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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.
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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
Research Question #2 ......................................................................................................................... 51
Research Question #3 ......................................................................................................................... 53
Research Question #4 ......................................................................................................................... 56
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 IMPLEMENTATION 13
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
PERIOPERATIVE IMPLEMENTATION 14
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,
PERIOPERATIVE IMPLEMENTATION 15
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?
PERIOPERATIVE IMPLEMENTATION 16
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 .
PERIOPERATIVE IMPLEMENTATION 17
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
PERIOPERATIVE IMPLEMENTATION 18
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.
PERIOPERATIVE IMPLEMENTATION 19
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
PERIOPERATIVE IMPLEMENTATION 20
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
PERIOPERATIVE IMPLEMENTATION 21
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 .
PERIOPERATIVE IMPLEMENTATION 22
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
PERIOPERATIVE IMPLEMENTATION 23
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 .
PERIOPERATIVE IMPLEMENTATION 24
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;
PERIOPERATIVE IMPLEMENTATION 25
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.
PERIOPERATIVE IMPLEMENTATION 26
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.
PERIOPERATIVE IMPLEMENTATION 27
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.
PERIOPERATIVE IMPLEMENTATION 28
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 .
PERIOPERATIVE IMPLEMENTATION 29
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.
PERIOPERATIVE IMPLEMENTATION 30
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
PERIOPERATIVE IMPLEMENTATION 31
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
PERIOPERATIVE IMPLEMENTATION 32
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
PERIOPERATIVE IMPLEMENTATION 33
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.
PERIOPERATIVE IMPLEMENTATION 34
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
PERIOPERATIVE IMPLEMENTATION 35
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
PERIOPERATIVE IMPLEMENTATION 36
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?
PERIOPERATIVE IMPLEMENTATION 37
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
PERIOPERATIVE IMPLEMENTATION 38
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.
PERIOPERATIVE IMPLEMENTATION 39
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
PERIOPERATIVE IMPLEMENTATION 40
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
PERIOPERATIVE IMPLEMENTATION 41
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
PERIOPERATIVE IMPLEMENTATION 42
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:
PERIOPERATIVE IMPLEMENTATION 43
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.,
PERIOPERATIVE IMPLEMENTATION 44
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 .
PERIOPERATIVE IMPLEMENTATION 45
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 .
PERIOPERATIVE IMPLEMENTATION 46
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%
PERIOPERATIVE IMPLEMENTATION 47
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%
PERIOPERATIVE IMPLEMENTATION 48
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
PERIOPERATIVE IMPLEMENTATION 49
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 .
PERIOPERATIVE IMPLEMENTATION 50
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
PERIOPERATIVE IMPLEMENTATION 51
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 .
Research Question #2
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 .
PERIOPERATIVE IMPLEMENTATION 52
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
PERIOPERATIVE IMPLEMENTATION 53
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.
Research Question #3
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
PERIOPERATIVE IMPLEMENTATION 54
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
The Spearman rho’s for each level of measurement in Hooper’s tool indicates
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.
The Spearman rho’s for each level of measurement in Hooper’s tool indicates
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
PERIOPERATIVE IMPLEMENTATION 55
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%
PERIOPERATIVE IMPLEMENTATION 56
Research Question #4
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
PERIOPERATIVE IMPLEMENTATION 57
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.
PERIOPERATIVE IMPLEMENTATION 58
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
PERIOPERATIVE IMPLEMENTATION 59
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.
PERIOPERATIVE IMPLEMENTATION 60
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.
PERIOPERATIVE IMPLEMENTATION 61
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.
PERIOPERATIVE IMPLEMENTATION 62
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
PERIOPERATIVE IMPLEMENTATION 63
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.
PERIOPERATIVE IMPLEMENTATION 64
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.
PERIOPERATIVE IMPLEMENTATION 65
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.
PERIOPERATIVE IMPLEMENTATION 66
Appendices
Appendix A
Tables and Graphs
PERIOPERATIVE IMPLEMENTATION 67
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%
Total Responses 545 100.0%
PERIOPERATIVE IMPLEMENTATION 68
Table A3
“Please indicate your gender.”
Response N %Male 32 6.1%Female 489 93.0%Prefer Not to Answer 5 1.0%
Total Responses 526 100.1%
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%
Total Responses 529 100.0%
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
PERIOPERATIVE IMPLEMENTATION 69
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
PERIOPERATIVE IMPLEMENTATION 70
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
Missing System 730 81.7Total 893 100.0
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
PERIOPERATIVE IMPLEMENTATION 71
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
PERIOPERATIVE IMPLEMENTATION 72
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
PERIOPERATIVE IMPLEMENTATION 73
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
Diploma/Associate 132 2.1669 .69027 Bachelor’s 192 2.2390 .71836 Master’s/Doctoral 110 2.2615 .74083 Total 434 2.2228 .71511
Factor 3: Innovation
Diploma/Associate 132 1.8292 .65129 Bachelor’s 192 1.8406 .65535 Master’s/Doctoral 110 1.9073 .64907 Total 434 1.8540 .65179
Factor 4: Communication
Diploma/Associate 132 2.0274 .74736 Bachelor’s 192 2.0559 .70296 Master’s/Doctoral 110 2.0502 .72149 Total 434 2.0458 .71983
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
PERIOPERATIVE IMPLEMENTATION 74
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
PERIOPERATIVE IMPLEMENTATION 75
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
Factor 2: Organization
Staff Nurse 207 2.2464 .75172Admin/Leader/Manager 130 2.1061 .67104CNS/Educ/Faculty 64 2.2974 .63395Mid‐Level/Practitioner 36 2.3413 .76941Total 437 2.2200 .71561
Factor 3: Innovation
Staff Nurse 207 1.8081 .66047Admin/Leader/Manager 130 1.8377 .62952CNS/Educ/Faculty 64 2.0010 .63815Mid‐Level/Practitioner 36 1.8866 .66223Total 437 1.8516 .64941
Factor 4: Communication
Staff Nurse 207 2.0314 .73184Admin/Leader/Manager 130 2.0576 .70430CNS/Educ/Faculty 64 2.0510 .64983Mid‐Level/Practitioner 36 2.0403 .81382Total 437 2.0428 .71703
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
PERIOPERATIVE IMPLEMENTATION 76
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
PERIOPERATIVE IMPLEMENTATION 77
Table A26
ANOVA: Factor 2: Organization by Role
Unique Method SS df MS F Sig.
Factor 2: Organization
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
Unique Method SS df MS F Sig.
Factor 3: Innovation
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
PERIOPERATIVE IMPLEMENTATION 78
Table A29
Mean Innovation Score by Role
Role N MStaff Nurse 211 1.8070Admin/Leader/Manager 130 1.8377CNS/Educ/Faculty 64 2.0010Mid‐Level/Practitioner 38 1.8675Total 443 1.8492
Table A30
ANOVA: Factor 4: Communication by Role
Unique Method SS df MS F Sig.
Factor 4: Communication
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
Role N MStaff Nurse 258 2.0738Admin/Leader/Manager 137 2.0539CNS/Educ/Faculty 71 2.0221Mid‐Level/Practitioner 43 2.0593Total 509 2.0600
PERIOPERATIVE IMPLEMENTATION 79
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
At the time of arrival of the patient, how often did you document the patients’ description of their thermal comfort?
.161** 447
**. Correlation is significant at the 0.01 level 2‐tailed .
PERIOPERATIVE IMPLEMENTATION 80
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
At the time of arrival of the patient, how often did you document the patients’ description of their thermal comfort?
.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
At the time of arrival of the patient, how often did you document the patients’ description of their thermal comfort?
.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
PERIOPERATIVE IMPLEMENTATION 81
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
Missing System 228 25.5Total 893 100.0
PERIOPERATIVE IMPLEMENTATION 82
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
Missing System 228 25.5Total 893 100.0
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
PERIOPERATIVE IMPLEMENTATION 83
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%
PERIOPERATIVE IMPLEMENTATION 84
Appendix B
ASPAN Algorithms
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Appendix C
Hooper Data Collection Tool
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PERIOPERATIVE IMPLEMENTATION 90
Appendix D
Survey Questionnaire
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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.”
PERIOPERATIVE IMPLEMENTATION 92
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?
PERIOPERATIVE IMPLEMENTATION 93
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?
How often did you apply any interventions to manage the patient’s temperature?
At the time of arrival of the patient, how often did you ask the patient to describe their thermal comfort?
At the time of arrival of the patient, how often did you document the patients’ description of their thermal comfort?
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
PERIOPERATIVE IMPLEMENTATION 94
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
PERIOPERATIVE IMPLEMENTATION 95
To No Extent
To a Little Extent
To a Moderate 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 Moderate 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
PERIOPERATIVE IMPLEMENTATION 96
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
PERIOPERATIVE IMPLEMENTATION 97
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
PERIOPERATIVE IMPLEMENTATION 98
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 ___________________________________
PERIOPERATIVE IMPLEMENTATION 100
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
PERIOPERATIVE IMPLEMENTATION 101
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
PERIOPERATIVE IMPLEMENTATION 102
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? ____________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PERIOPERATIVE IMPLEMENTATION 103
Appendix E
Face Validity Questionnaire
PERIOPERATIVE IMPLEMENTATION 104
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
PERIOPERATIVE IMPLEMENTATION 105
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
PERIOPERATIVE IMPLEMENTATION 106
If you answered, “No,” what other factors should be
added?________________________________________________________________________________________
_________________________________________________________________________________________________
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Appendix F
Content Analysis Checklist
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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?
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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?
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?
At the time of arrival of the patient, how often did you ask the patient to describe their thermal comfort?
At the time of arrival of the patient, how often did you document the patients’ description of their thermal comfort?
Which of the following thermal management interventions do you use in perioperative care of adults on a regular basis? Please select all that apply.
None Cotton blankets Carbon‐fiber blanket Forced‐air warming blanket Circulating water blanket Circulating water garment Increased room temperature
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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
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
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
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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
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
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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
If not currently employed in the United States, please select the country where you are employed. select one
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
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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
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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 ____________________________________________
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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:________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
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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
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Rater #01
Rater #02
Rater #03
Rater #04
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
Do you believe a nurse should use this AORN Recommended Practice?
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
How often did you apply any interventions to manage the patient’s temperature?
4 4 4 4 4 1.0
At the time of arrival of the patient, how often did you ask the patient to describe their thermal comfort?
4 4 4 4 4 1.0
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Rater #01
Rater #02
Rater #03
Rater #04
Rater#05 CVI
At the time of arrival of the patient, how often did you document the patients’ description of their thermal comfort?
4 4 4 4 4 1.0
Which of the following thermal management interventions do you use in perioperative care of adults on a regular basis? Please select all that apply.
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
Rater #04
Rater#05 CVI
Research reports/articles are not readily available
4 4 4 4 4 1.0
Implications for practice are not made clear
4 4 4 4 4 1.0
Statistical analyses are not understandable
4 4 4 4 4 1.0
The research is not relevant to my nursing practice
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
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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
I am uncertain whether to believe the results of the research
4 4 4 4 4 1.0
The research has methodological inadequacies
4 4 3 4 4 0.9
The relevant literature is not compiled in one place
4 4 4 4 4 1.0
I do not feel I have enough authority to change patient care procedures
4 4 4 4 4 1.0
I feel results are not generalizable to my practice setting
4 4 4 4 4 1.0
I am isolated from knowledgeable colleagues with whom to discuss the research
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
Physicians will not cooperate with implementation
4 4 4 4 4 1.0
Administration will not allow implementation
4 4 4 4 4 1.0
I do not see the value of research for practice
4 4 4 4 4 1.0
There is not a documented need to change practice
4 4 4 4 4 1.0
The conclusions drawn from the research are not justified
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
Other staff are not supportive of implementation
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
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Rater #01
Rater #02
Rater #03
Rater #04
Rater#05 CVI
I do not feel capable of evaluating the quality of the research
4 4 4 4 4 1.0
There is insufficient time on the job to implement new ideas
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
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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
In what region of the country are you currently employed? select one
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
If not currently employed in the United States, please select the country where you are employed. select one
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
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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
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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
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#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
Which of the following certifications do you have? select all that apply
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
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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:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Appendix G
AORN Research Committee Support
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127
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Appendix H
Simmons College IRB Approval
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Appendix I
AORN Approval to use Membership Database
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131
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Appendix J
AORN Informz.net Invitation Content
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133
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Appendix K
Demographics
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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
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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
In what region of the country are you currently employed? select one
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
If not currently employed in the United States, please select the country where you are employed. select one
Response % NAustralia 18% 2Canada 27% 3East Timor 9% 1Ethiopia 9% 1Germany 9% 1Jamaica 9% 1Spain 9% 1Turkmenistan 9% 1
Total Responses 11
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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
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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
PERIOPERATIVE IMPLEMENTATION 139
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
PERIOPERATIVE IMPLEMENTATION 140
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
PERIOPERATIVE IMPLEMENTATION 141
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
50 or more 0.2% 1Total Responses 538
Table K14
Which of the following certifications do you have? select all that apply
Response % N
BC 1.6% 9C 1.1% 6CNOR 67.2% 368CRNFA 5.7% 31
PERIOPERATIVE IMPLEMENTATION 142
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
PERIOPERATIVE IMPLEMENTATION 143
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
41 or more 3.0% 16Total Responses 537
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
PERIOPERATIVE IMPLEMENTATION 144
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
PERIOPERATIVE IMPLEMENTATION 145
Appendix L
BARRIERS Narrative Data
PERIOPERATIVE IMPLEMENTATION 146
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
PERIOPERATIVE IMPLEMENTATION 147
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
PERIOPERATIVE IMPLEMENTATION 148
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
PERIOPERATIVE IMPLEMENTATION 149
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
PERIOPERATIVE IMPLEMENTATION 150
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
PERIOPERATIVE IMPLEMENTATION 151
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
PERIOPERATIVE IMPLEMENTATION 152
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
PERIOPERATIVE IMPLEMENTATION 153
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