KK. 36 LL. 37 MM. 38 NN. 39 OO. 40 PP. 41 or more

7. What is your current title? select one A. Staff Nurse B. Hospital/Facility Administrator C. Director/VP/Assistant Director Nursing D. Nurse Manager/Supervisor/Coordinator/Team Leader/Business Manager E. Educator/Staff Development F. Educator/Faculty G. Clinical Nurse Specialist H. RN First Assistant I. Nurse Practitioner J. Consultant K. Other ___________________________________

8. What percentage of your work week are you providing direct patient care? select

one A. 0% B. 10% C. 20% D. 30% E. 40% F. 50% G. 60% H. 70% I. 80% J. 90% K. 100%

9. Which of the following areas are you responsible for, or in which do you PRIMARILY

work? select all that apply A. Operating room B. Post‐anesthesia care unit C. Endoscopy D. Ambulatory or outpatient surgery unit E. Office‐based setting F. Preadmission testing G. Central supply/Sterile processing department H. Emergency department I. 24‐hour observation unit J. Pain management K. Anesthesia L. Hybrid Room M. Interventional Suite e.g., Cardiac Catheterization Laboratory, Interventional

Radiology Suite, GI Suite N. Other ___________________________________


10. Please indicate your affiliation with your primary workplace: select one A. Full‐time employee ‐‐ work 32 hours per week B. Part‐time employee C. Full‐time employee for a staffing agency ‐‐ work 32 hours per week D. Part‐time employee for a staffing agency E. Per diem for a health care facility or staffing agency F. Currently unemployed G. Other ___________________________________

Please tell us about yourself. Your individual responses to this section will be kept COMPLETELY CONFIDENTIAL. Only group information will be reported. No individual data will be released. 11. What is your highest level of education? select one

A. Diploma B. Associate degree C. Bachelor’s in Nursing D. Bachelor’s in another field E. Master’s in Nursing F. Master’s in another field G. Doctorate in nursing H. Doctorate in another field I. Other ___________________________________

12. How many years has it been since you achieved the level of education mentioned

above? select one A. 0B. 1 C. 2 D. 3 E. 4 F. 5 G. 6 H. 7 I. 8 J. 9 K. 10 L. 11 M. 12 N. 13

O. 14 P. 15 Q. 16 R. 17 S. 18 T. 19 U. 20 V. 21 W. 22 X. 23 Y. 24 Z. 25 AA. 26

BB. 27 CC. 28 DD. 29 EE. 30 FF. 31 GG. 32 HH. 33 II. 34 JJ. 35 KK. 36 LL. 37 MM. 38 NN. 39

OO. 40 PP. 41 QQ. 42 RR. 43 SS. 44 TT. 45 UU. 46 VV. 47 WW. 48 XX. 49 YY. 50 or more

13. Which of the following certifications do you have? select all that apply

A. BC B. C C. CNOR


D. CRNFA E. CPAN and/or CAPA F. CPSN G. NE‐ previously CNA H. NEA previously CNAA I. ONC J. CNS K. NP L. I have no certifications M. Other ___________________________________

14. How many years have you been employed as a Perioperative Nurse? select one

A. 0 B. 1 C. 2 D. 3 E. 4 F. 5 G. 6 H. 7 I. 8 J. 9 K. 10

L. 11 M. 12 N. 13 O. 14 P. 15 Q. 16 R. 17 S. 18 T. 19 U. 20 V. 21

W. 22 X. 23 Y. 24 Z. 25 AA. 26 BB. 27 CC. 28 DD. 29 EE. 30 FF. 31 GG. 32

HH. 33 II. 34 JJ. 35 KK. 36 LL. 37 MM. 38 NN. 39 OO. 40 PP. 41 or more

15. What shift do you usually work? select one

A. Day B. Afternoon/Evening C. Nights D. Weekends Day E. Weekends Night F. Other ___________________________________

16. How many years have you been an AORN member? select one

A. Not an AORN Member B. Less than 1 year C. 1‐3 years D. 4‐6 years E. 7‐9 years F. 10‐12 years G. 13‐15 years H. More than 15 years

17. Please indicate your gender: select one A. Female B. Male C. Prefer Not to Answer


18. What is your age? select one A. Under 18 B. 18‐24 C. 25‐34 D. 35‐44 E. 45‐54 F. 55‐64 G. 65 or Above H. Prefer Not to Answer

19. Do you have any other comments you would like to share with us? ____________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Appendix E

Face Validity Questionnaire


Face Validity Questionnaire:

Dear Perioperative Nurse,

You have been selected to participate in a pilot test of a survey developed to explore

perioperative nurses’ knowledge and attitudes about implementation of evidence‐

based clinical practice guidelines related to patient temperature regulation in

perioperative settings. Please complete the survey, and answer the questions below

relating to the structure and content of the survey.

1. a. How long in minutes did it take you to complete the survey? ____

b. Did you feel that completion of the survey took too much time? □Yes □ No

2. Are the instructions for completing the survey clearly written? □Yes □ No

If you answered, “No,” please explain which instructions were

unclear._______________________________________________________________________________________

_________________________________________________________________________________________________

3. Are the questions clearly written? □Yes □ No

If you answered “No,” please indicate the questions that need to be worded more

clearly:________________________________________________________________________________________

_________________________________________________________________________________________________

4. Are there any questions that should have more choices for answers than those

given? □Yes □ No

If you answered “Yes,” please indicate the questions that need to have choices

added. Please specify the choices that you would


add.____________________________________________________________________________________________

_________________________________________________________________________________________________

5. Which, if any, questions should be omitted?______________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

6. Should any questions be added to the survey? Please

specify.________________________________________________________________________________________

_________________________________________________________________________________________________

7. Did the survey adequately assess your understanding of the level of knowledge that

exists among perioperative nurses related to evidence‐based clinical practice

guidelines for the prevention of unplanned perioperative hypothermia? □Yes □ No

If you answered, “No,” what other questions about knowledge should be

added?________________________________________________________________________________________

________________________________________________________________________________________________

8. Did the survey adequately assess your knowledge of the barriers to perioperative

nurses’ implementation of evidence‐based clinical practice guidelines relating to

management of perioperative normothermia? □Yes □ No

If you answered, “No,” what other questions about attitudes should be

added?________________________________________________________________________________________

_____________________________________________________________________________________________

9. Did the survey adequately assess the nursing interventions that are used for

thermal regulation and management in the perioperative setting? □Yes □ No


If you answered, “No,” what other factors should be

added?________________________________________________________________________________________

_________________________________________________________________________________________________


Appendix F

Content Analysis Checklist


Content Analysis Checklist

Evidencebased Clinical Practice Guidelines

Please read each question on the survey. Score each item for its relevance in answering the research questions posed in the study i.e., what level of knowledge exists among perioperative nurses related to evidence‐based clinical practice guidelines for the prevention of unplanned perioperative hypothermia, what are the barriers to perioperative nurses’ implementation of evidence‐based clinical practice guidelines relating to management of perioperative normothermia, and what nursing interventions are used for thermal regulation and management in the perioperative setting .

Please comment on any of the items, including possible revisions or substitutions, as well as your thoughts about why an item is not relevant. Please suggest any additional items you feel would improve the survey’s measurement of knowledge, barriers and interventions affecting implementation of evidence‐based clinical practice guidelines.

NotRelevant

Somewhat Relevant

Quite Relevant

HighlyRelevant

In what phase of perioperative nursing do you currently practice? Please select the one best answer for each question.

Preoperative / Admitting Area: Intraoperative: Postoperative / Recovery Area:

In what age‐specific area of perioperative nursing do you currently practice? Please select the one best answer for each question.

Adult only Pediatric only: Both adult and pediatric

The following questions ask about your nursing practice related to the AORN Recommended Practice “The Prevention of Unplanned Perioperative Hypothermia.”

Have you heard about the AORN Recommended Practice, “The Prevention of Unplanned Perioperative Hypothermia”?

Have you read about this AORN Recommended Practice?

Have you followed this AORN Recommended Practice?


Have you learned about this AORN Recommended Practice formal education offering, in‐service, or training experience ?


How often do you use this AORN Recommended Practice?

Please indicate which evidence‐based clinical practice guideline if any you utilize to plan and deliver perioperative nursing care:

AORN Recommended Practice ASPAN Clinical Practice Guideline Other evidence‐based clinical practice guideline: ______________________________

Please describe a typical adult patient’s experience from a recent workday as you answer the following clinical focused questions. Indicate the frequency of your actions for each question by selecting one choice.

How often did you document patient temperature?

How often did you apply any interventions to manage the patient’stemperature?




None Cotton blankets Carbon‐fiber blanket Forced‐air warming blanket Circulating water blanket Circulating water garment Increased room temperature


Radiant heat Gel pad surface warming Resistive heating Warmed IV fluids Warmed irrigation fluids Humidified warmed oxygen Other please specify : ______________________________________

Barriers and Facilitators NotRelevant

Somewhat Relevant

Quite Relevant

HighlyRelevant





I am unaware of the research The facilities are inadequate for implementation

I do not have time to read research The research has not been replicated I feel the benefits of changing practice will be minimal







I see little benefit for myself Research reports/articles are not published fast enough







The literature reports conflicting results The research is not reported clearly and readably


I am unwilling to change/try new ideas The amount of research information is overwhelming



Demographics NotRelevant

SomewhatRelevant

Quite Relevant

HighlyRelevant

In what type of setting do you primarily work? select one

Acute Care Hospital Ambulatory Surgery Center ‐‐ Hospital based

Ambulatory Surgery Center ‐‐ Free standing

Ambulatory Surgery Center ‐‐ Office based

Industry School of Nursing Independent Consultant

If you work in a hospital setting, which term best describes your primary place of employment? select one

General/Community hospital Specialty Hospital/Facility University/Academic Medical Center Other

Which term best describes the ownership of your primary place of employment? select one

Government/Nonfederal e.g., County


Hospital Government/Federal e.g., VA hospital Military Private, Investor‐owned/For profit Non‐Government/Nonprofit

How would you describe the location of your workplace? select one

Urban Suburban Rural

In what region of the country are you currently employed? select one

New England NH, VT, ME, CN, RI, MA Mid‐Atlantic NJ, DE, MD, PA, NY, Washington, DC

South Atlantic WV, VA, NC, SC, GA, FL East North Central WI, MI, IL, IN, OH West North Central ND, SD, MN, NE, IA, KS, MO

East South Central KY, TN, MS, AL West South Central OK, AR, TX, LA Mountain MT, ID, WY, NV, UT, CO, AZ, NM

Pacific AK, WA, OR, CA, HI Outside of United States


What is the total number of ORs in your facility? Include CVOR, ASC, Ambulatory OR, Hybrid Room, Inveterventional Suite e.g., Cardiac Catheterization Laboratory, Interventional Radiology Suite, GI Suite Endo rooms and Cysto rooms. select one

What is your current title? select one

Staff Nurse Hospital/Facility Administrator Director/VP/Assistant Director Nursing Nurse Manager/Supervisor/Coordinator/Tea


m Leader/Business ManagerEducator/Staff Development Educator/Faculty Clinical Nurse Specialist RN First Assistant Nurse Practitioner Consultant Other

What percentage of your work week are you providing direct patient care? select one

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Which of the following areas are you responsible for or in which do you PRIMARILY work? select all that apply

Operating Room Post‐Anesthesia Care Unit Endoscopy Ambulatory or outpatient surgery unit Office‐based setting Preadmission testing Central Supply/Sterile Processing Department

Emergency Department 24‐hour observation unit Pain management Anesthesia Hybrid Room Interventional Suite e.g., Cardiac Catheterization Laboratory, Interventional Radiology Suite, GI Suite

Other _________________________________________

Please indicate your affiliation with your


primary workplace: select oneFull‐time employee ‐‐ work 32 hours per week

Part‐time employee Full‐time employee for a staffing agency ‐‐ work 32 hours per week

Part‐time employee for a staffing agency Per diem for a health care facility or staffing agency

Currently unemployed Other _________________________________________

What is your highest level of education? select one

Diploma Associate degree Bachelor’s in Nursing Bachelor’s in another field Master’s in Nursing Master’s in another field Doctorate in Nursing Doctorate in another field Other _________________________________________

How many years has it been since you achieved the level of education mentioned above? select one

Which of the following certifications do you have? select all that apply

BC C CNOR CRNFA CPAN and/or CAPA CPSN NE previously CNA NEA previously CNAA ONC CNS NP I have no certifications Other ____________________________________________


How many years have you been employedas a Perioperative Nurse? select one

What shift do you usually work? select one

Day Afternoon/Evening Nights Weekends Day Weekends Night Other ______________________________________

How many years have you been an AORN member? select one

Not an AORN Member Less than 1 year 1‐3 years 4‐6 years 7‐9 years 10‐12 years 13‐15 years More than 15 years

Please indicate your gender: select one

Male Female Prefer Not to Answer

What is your age? select one

Under 18 18‐24 25‐34 35‐44 45‐54 55‐64 65 or Above Prefer Not to Answer

Comments:________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________


Content Analysis Checklist Evidencebased Clinical Practice Guidelines

Please read each question on the survey. Score each item for its relevance in

answering the research questions posed in the study i.e., what level of knowledge exists among perioperative nurses related to evidence‐based clinical practice guidelines for the prevention of unplanned perioperative hypothermia, what are the barriers to perioperative nurses’ implementation of evidence‐based clinical practice guidelines relating to management of perioperative normothermia, and what nursing interventions are used for thermal regulation and management in the perioperative setting .

Please comment on any of the items, including possible revisions or substitutions, as well as your thoughts about why an item is not relevant. Please suggest any additional items you feel would improve the survey’s measurement of knowledge, barriers and interventions affecting implementation of evidence‐based clinical practice guidelines.

Rater #01

Rater #02

Rater #03

Rater #04

Rater#05 CVI

In what phase of perioperative nursing do you currently practice? Please select the one best answer for each question.

4 4 4 4 4 1.0

Preoperative / Admitting Area: 4 4 4 4 4 1.0Intraoperative: 4 4 4 4 4 1.0Postoperative / Recovery Area: 4 4 4 4 4 1.0

In what age‐specific area of perioperative nursing do you currently practice? Please select the one best answer for each question.

4 4 4 4 4 1.0

Adult only 4 4 4 4 4 1.0Pediatric only: 4 4 4 4 4 1.0Both adult and pediatric 4 4 4 4 4 1.0

The following questions ask about your nursing practice related to the AORN Recommended Practice “The Prevention of Unplanned Perioperative Hypothermia.”

4 4 4 4 4 1.0

Have you heard about the AORN Recommended Practice, “The Prevention of Unplanned Perioperative Hypothermia”?

4 4 4 4 4 1.0


Rater #01

Rater #02

Rater #03

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Rater#05 CVI

Have you read about this AORN Recommended Practice?

4 4 4 4 4 1.0

Have you followed this AORN Recommended Practice?

4 4 4 4 4 1.0

Have you learned about this AORN Recommended Practice formal education offering, in‐service, or training experience ?

3 4 4 4 4 0.9


4 4 4 4 4 1.0

How often do you use this AORN Recommended Practice?

4 4 4 4 4 1.0

Please indicate which evidence‐based clinical practice guideline if any you utilize to plan and deliver perioperative nursing care:

4 4 4 4 4 1.0

AORN Recommended Practice 4 4 4 4 4 1.0ASPAN Clinical Practice Guideline

4 4 4 4 4 1.0

Other evidence‐based clinical practice guideline: ______________________________

4 4 4 4 4 1.0

Please describe a typical adult patient’s experience from a recentworkday as you answer the following clinical focused questions. Indicate the frequency of your actions for each question by selecting one choice.

4 4 4 4 4 1.0

How often did you document patient temperature?

4 4 4 4 4 1.0


4 4 4 4 4 1.0


4 4 4 4 4 1.0


Rater #01

Rater #02

Rater #03

Rater #04

Rater#05 CVI


4 4 4 4 4 1.0


4 4 4 4 4 1.0

None 4 4 4 4 4 1.0Cotton blankets 4 4 4 4 4 1.0Carbon‐fiber blanket 4 4 4 4 4 1.0Forced‐air warming blanket 4 4 4 4 4 1.0Circulating water blanket 4 4 4 4 4 1.0Circulating water garment 4 4 4 4 4 1.0Increased room temperature 4 4 4 4 4 1.0Radiant heat 4 4 4 4 4 1.0Gel pad surface warming 4 4 4 4 4 1.0Resistive heating 4 4 4 4 4 1.0Warmed IV fluids 4 4 4 4 4 1.0Warmed irrigation fluids 4 4 4 4 4 1.0Humidified warmed oxygen 4 4 4 4 4 1.0Other please specify : ______________________________________

4 4 4 4 4 1.0

Barriers and Facilitators Rater #01

Rater #02

Rater #03

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Rater#05 CVI


4 4 4 4 4 1.0


4 4 4 4 4 1.0


4 4 4 4 4 1.0


4 4 4 4 4 1.0

I am unaware of the research 4 4 4 4 4 1.0The facilities are inadequate for implementation

4 4 4 4 4 1.0

I do not have time to read research

4 4 4 4 4 1.0


Rater #01

Rater #02

Rater #03

Rater #04

Rater#05 CVI

The research has not been replicated

4 4 4 4 4 1.0

I feel the benefits of changing practice will be minimal

4 4 4 4 4 1.0


4 4 4 4 4 1.0


4 4 3 4 4 0.9


4 4 4 4 4 1.0


4 4 4 4 4 1.0


4 4 4 4 4 1.0


4 4 4 4 4 1.0

I see little benefit for myself 4 4 4 4 4 1.0Research reports/articles are not published fast enough

4 4 4 4 4 1.0


4 4 4 4 4 1.0


4 4 4 4 4 1.0


4 4 4 4 4 1.0


4 4 4 4 4 1.0


4 4 4 4 4 1.0

The literature reports conflicting results

4 4 4 4 4 1.0

The research is not reported clearly and readably

4 4 4 4 4 1.0


4 4 4 4 4 1.0

I am unwilling to change/try new ideas

4 4 4 4 4 1.0

The amount of research information is overwhelming

4 4 4 4 4 1.0


Rater #01

Rater #02

Rater #03

Rater #04

Rater#05 CVI


4 4 4 4 4 1.0


4 4 4 4 4 1.0

Demographics Rater #01

Rater #02

Rater #03

Rater #04

Rater#05 CVI

In what type of setting do you primarily work? select one

4 4 4 4 4 1.0

Acute Care Hospital 4 4 4 4 4 1.0Ambulatory Surgery Center ‐‐Hospital based

4 4 4 4 4 1.0

Ambulatory Surgery Center ‐‐Free standing

4 4 4 4 4 1.0

Ambulatory Surgery Center ‐‐Office based

4 4 4 4 4 1.0

Industry 4 4 4 4 4 1.0School of Nursing 4 4 4 4 4 1.0Independent Consultant 4 4 4 4 4 1.0

If you work in a hospital setting, which term best describes your primary place of employment? select one

4 4 4 4 4 1.0

General/Community hospital 4 4 4 4 4 1.0Specialty Hospital/Facility 4 4 4 4 4 1.0University/Academic Medical Center

4 4 4 4 4 1.0

Other 4 4 4 4 4 1.0 Rater

#01Rater #02

Rater #03

Rater #04

Rater#05 CVI

Which term best describes the ownership of your primary place of employment? select one

4 4 4 4 4 1.0

Government/Nonfederal e.g., County Hospital

4 4 4 4 4 1.0

Government/Federal e.g., VA hospital

4 4 4 4 4 1.0

Military 4 4 4 4 4 1.0Private, Investor‐owned/For profit

4 4 4 4 4 1.0


Non‐Government/Nonprofit 4 4 4 4 4 1.0 How would you describe the location of your workplace? select one

4 4 4 4 4 1.0

Urban 4 4 4 4 4 1.0Suburban 4 4 4 4 4 1.0Rural 4 4 4 4 4 1.0


4 4 4 4 4 1.0

New England NH, VT, ME, CN, RI, MA

4 4 4 4 4 1.0

Mid‐Atlantic NJ, DE, MD, PA, NY, Washington, DC

4 4 4 4 4 1.0

South Atlantic WV, VA, NC, SC, GA, FL

4 4 4 4 4 1.0

East North Central WI, MI, IL, IN, OH

4 4 4 4 4 1.0

West North Central ND, SD, MN, NE, IA, KS, MO

4 4 4 4 4 1.0

East South Central KY, TN, MS, AL

4 4 4 4 4 1.0

West South Central OK, AR, TX, LA

4 4 4 4 4 1.0

Mountain MT, ID, WY, NV, UT, CO, AZ, NM

4 4 4 4 4 1.0

Pacific AK, WA, OR, CA, HI 4 4 4 4 4 1.0Outside of United States 4 4 4 4 4 1.0


4 4 4 4 4 1.0

What is the total number of ORs in your facility? Include CVOR, ASC, Ambulatory OR, Hybrid Room, Inveterventional Suite e.g., Cardiac Catheterization Laboratory, Interventional Radiology Suite, GI Suite Endo rooms and Cysto rooms. select one

4 4 4 4 4 1.0


Rater #01

Rater #02

Rater #03

Rater #04

Rater#05 CVI

What is your current title? select one

4 4 4 4 4 1.0

Staff Nurse 4 4 4 4 4 1.0Hospital/Facility Administrator 4 4 4 4 4 1.0Director/VP/Assistant Director Nursing

4 4 4 4 4 1.0

Nurse Manager/Supervisor/Coordinator/Team Leader/Business Manager

4 4 4 4 4 1.0

Educator/Staff Development 4 4 4 4 4 1.0Educator/Faculty 4 4 4 4 4 1.0Clinical Nurse Specialist 4 4 4 4 4 1.0RN First Assistant 4 4 4 4 4 1.0Nurse Practitioner 4 4 4 4 4 1.0Consultant 4 4 4 4 4 1.0Other 4 4 4 4 4 1.0

What percentage of your work week are you providing direct patient care? select one

4 4 4 4 4 1.0

0% 4 4 4 4 4 1.010% 4 4 4 4 4 1.020% 4 4 4 4 4 1.030% 4 4 4 4 4 1.040% 4 4 4 4 4 1.050% 4 4 4 4 4 1.060% 4 4 4 4 4 1.070% 4 4 4 4 4 1.080% 4 4 4 4 4 1.090% 4 4 4 4 4 1.0100% 4 4 4 4 4 1.0

Which of the following areas are you responsible for or in which do you PRIMARILY work? select all that apply

4 4 4 4 4 1.0

Operating Room 4 4 4 4 4 1.0Post‐Anesthesia Care Unit 4 4 4 4 4 1.0Endoscopy 4 4 4 4 4 1.0Ambulatory or outpatient surgery unit

4 4 4 4 4 1.0


Office‐based setting 4 4 4 4 4 1.0Preadmission testing 4 4 4 4 4 1.0Central Supply/Sterile Processing Department

4 4 4 4 4 1.0

Emergency Department 4 4 4 4 4 1.024‐hour observation unit 4 4 4 4 4 1.0Pain management 4 4 4 4 4 1.0Anesthesia 4 4 4 4 4 1.0Hybrid Room 4 4 4 4 4 1.0Interventional Suite e.g., Cardiac Catheterization Laboratory, Interventional Radiology Suite, GI Suite

4 4 4 4 4 1.0

Other ______________________________________

4 4 4 4 4 1.0

Please indicate your affiliation with your primary workplace: select one

4 4 4 4 4 1.0

Full‐time employee ‐‐ work 32 hours per week

4 4 4 4 4 1.0

Part‐time employee 4 4 4 4 4 1.0Full‐time employee for a staffing agency ‐‐ work 32 hours per week

4 4 4 4 4 1.0

Part‐time employee for a staffing agency

4 4 4 4 4 1.0

Per diem for a health care facility or staffing agency

4 4 4 4 4 1.0

Currently unemployed 4 4 4 4 4 1.0Other ________________________________

4 4 4 4 4 1.0

What is your highest level of education? select one

4 4 4 4 4 1.0

Diploma 4 4 4 4 4 1.0Associate degree 4 4 4 4 4 1.0Bachelor’s in Nursing 4 4 4 4 4 1.0Bachelor’s in another field 4 4 4 4 4 1.0Master’s in Nursing 4 4 4 4 4 1.0Master’s in another field 4 4 4 4 4 1.0Doctorate in Nursing 4 4 4 4 4 1.0

Rater Rater Rater Rater Rater CVI


#01 #02 #03 #04 #05 Doctorate in another field 4 4 4 4 4 1.0Other ______________________________

4 4 4 4 4 1.0

How many years has it been since you achieved the level of education mentioned above? select one

4 4 4 4 4 1.0


4 4 4 4 4 1.0

BC 4 4 4 4 4 1.0C 4 4 4 4 4 1.0CNOR 4 4 4 4 4 1.0CRNFA 4 4 4 4 4 1.0CPAN and/or CAPA 4 4 4 4 4 1.0CPSN 4 3 4 4 4 .9NE previously CNA 4 4 4 4 4 1.0NEA previously CNAA 4 4 4 4 4 1.0ONC 4 4 4 4 4 1.0CNS 4 4 4 4 4 1.0NP 4 4 4 4 4 1.0I have no certifications 4 4 4 4 4 1.0Other _______________________________________

4 4 4 4 4 1.0

How many years have you been employed as a Perioperative Nurse? select one

4 4 4 4 4 1.0

What shift do you usually work? select one

4 4 4 4 4 1.0

Day 4 4 4 4 4 1.0Afternoon/Evening 4 4 4 4 4 1.0Nights 4 4 4 4 4 1.0Weekends Day 4 4 4 4 4 1.0Weekends Night 4 4 4 4 4 1.0Other _________________________________

4 4 4 4 4 1.0

How many years have you been an AORN member? select one

4 4 4 4 4 1.0

Not an AORN Member 4 4 4 4 4 1.0Less than 1 year 4 4 4 4 4 1.0


Rater #01

Rater #02

Rater #03

Rater #04

Rater#05 CVI

1‐3 years 4 4 4 4 4 1.04‐6 years 4 4 4 4 4 1.07‐9 years 4 4 4 4 4 1.010‐12 years 4 4 4 4 4 1.013‐15 years 4 4 4 4 4 1.0More than 15 years 4 4 4 4 4 1.0

Please indicate your gender: select one

4 4 4 4 4 1.0

Male 4 4 4 4 4 1.0Female 4 4 4 4 4 1.0Prefer Not to Answer 4 4 4 4 4 1.0

What is your age? select one 4 4 4 4 4 1.0

Under 18 4 4 4 4 4 1.018‐24 4 4 4 4 4 1.025‐34 4 4 4 4 4 1.035‐44 4 4 4 4 4 1.045‐54 4 4 4 4 4 1.055‐64 4 4 4 4 4 1.065 or Above 4 4 4 4 4 1.0Prefer Not to Answer 4 4 4 4 4 1.0 Rater

#01Rater #02

Rater#03

Rater #04

Rater#05 CVI

0.999 0.999 0.999 1.0 1.0 Overall 0.999

Comments:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Appendix G

AORN Research Committee Support

PERI

IOPERATIVEE IMPLEMEENTATION

127


Appendix H

Simmons College IRB Approval

PERI

IOPERATIVEE IMPLEMEENTATION 129


Appendix I

AORN Approval to use Membership Database

PERI


131


Appendix J

AORN Informz.net Invitation Content

PERI


133


Appendix K

Demographics


Table K1

In what type of setting do you primarily work? Response % NAcute Care Hospital 73.1% 400 Ambulatory Surgery Center ‐‐ Hospital based 12.2% 67 Ambulatory Surgery Center ‐‐ Free standing 10.4% 57 Ambulatory Surgery Center ‐‐ Office based 0.9% 5Industry 0.4% 2School of Nursing 0.2% 1Independent Consultant 0.5% 3Other 2.2% 12

Total Responses 547

Table K2

If you work in a hospital setting which term best describes your primary place of employment?

Response % NGeneral/Community Hospital 69.6% 341Specialty Hospital/Facility 6.9% 34University/Academic Medical Center 20.4% 100Other 3.1% 15

Total Responses 490

Table K3

Which term best describes the ownership of your primary place of employment?

Response % NGovernment/Nonfederal e.g., County Hospital

9.6% 52

Government/Federal e.g., VA hospital 2.8% 15Military 0.7% 4Private, Investor‐owned/For profit 26.8% 145Non‐Government/Nonprofit 57.7% 312Other 2.4% 13

Total Responses 541


Table K4

How would you describe the location of your workplace?

Response % NUrban 40.6% 220Suburban 38.9% 211Rural 20.5% 111

Total Responses 542

Table K5


Response % N New England NH, VT, ME, CN, RI, MA 7.2% 39 Mid‐Atlantic NJ, DE, MD, PA, NY, Washington, DC 16.7% 91 South Atlantic WV, VA, NC, SC, GA, FL 15.4% 84 East North Central WI, MI, IL, IN, OH 17.1% 93 West North Central ND, SD, MN, NE, IA, KS, MO 6.8% 37 East South Central KY, TN, MS, AL 5.1% 28 West South Central OK, AR, TX, LA 8.6% 47 Mountain MT, ID, WY, NV, UT, CO, AZ, NM 5.7% 31 Pacific AK, WA, OR, CA, HI 15.3% 83 Outside of United States 2.0% 11

Total Responses 544

Table K6


Response % NAustralia 18% 2Canada 27% 3East Timor 9% 1Ethiopia 9% 1Germany 9% 1Jamaica 9% 1Spain 9% 1Turkmenistan 9% 1

Total Responses 11


Table K7

What is the total number of ORs in your facility?

Response % N 0.2% 11 2.2% 122 4.4% 243 4.3% 234 6.1% 335 5.4% 296 5.4% 297 3.0% 168 3.9% 219 4.3% 2310 6.3% 3411 3.1% 1712 4.6% 2513 1.9% 1014 3.1% 1715 2.2% 1216 3.9% 2117 1.9% 1018 1.9% 1019 1.7% 920 3.7% 2021 0.7% 422 2.0% 1123 1.1% 624 1.7% 925 2.0% 1126 0.7% 427 0.7% 428 1.1% 629 0.6% 330 4.1% 2231 0.2% 132 0.0% 033 0.6% 334 0.6% 335 0.7% 436 0.7% 437 0.4% 238 0.2% 1


39 0.4% 240 0.7% 4

41 or more 7.4% 40Total Responses 540

Table K8

What is your current title?

Response % N Staff Nurse 53.4% 291 Hospital/Facility Administrator 0.7% 4 Director/VP/Assistant Director Nursing 5.9% 32 Nurse Manager/Supervisor/Coordinator/Team Leader/Business Manager

17.6% 96

Educator/Staff Development 10.5% 57 Educator/Faculty 1.1% 6 Clinical Nurse Specialist 1.7% 9 RN First Assistant 7.3% 40 Nurse Practitioner 0.6% 3 Consultant 0.6% 3 Other 0.7% 4

Total Responses 545

Table K9

What percentage of your work week are you providing direct patient care?

Response % N 0% 4.9% 2610% 10.1% 5420% 3.8% 2030% 4.5% 2440% 4.9% 2650% 3.9% 2160% 3.0% 1670% 4.9% 2680% 6.8% 3690% 14.3% 76100% 39.0% 208Total Responses 533


Table K10

Which of the following areas are you responsible for or in which do you primarily work? select all that apply

Response % N Operating Rooms 92.0% 508 Post‐Anesthesia Care Unit 26.6% 147 Endoscopy 18.8% 104 Ambulatory or outpatient surgery unit 28.6% 158 Office‐based setting 4.5% 25 Preadmission testing 12.9% 71 Central Supply/Sterile Processing Department 14.9% 82 Emergency Department 0.5% 3 24‐hour observation unit 0.7% 4 Pain management 8.0% 44 Anesthesia 8.5% 47 Hybrid Room 2.5% 14 Interventional Suite e.g., Cardiac Catheterization Laboratory, Interventional

4.7% 26

Other 1.1% 6 Total Responses 552

Table K11

Please indicate your affiliation with your primary workplace.

Response % N Full‐time employee ‐‐ work 32 hours per week 84.5% 457Part‐time employee 9.4% 51Full‐time employee for a staffing agency ‐‐ work 32 hours per week

0.4% 2

Part‐time employee for a staffing agency 0.2% 1Per diem for a health care facility or staffing agency 4.3% 23Currently unemployed 0.6% 3Other 0.7% 4

Total Reponses 541


Table K12

What is your highest level of education?

Response % NDiploma 10.9% 59Associate degree 20.7% 112Bachelor’s in Nursing 39.6% 214Bachelor’s in another field 6.8% 37Master’s in Nursing 13.7% 74Master’s in another field 7.2% 39Doctorate in Nursing 0.4% 2Doctorate in another field 0.0% 0Other 0.7% 4

Total Responses 541

Table K13

How many years has it been since you achieved the level of education mentioned above?

Response % N 0 3.3% 181 5.6% 302 4.6% 253 3.7% 204 4.1% 225 3.2% 176 2.4% 137 1.7% 98 1.7% 99 1.5% 810 4.5% 2411 2.2% 1212 2.2% 1213 2.6% 1414 2.0% 1115 2.2% 1216 2.6% 1417 1.3% 718 0.4% 219 1.1% 620 5.0% 27


21 2.0% 1122 1.3% 723 1.3% 724 1.5% 825 3.7% 2026 1.3% 727 2.4% 1328 3.2% 1729 0.9% 530 3.5% 1931 2.6% 1432 1.9% 1033 1.9% 1034 1.3% 735 3.7% 2036 1.5% 837 0.7% 438 1.3% 739 0.7% 440 2.2% 1241 0.2% 142 0.6% 343 0.6% 344 0.4% 245 0.7% 446 0% 047 0.2% 148 0.2% 149 0% 0


Table K14


Response % N

BC 1.6% 9C 1.1% 6CNOR 67.2% 368CRNFA 5.7% 31


CPAN and/or CAPA 2.6% 14CPSN 0.4% 2NE previously CNA 0.2% 1NEA previously CNAA 0% 0ONC 1.1% 6CNS 0.9% 5NP 2.0% 11No certifications 22.4 123Other 5.1% 28

Total Responses 604

Table K15

How many years have you been employed as a Perioperative Nurse?

Response % N1 0.6% 32 0.9% 53 2.0% 114 3.4% 185 1.9% 106 2.0% 117 1.7% 98 2.8% 159 2.0% 1110 3.4% 1811 3.2% 1712 2.8% 1513 2.6% 1414 2.0% 1115 3.4% 1816 3.5% 1917 1.7% 918 2.0% 1119 2.2% 1220 5.6% 3021 2.6% 1422 2.6% 1423 1.9% 1024 2.2% 12


25 7.3% 3926 1.7% 927 2.4% 1328 2.2% 1229 1.9% 1030 3.5% 1931 2.0% 1132 1.1% 633 1.9% 1034 2.0% 1135 2.6% 1436 2.6% 1437 1.9% 1038 2.0% 1139 0.6% 340 2.2% 12


Table K16

What shift do you usually work?

Response % NDay 89.9% 479Afternoon/Evening 6.8% 36Nights 1.1% 6Weekends Day 0.6% 3Weekends Night 0.6% 3Other 1.1% 6

Total Responses 533


Table K17

How many years have you been an AORN member?

Response % NNot an AORN Member 0% 0Less than 1 year 5.8% 311‐3 years 14.1% 754‐6 years 17.1% 917‐9 years 8.1% 4310‐12 years 11.7% 6213‐15 years 6.8% 36More than 15 years 36.5% 194

Total Responses 532

Table K18

Please indicate your gender.

Response % NMale 6.1% 32Female 93.0% 489Prefer Not to Answer 1.0% 5

Total Responses 526

Table K19

What is your age?

Response % NUnder 18 0% 018‐24 0% 025‐34 5.3% 2835‐44 12.1% 6445‐54 37.1% 19655‐64 39.3% 20865 or Above 4.7% 25Prefer Not to Answer 1.5% 8

Total Responses 529


Appendix L

BARRIERS Narrative Data


BARRIERS Narrative Data 1 Our SCIP scores are currently satisfactory; therefore, there is not a strong

driving force behind making any additional changes that would result in an additional financial commitment

2 Workplace culture 3 In my institution, management is not receptive and does not make enough time

for staff to discuss changes in practice4 Availability to the nursing staff5 Mainly just equal access for the entire department and administration 6 Unwillingness of the institution to allow implementation of change that might

cost money 7 The main barrier is changing postoperative culture in regards to the use of

forced‐air warming blankest sic in our institution8 Poor communication between shifts in or settings9 Resistance to change by staff/physicians, e.g., anesthesia to change 10 Availability of money for some changes11 At the current facility where I work, anesthesia and most staff are very

reluctant to initiate and continue with normothermic sic practices 12 Inadequate managerial support of changes in clinical practice, usually $$

related 13 Language of staff, contextual barriers I work in emergency humanitarian aid

in resource poor environments14 The price of some journals15 Lack of motivation on the part of the staff to read and learn about the research16 Often too general 17 Comparing like items. I.e., chloraprep to betadine instead of to duraprep18 Financial resources 19 The greatest factor is TIME. There are a lot of things to be done for every

patient but I feel patients were being short change sic every time they come in the OR. Too much sic things to do for little sic time given because I feel we always have to keep up with the standard turn over time of not more than 15 minutes for a major case. And no support from nursing management, doctors & administrations sic . Everyone is just looking at the time spend sic for every case. And for nurses who are actually setting up everything for each surgery, it is really frustrating

20 Inadequate time to initiate programs for change21 Physicians 22 Management 23 Peer apathy 24 Some things are done by anesthesia people like recording, interpretation and

management of temperature of the patient / as sic a nurse I just help so one barrier is that we work as a team but we have set sic of things to do to arrive on a common goal and that is safety of the patient


25 Administration. I have written suggestions for warming irrigation solutions for arthroscopic procedures and have been ignored to a large extent

26 Anesthesia team members control the Bair Hugger practices in the OR‐‐same with T monitoring. If there were enough Bair Huggers then it might be feasible. You need someone to champion the cause or bring the attention to the forefront like you are doing. You spend your time and energy focusing on the patients well being, little energy is left over. Great idea for a thesis

27 If there are any additional costs involved28 I have a difficult time convincing my fellow colleagues of the value of the

research sic 29 MD's 30 Apathy from staff 31 Statistical analysis and interpretation is intimidating for many most nurses32 Physicians unwilling to adapt to newer methods33 Physicians do not like to be told what to do especially by nursing 34 Time and Money to implement new practices35 Historically research reports show what THEY want it to show. Depends on

what is being sold! 36 Time during working hours. We have no set time for research utilization. If

census is low, we are sent home rather than to expand our practice 37 Many times it does not apply to a single specialty small surgery center 38 Difficult for most OR nurses to understand39 Time and money. Staff not having dedicated time for research investigation

and process implementation40 Staff by‐in sic 41 Not encouraged by nursing administration42 Cost and having the latest technology available at our facility 43 Management 44 My facility functions under a strict biomedical model. Nursing must be

practiced in secret, therefore implementation of evidence‐based nursing research is a danger to one's career

45 Finding the time to read the journals is the biggest obstacle I face, however we are in the process of organizing a journal club which I feel would be more beneficial

46 ADN nurses do not have the theoretical background to apply research 47 Much research is conducted with bias for financial interests pharmaceutical

companies paying for drug studies, manufacturers of implants paying for research????? sic Who's kidding who?

48 In general, it is not required of staff nurses who are involved in the majority of patient care

49 Sometimes published research is not completely impartial or is sponsored by a company

50 Game playing sic power vs. pt care no backing from administration in general so RNs do not feel empowered to want change


51 The time factor is huge. Time to research, develop a plan, present to leadership, engage and educator sic the staff and medical staff of needed EBP. Certainly, I believe it is worth it. It is how improve sic outcomes. We have so many outcomes we are now responsible for including CORE measures, HCAPS, financial return, etc. There are not enough educators!

52 Staff and administration will not change because surgeons won’t change53 Average age of peri‐operative nurses may influence the readiness to change

practice 54 Clarification‐ RNs don't record pt temp, anesthesia does on their record55 Sometimes it is difficult to involve peers in practice change even when the

evidence is overwhelming for change to due sic practice habits 56 No barriers with my coworkers or the management. We are currently doing

our own QI on temperature management57 AORN Best Practice sic regarding hypothermia is referenced, but is not truly

"evidence‐based" in that there was no systematic review or ranking of the level/quality of the evidence

58 Barrier for me and this survey is I see patients prior to day of surgery so much was not necessarily relevant

59 Not discussed in staff meetings60 1. Staff being inadequately educated & prepared sic for use. 2. Insufficient

quantity of needed supplies warming blankets, Thermal Drapes 3. Inadequate supply of clean linens, including blankets provided by the linen service mostly due to incorrect ordering approval by administration who are trying to hold down our linen costs 4. Difference of opinions by the staff to do extra tasks, like warming the bed, warming IV fluids & the like. 5. No warmers for IV/irrigation fluid

61 Facility funding 62 Research is limited, too little time, everyone is concerned about turn over time

and getting cases done 63 Cost of implementing if need to purchase items not already in the budget64 Physician buy in 65 Cost of implementation and training66 I personally do not have any barriers to research utilization 67 Surgeons and other MD's often do not like change unless it is their idea and

bringing forth new ideas for change does not go over very well 68 Studies are not valid or useful69 Funding 70 Communication 71 Financial justification 72 Frequently money is a deciding factor on change73 The physicians don't seem to care at sic AORN standards74 Reliability of staff nurses commitment to make change75 Not enough time to do research when also doing clinical76 People being open to change and to try new ideas77 Individual unwillingness to change current work practices


78 Economics and availability of products79 It takes entirely too much time for research to become practice. e.g., 17years?!?

sic 80 Lack of sufficient time/information regarding current updates from work ‐

continuing education is NOT supported at work81 Just try to get throughout the work day...always rush, rush, rush! sic 82 Often, I feel like it has to be surgeon driven instead of EBP driven 83 Costs 84 I work in a for profit asc. everything is done on the "cheap" sic and in a hurry85 Nursing administration at my institute is not interested in pursuing or

implementing evidenced based practice. Short cuts seem to be easier for them86 Facility budget 87 Time to locate and the availability of research88 Cost of implementing changes89 Management/administration that is not up to date on research 90 Time it takes to implement change91 There is a lot of information and research of the importance of maintaining

normal thermia sic . It seems the anesthesia world has been more on top of this in the past and now nursing is beginning to take a strong notice of the negative effects/outcomes of hypothermia for our patients. We need to work together as a team...and I feel this team atmosphere can be worked on by all

92 Surgeons wish to order as needed93 We are too busy to stop and fill out extra forms. Maybe the info could be

obtained by computer data collections and analyzed94 Management 95 Direct nurse education is often lacking the written proof whereby the results

are shown to be successful96 Implementation by management is not consistent97 Some staff are resistant to change98 I work in a non‐profit hospital, but I think that profitability would be an issue99 Most hospitals that I work at practice AORN standards and utilize evidence

practice for hypothermia. I work at Ambulatory Care Centers and they are less likely to utilize the AORN standards because of cost and time issues. Most Ambulatory Care Centers are surgeon owned and their bottom line is cost not necessarily patient safety. They have no understanding of AORN standards and don't care to be bothered. I am recently working for an Office Based surgical practice. We were in the process of obtaining AAAHC accreditation and I suggested that he needed to get a copy of the current AORN standards to have as a reference. He disdainfully replied," I'm not spending any money on that!" It's not the nurses that we need to educate about the need to utilize the AORN standards in our practice. It is the surgeon's that need to know the advantages of having knowledgeable nurses who are well versed in the AORN standards and recommendations and the availability of all of the other organizations that support patient safety

100 Not enough available computers in the practice setting


101 Unit director resistant to change not supportive of EBP102 Sometimes it can be cost barriers103 All the questions are covered in the survey 104 The management does not back the research they back the physicians 105 Poor leadership 106 Time 107 Lack of knowledge for the change108 Not in‐hospital Perioperative educators to help keep the staff current and

interested 109 Need to find time to read new research110 Lack of desire to learn how to read research results by staff nurses 111 The average perioperative nurses at my facility are low on the food chain of

decision and policy making112 Time, availability, cooperation113 Budgetary concerns depending on the change in practice114 Private sites requiring a paid subscription115 Institution that blocks Master level nurses and elimination of clinical nurse

specialist positions 116 One surgeon wants the room temp at 62 F. Working with this individual is

challenging 117 Availability of new products, must pass through committee before tested118 Same day does NOT initiate a forced‐air warming blanket here in ND, when in

CA each person gets a warming blanket and it continues through‐out their stay!119 Decreasing number of RN staff, present in facilities, to lead ancillary personnel

to implement change 120 The other members of the staff don't want nursing's improvement 121 National OR accrediting agencies have requirements that can conflict 122 Product research seems to be manipulated to get result company wants123 Administrative support124 Budget 125 I will make any changes if it is good for the patient126 Time is critical and we feel like we work on as assembly line in the OR 127 Administration 128 Staff comfortable with "old" ways129 Research reports have been corrupt in their reporting. The results are bought130 Interested staff. Disinterest in professional and educational development131 Cost of warming devices132 Not paid to do the research to improve pt care133 BSN nurses from accelerated courses are not receiving the quality education of

a traditional BSN program134 Much research I have read on AORN website the "evidence" is based on petri

dish sic results not patients, outcomes not well documented suggesting theoretical results not actual results. Shame on AORN


135 A few co‐workers do not accept that chlorhexidine sic is the better surgical prep, do not like because not easily visible so they feel uncomfortable. Should just open more prep and go over any questionable area

136 There is not leadership from management137 I am put now in a GU clinic with a CNOR status. Either too old, people do not

want to change in the OR‐ I have transferred to a new OR138 Reluctant to change practice before study can be validated in practice by

others 139 Materials needed 140 Time constraints 141 The physicians don't seem to want to change the way they do things regardless

of the evidence 142 Implementation and creating a pilot of practice143 The terminology is difficult to negotiate for myself to understand and I am

interested in EBP 144 Time and /or supplies often affect EBO implementation145 Another barrier is there needs to be more machines, technology which is easier

to use in the perioperative arena. Some of the warming blankets etc have heavy & bulky machines

146 Anesthesia wish to order as needed147 Lots of staff do not read what’s out there in research148 Limited or no down time to do research or work on projects due to inadequate

staffing 149 Cost effectiveness 150 Unmotivated staff 151 Money 152 Staff don't see the need for change or know how to change153 Staff nurses do not care about improving themselves by joining AORN and

keeping up with evidence based research, new findings154 Need active Research Committees in hospitals ‐ we have one and push research

all the time155 We may all take something on in our practice because it is common sense, but

if it costs the administration any significant amount of money it is likely to not be implemented

156 Lack of managerial support for journal clubs and for initiatives to implement research findings

157 As a traveling nurse, I see such a wide discrepancies in the practice for normothermia

158 Evidenced based website would be nice. Central location for trusted articles159 Support from anesthesia providers and surgeons160 Nurse‐patient ratios 161 Is change an option? 162 Lack of educated, qualified staff that know and can conduct research studies163 Certain people are on the committees not allowing new ideas


164 Lack of professionalism in nursing as a whole. Nurses focusing more on the day to day tasks without concern for keeping their practice current by Evidence‐Based methods

165 Research to be used practically MUST BE UNBIASED! sic Not for financial gain

166 Another area 1st floor of operating room, 24 rooms, they do not practice flammable safety when prepping by using towels around area when using chlorhexidine, but checkmark the "safety precautions" part of the care plan. I have brought this up to management, but no change

167 Research needs to be simple, fast to understand and to implement 168 Staff perception sic of needed change in practice169 Interest from upper management170 Management does not back me when trying to implement new ideas AORN

comes out with 171 The terminology is difficult to explain to the disengaged coworkers 172 Nursing culture does not support nursing changes173 Cutting costs means less in budget for change expenditures174 Surgeons do not believe the research175 Staff shortages 176 It takes time and energy to change177 Time ‐ many nurses do not think they have enough time to look up information

on their practice 178 I don't think the average OR nurse in smaller facilities has time to read studies.

We wear too many hats at our place to have down time to read. If we have down time, we are sent home to save the facility payroll costs

179 Often anesthetists will say "the case is not long enough to waste a warming blanket! sic or other such idiotic remarks

180 Lack of buy in sic from the administration and leadership of health care facilities

181 Theory needs to prove the practice implications are relevant PERIOD sic . Not to get recognition for authoring a "White Paper"!

182 Anesthesiologists don't always believe/comply w/ evidence based practice/policies ‐ they do not "get" the importance of timely administration of antibiotics. They were subsequently embarrassed when the statistics of various hospitals showed we were only moderately complying

183 I like being in the OR, but this OR is not going to change because the Nurse Manager will not let it change

184 Convincing management of needed change in practice185 Nurses do not support each other186 AORN RP and Standards are expensive, not easily available and need to be

updated every year. This is a real problem ‐ it should be free 187 Decreased turnaround times/efficiency ‐‐ production line mentality 188 It's easier not to change189 Education of staff on how to look up research and implement it


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