Abstract
Unintentional perioperative hypothermia can cause potentially life-threatening complications. The aim of this study was to determine the awareness and practices of nurses regarding unintentional perioperative hypothermia prevention. The study was conducted at a teaching hospital in Gambia with descriptive cross-sectional design. A total of 53 nurses voluntarily participated in this study. The questionnaire used in this study was developed based on the American periOperative Registered Nurses (AORN) and National Institute for Health and Care Excellence perioperative hypothermia guidelines. Descriptive statistics, Pearson correlation, Student t-test, and one-way ANOVA were used in the analysis of data. The result of the study showed that nurses had high level of awareness of unintentional perioperative hypothermia prevention; however, practice levels were found to be low. Based on the results of the study, development of policies, implementation of the unintentional perioperative hypothermia prevention guidelines, and continuous education to improve nurses' knowledge and practices were recommended.
Keywords: hypothermia, unintentional perioperative hypothermia, prevention, nursing
Introduction
Maintaining a constant internal environment is crucial to human life (Charkoudian, 2010; Lim et al, 2008; Osilla et al, 2021; Peiris et al, 2018). Unintentional perioperative hypothermia, a form of hypothermia that emerges during the perioperative phase, is a frequent complication in perioperative patients (Ruetzler and Kurz, 2018). Perioperative hypothermia occurs when appropriate actions are not taken to ensure that surgical clients' core temperature stays within those acceptable levels during surgical procedures. Even though published researches on the frequency of unintentional perioperative hypothermia differ based on the patient demographic, type of operation, clinical environment, and concept of hypothermia used, researches have demonstrated that 26% to 90% of patients undergoing elective procedure experience postoperative hypothermia (Moola and Lockwood, 2011).
A survey of 255 patients having major colorectal surgical procedure revealed that 74% of patients had mild hypothermia during surgery (Mehta and Barclay, 2014). A cross-sectional survey of 3132 clients under general anesthesia in 28 hospitals in China found that the overall incidence of intraoperative hypothermia was 44.3% (Yi et al, 2017). Another research in Ethiopia found the total occurrence rate of hypothermia in the preoperative, intraoperative, and postoperative phases to be 16.2%, 53.2%, and 31.3%, respectively (Fekede and Sahile, 2016).
Unintentional perioperative hyperthermia can lead to serious complications in surgical patients. For example, blood catecholamines increase the blood pressure, heart rate, and the cardiac afterload. This therefore elevates the overall burden on the cardiovascular system by plummeting the oxygen intake of heart muscles (Kasai et al, 2003). Hypothermia could also inhibit respiratory function, leading to rapid, shallow respiration (Ghaffaripour et al, 2013). Shivering occurs as a compensatory mechanism, leading to an increase in spontaneous muscle contraction and oxygen intake of almost 300%. Reduced breathing and elevated cardiac output per minute will lead to irregular heartbeat, heart failure, and myocardial infarction. All of these negative consequences delay recovery after surgical intervention. Unintentional perioperative hypothermia as well also delays discharge from the recovery room, increases postoperative infection rates, and exasperate thermal discomfort (Cooper, 2006; Seamon et al, 2012; Yi et al, 2017).
As shown by the results of a research undertaken by Ralph et al (2019) in Australia, the burden of unintentional perioperative hypothermia on the health care systems is estimated to be ∼$1,259,725,856. According to Sessler (2016), perioperative hypothermia is associated with adverse effects such as coagulopathy, increased transfusion demands, surgical site inflammation, impaired medication synthesis, extended healing, and thermal disturbance (Sessler, 2016). Hypothermia can also inhibit the efficacy of medications and extend the patient's recovery and hospital stay (Lista et al, 2012; Panagiotis et al, 2005).
Unintentional perioperative hypothermia is a common, but preventable complication of perioperative procedures, which is associated with poor outcomes for patients. There are guidelines such as The National Institute for Health and Care Excellence (NICE) guideline and The American periOperative Registered Nurses (AORN) Association that are used by health practitioners to prevent and manage perioperative hypothermia. The AORN and NICE guideline contain interventions that provide methods for the assessment and management of surgical patients to prevent hypothermia throughout the perioperative cycle, thereby preventing complications surgical patients may encounter as a result of unintentional perioperative hypothermia (AORN, 2016; NICE, 2008).
Due to complications that unintentional perioperative hypothermia is likely to cause surgical patients, nurses must play a crucial role in the prevention of perioperative hypothermia throughout the perioperative cycle. Nurses should employ interventions such as use perioperative pharmacologic vasodilation and prewarming before anesthesia, passive warming, active warming, warming of intravenous and irrigation fluids, and warming of anesthetic gases to help prevent perioperative hypothermia, thereby minimizing the risk for postoperative complications (Madrid et al, 2016).
Preoperative assessment is essential to enable identification of at-risk patients. Simple precautions taken by nurses will dramatically reduce the amount of heat lost, decrease the likelihood of associated complications, and eventually increase the short- and long-term rehabilitation of patients. Reducing the exposure of the skin, supplying sufficient bed sheets for transport to theater, and informing patients about the significance of maintaining the perioperative warm are all highly significant. Also, the usage of forced air warming preoperatively, implementation of active warming may be effective in the prevention of hypothermia during the perioperative phase (Burger and Fitzpatrick, 2009).
Since nurses play a primary role in caring for and monitoring of patients throughout the perioperative process, better understanding of nurses' knowledge and practices of unintentional perioperative hypothermia is an important part of improving patient outcomes. Determining the knowledge and practices of nurses regarding unintentional perioperative hypothermia prevention may be useful in improving their perioperative hypothermia prevention strategies, thus increasing the quality of perioperative care. A study on the topic was not found in The Gambia. Therefore, the result of this study will help to shed light on the awareness and practices of nurses regarding unintentional perioperative hypothermia prevention in The Gambia.
Purpose of the study
The purpose of the study was to determine nurse's awareness and practices regarding unintentional perioperative hypothermia prevention. Study questions are as follows:
What is the level of awareness of nurses on unintentional perioperative hypothermia prevention?
What are practices of nurses regarding unintentional perioperative hypothermia prevention?
Is there any correlation between the level of awareness and practices of nurses on unintentional perioperative hypothermia prevention?
Is there any difference between the descriptive data, and awareness and practices of nurses on unintentional perioperative hypothermia prevention?
Methods
Study design
The study was conducted with a descriptive and cross-sectional design.
Sample and setting
This research was carried out at a main referral teaching hospital in The Gambia. The study was performed on the nurses who work at the operating theater, ICU, orthopedic unit, female and male surgical ward, accident and emergency surgical ward, and maternity ward of the hospital. A total of 64 nurses work in these departments. All voluntary nurses were included in the sample of the study. Eleven nurses declined to participate in this survey and the final sample was composed of 53 nurses, with an access rate of 82.8%.
Study tools
The data were collected using a questionnaire developed by the researchers based on the guidelines of the AORN Association and NICE perioperative hypothermia prevention (AORN, 2016; NICE, 2008). Opinions of three faculty members in the surgical nursing field regarding the content of the questionnaire have been obtained.
The questionnaire consists of three sections. The section A regarding the demographic characteristics of nurses constitutes eight questions. The section B is divided into four parts. The part 1 consists of eight statements on general knowledge about unintentional perioperative hypothermia prevention, part 2 consists of five statements on preoperative hypothermia prevention, part 3 consists of six statements on intraoperative hypothermia prevention, and part 4 consists of five statements on postoperative hypothermia prevention with three choices (True, False, and don't know). Section C consists of 11 questions on unintentional perioperative hypothermia prevention practices with four choices (Always, Sometimes, Never, and Explanation).
Data collection
Data were collected using a questionnaire in June 2020. The questionnaires were administered on nurses while they are in the wards or clinics using self-completion method during duty shift and collected once completed. Completion of the questionnaire took almost 30 minutes.
Ethical consideration
Ethical approval was obtained from the Institutional Review Board (IRB) of a university and the hospital before conducting the study. All nurses were given adequate information about the research, and its aim and objective and their consent were obtained to ensure the willingness to voluntarily participate in the study.
Data analysis
All the analyses were performed using SPSS software version 26.0. The data were first assessed for any error in entry and coding. The categorical variables were analyzed using frequency, percentages, and mean and standard deviation. “True,” “False,” and “Don't know” were used to evaluate statements on awareness. Comparisons were made using only correct answers on awareness and gender, age, educational level, and working experience. Pearson correlation was used to determine the difference between the correct answers of awareness and always practices of nurses. Student t-test and one-way ANOVA were used to determine the differences between correct answers of awareness with gender, age, educational level, and working experience. The same test was done for always practices with gender, age, educational level, and working experience.
For all the tests, p < 0.05 was considered significant. For each statement on awareness, the answers were categorized as “correct answer” and “wrong/don't know answer.” Later, a variable known as “Correct answer score” was created, which constituted only of “correct answer.” Descriptive statistics were later used to calculate the mean and standard deviation using the correct answer score. With regard to “always practice,” for calculating mean and standard deviation, a variable known as “Always practice score” was created. Only respondents who choose always practice were recorded under this variable. Descriptive statistics were used to calculate the mean and standard deviation from the “Always practice score.”
Results
Among the nurses, 77.4% were female and the mean age of the nurses was 29.9 years. The majority of nurses had ≤5 years working experience. A 66.0% of the participants had bachelor degree, 17% of them work at the maternity unit and orthopedic ward. The majority of the nurses stated that they have not received training on unintentional perioperative hypothermia prevention and need training on unintentional perioperative hypothermia (67.3%).
Awareness/knowledge of nurses on unintentional perioperative hypothermia prevention
Awareness/knowledge of nurses on unintentional perioperative hypothermia prevention was evaluated with general, preoperative, intraoperative, and postoperative hypothermia prevention domains.
General unintentional perioperative hypothermia prevention awareness
Table 1 shows the awareness/knowledge of nurses on unintentional perioperative hypothermia prevention. With regard to the general knowledge of nurses on unintentional perioperative hypothermia prevention, most nurses had the correct answer (eight out of eight) items.
Table 1.
Nurses' Awareness of Unintentional Perioperative Hypothermia Prevention (N = 53)
| Statements on unintentional perioperative hypothermia prevention | True/false | Correct answer |
Wrong answer/I don't know |
||
|---|---|---|---|---|---|
| N | % | N | % | ||
| Part 1. General knowledge | |||||
| The internal environment of humans can be maintained by thermoregulation. | (T) | 52 | 98.1 | 1 | 1.9 |
| Perioperative hypothermia at any time during the perioperative cycle is characterized as a core body temperature <35°C. | (T) | 51 | 96.2 | 2 | 3.8 |
| Perioperative hypothermia is associated with complications such as changes in drug metabolism, healing complications, shivering, clotting defects, cardiac morbidity, and prolonged postanesthetic recovery. | (T) | 42 | 79.2 | 11 | 20.8 |
| To minimize surgical complications postoperatively, nurses should advise patients to bring along additional clothing to help them stay warm before surgery. | (T) | 33 | 62.3 | 20 | 37.7 |
| The pulmonary artery catheter, distal esophagus, urinary bladder or zero-heat-flux can be used for temperature measurement. | (T) | 41 | 77.4 | 12 | 22.6 |
| Nurses should be well trained and knowledgeable about the use of both temperature recording and warming devices | (T) | 51 | 96.2 | 2 | 3.8 |
| Forced-air warming devices, warm water circulating devices, and conductive devices are not some of the devices for warming surgical patients | (F) | 30 | 56.6 | 23 | 43.4 |
| The method for temperature monitoring should not be chosen based on the criteria for a procedure | (F) | 33 | 62.3 | 20 | 37.7 |
| Part 2. Preoperative hypothermia prevention | |||||
| Patients with a temperature below 36.0°C undergoing anesthesia and those having a high risk of cardiovascular complications are at higher risk for inadvertent perioperative hypothermia | (T) | 46 | 86.8 | 7 | 13.2 |
| It is not necessary to measure patients' temperature in the hour before departing the ward since it will be measured at the theater. | (F) | 46 | 86.8 | 7 | 13.2 |
| Except in urgent circumstances, preoperative patients with temperatures of <36.0°C should be warmed for 30 minutes using active warming methods. | (T) | 40 | 75.5 | 13 | 24.5 |
| Special attention should be given to the comfort of surgical patients having difficulties to express themselves. | (T) | 50 | 94.3 | 3 | 5.7 |
| The method for warming surgical patients should be chosen based on the planned surgical procedure, positioning of the patient, intravenous access site, and warming equipment constraints. | (T) | 44 | 83.0 | 7 | 17.0 |
| Part 3. Intraoperative hypothermia prevention | |||||
| Critical incidence reporting is not necessary for patients coming into the theater with a temperature of <36.0°C. | (F) | 48 | 90.6 | 5 | 9.4 |
| The theater's room temperature should be at least 21°C, which can be adjusted to allow better working once active warming is initiated. | (T) | 47 | 88.7 | 6 | 11.3 |
| Thermostat-controlled cabinet to temperature of 33°C to 40° should not be used to warm irrigation fluids. | (F) | 38 | 71.7 | 15 | 28.3 |
| Fluid warming devices should be used to warm intravenous fluids (500 mLs or more) and blood products to 37°C. | (T) | 51 | 96.2 | 2 | 3.8 |
| Regardless of the temperatures of patients before leaving the ward or emergency department, they should be warmed using active warming method once in the theater | (T) | 44 | 83.0 | 9 | 17.0 |
| The surgical patient should be well covered throughout surgery to conserve heat and only be exposed during surgical preparation. | (T) | 51 | 96.2 | 2 | 3.8 |
| Part 4. Postoperative hypothermia prevention | |||||
| During the postoperative period, hypothermic patients should be warmed using active warming method until they become warm before transferring them to the ward. | (T) | 52 | 98.1 | 1 | 1.9 |
| Patients should be provided with at least 1 cotton sheet, 2 blankets, or a duvet during the postoperative phase. | (T) | 51 | 96.2 | 2 | 3.8 |
| While in the theater, patients' temperatures should be measured every 15 minutes and every 30 minutes while in the recovery room. | (F) | 8 | 15.1 | 45 | 84.9 |
| It is not necessary to keep patient warm in the emergency unit and the ward since the patient was warmed in the theater. | (F) | 40 | 75.5 | 13 | 24.5 |
| The temperature of postoperative patients should be recorded on arrival to the ward and be taken and documented as part of a routine for hourly observations. | (T) | 52 | 98.1 | 1 | 1.9 |
T, True; F, False.
Among the statements, most frequent correct answers of nurses were “The internal environment of humans can be maintained by thermoregulation” (T) (98.1%), “Perioperative hypothermia at any time during the perioperative cycle is characterized as a core body temperature <35°C” (T) (96.2%), and “Nurses should be well trained and knowledgeable about the use of both temperature recording and warming devices” (T) (96.2%). However, 56.6% of nurses gave the least frequent correct answer to the statement “Forced-air warming devices, warm water circulating devices, and conductive devices are not some of the devices for warming surgical patients” (F). The mean value of the general knowledge of nurses on unintentional perioperative hypothermia prevention was 6.3 (±1.2) (Table 3).
Table 3.
Mean Scores of Awareness and Practices of Nurses on Unintentional Perioperative Hypothermia Prevention (N = 53)
| Awareness and practices of nurses on unintentional perioperative hypothermia prevention | Total number of items | Mean scores of correct/always answers |
|
|---|---|---|---|
| Mean | SD | ||
| Domains of awareness | |||
| General knowledge | 8 | 6.3 | 1.2 |
| Preoperative hypothermia prevention | 5 | 4.3 | 0.9 |
| Intraoperative hypothermia prevention | 6 | 5.3 | 0.9 |
| Postoperative hypothermia prevention | 5 | 3.8 | 0.5 |
| Overall knowledge | 24 | 19.6 | 2.4 |
| Practice | 12 | 2.3 | 1.5 |
Preoperative unintentional hypothermia prevention awareness
With regard to the statements on preoperative hypothermia prevention, most nurses had the correct answer (five out of five) items. The majority of nurses (94.3%) answered the most frequent correct answer to the statement “Special attention should be given to the comfort of surgical patients having difficulties to express themselves” (T) (Table 1). Unintentional preoperative hypothermia prevention knowledge mean value was 4.3 (±0.9) (Table 3).
Intraoperative unintentional hypothermia prevention awareness
The majority of nurses answered all the statements correctly (six out of six) regarding intraoperative hypothermia prevention. The most frequent correct answers of nurses were “The surgical patient should be well covered throughout surgery to conserve heat and only be exposed during surgical preparation” (T) (96.2%) and “Fluid warming devices should be used to warm intravenous fluids (500 mLs or more) & blood products to 37°C” (T) (96.2%) (Table 1). The mean value of the knowledge of nurses on unintentional intraoperative hypothermia prevention was 5.3 (±0.9) (Table 3).
Postoperative unintentional hypothermia prevention awareness
With regard to the postoperative hypothermia prevention, majority of nurses answered correctly (four out of five). “During the postoperative period, hypothermic patients should be warmed using active warming method until they become warm before transferring them to the ward” (T) (98.1%), “The temperature of postoperative patients should be recorded on arrival to the ward and be taken and documented as part of a routine four hourly observations” (T) (98.1%), and “Patients should be provided with at least 1 cotton sheet, 2 blankets, or a duvet during the postoperative phase” (T) (96.2%) were the most frequent correct answers. However, only 15.1% of nurses gave the less frequent correct answer to the statement “While in the theater, the patients' temperature should be measured every 15 minutes and every 30 minutes while in the recovery room” (F) (Table 1). Unintentional postoperative hypothermia prevention knowledge mean value was 3.8 (±0.5) (Table 3).
Practices of nurses on unintentional perioperative hypothermia prevention
Results showed that, 64.2% chose the most frequent always practices to the question “Do you monitor and record patients' temperature readings regularly?,” whiles none of the nurses chose the less frequent always practice to the question “Do you use forced-air warming devices, warm water circulating devices, and conductive devices for warming surgical patients?” (Table 2). The mean value for always practice was 2.3 (±1.5) (Table 3).
Table 2.
Practices of Nurses Regarding Unintentional Perioperative Hypothermia Prevention (N = 53)
| Questions on unintentional perioperative hypothermia prevention practices (N = 53) | Always |
Sometimes |
Never |
|||
|---|---|---|---|---|---|---|
| N | % | N | % | N | % | |
| Do you monitor and record patients' temperature readings regularly? | 34 | 64.2 | 18 | 34.0 | 1 | 1.9 |
| Do you maintain ambient room temperature? | 22 | 41.5 | 18 | 34.0 | 13 | 24.5 |
| Do you develop and implement care plan on perioperative hypothermia prevention? | 14 | 26.4 | 36 | 67.9 | 3 | 5.70 |
| Do you include thermoregulation interventions and patient-related care to thermoregulation in your hand-over report? | 14 | 26.4 | 28 | 52.8 | 11 | 20.8 |
| Do you assess patients for their risk for perioperative hypothermia? | 12 | 22.6 | 22 | 41.5 | 19 | 35.8 |
| Do you advise patients to inform you when they feel cold during their hospitalization? | 11 | 20.8 | 21 | 39.6 | 21 | 39.6 |
| Do you advise patients to stay warm before surgery? | 4 | 7.5 | 20 | 37.7 | 29 | 54.7 |
| Do you document the site for temperature measurement in the patient's file? | 3 | 5.7 | 20 | 37.7 | 30 | 56.6 |
| Do you communicate your assessment findings on factors that could lead to perioperative hypothermia to all members of the perioperative team? | 3 | 5.7 | 8 | 15.1 | 42 | 79.2 |
| Do you warm intravenous, blood products and irrigation fluids using special warming devices before administering to patients? | 2 | 3.8 | 46 | 86.8 | 5 | 9.4 |
| Do you use active or passive warming methods to warm patients? | 1 | 1.9 | 37 | 69.8 | 15 | 28.3 |
| Do you use forced-air warming devices, warm water circulating devices, and conductive devices for warming surgical patients? | 0 | 0.0 | 2 | 3.8 | 51 | 96.2 |
Table 4 shows the correlation between overall awareness correct answer scores and practice scores of nurses. The Pearson correlation test result showed that there was no statistically significant relationship between overall correct answer awareness scores and practice scores (r = 0.064, p > 0.05) of nurses on unintentional perioperative hypothermia prevention.
Table 4.
Correlation Between Overall Awareness Correct Answers Scores and Practice Scores of Nurses
| Correlations | |||
|---|---|---|---|
| Awareness score and practices scores | Overall correct answer awareness score | Practice score | |
| Overall correct answer awareness score | Pearson correlation | 1 | −0.256 |
| Sig. (two tailed) | 0.064 | ||
| N | 53 | 53 | |
| Practice score | Pearson correlation | −0.256 | 1 |
| Sig. (two tailed) | 0.064 | ||
| N | 53 | 53 | |
Although it is not shown as table, comparison of descriptive characteristics and overall knowledge/awareness mean scores of nurses on unintentional perioperative hypothermia prevention showed that differences in age groups were statistically significant (p: 0.03, p < 0.05) with the ≥31 age group categories being the highest. Also, comparison of descriptive characteristics and the overall knowledge mean scores of nurses on unintentional perioperative hypothermia prevention showed that differences in working experiences were statistically significant with ≥11 years being higher than the others (p: 0.01, p < 0.05).
Discussion
Awareness/knowledge of nurses on unintentional perioperative hypothermia prevention
Preventing unintentional perioperative hypothermia is crucial for the prevention of negative outcomes such as coagulopathy, increased transfusion demands, surgical site infection, impaired medication synthesis, extended healing, and thermal disturbance among surgical patients (Sessler, 2016). Results of the study regarding nurses' awareness of unintentional perioperative hypothermia prevention showed that, majority of have a high level of awareness/knowledge on unintentional perioperative hypothermia prevention. This is in line with unintentional perioperative hypothermia prevention guidelines (AORN, 2016; NICE, 2008).
The results of our study are not compatible with the findings of the study by Ireland et al (2006) on nurses and medical personnel working at a single trauma unit in Australia, evaluating their awareness and understanding of unintended hypothermia and its impact on trauma patients in which nurses had limited knowledge regarding perioperative hypothermia. Nurses play a major role in the identification of individual's risk for hypothermia, temperature monitoring throughout the perioperative cycle, utilization of preventive strategies, and appropriate warming methods. For this reason, nurses' awareness on unintentional perioperative hypothermia is paramount to the prevention and management of hypothermia (Hudgins, 2019). Results of this study also showed that more than half the participants stated that they need training on perioperative hypothermia. Awareness of nurses about their knowledge needs is important for their improvement. AORN also recommends that nurses receive training on unintentional perioperative hypothermia (AORN, 2018).
Detailed evaluation of the awareness of nurses on unintentional perioperative hypothermia prevention domains, including general, preoperative, intraoperative, and postoperative hypothermia prevention, showed that, there are satisfying levels of awareness in all domains.
General unintentional perioperative hypothermia prevention awareness
The findings regarding the general knowledge domain of nurses on unintentional perioperative hypothermia prevention showed that, nurses had frequent correct answers to the statements related to the of thermoregulation, perioperative hypothermia definition, and necessity of nurses' training. Thermoregulation is responsible for ensuring optimal organ and enzymatic function. Anesthesia is known to destabilize normal thermoregulation mechanism and when coupled with exposure of surgical patients to cold environment, it can lead to hypothermia, which is associated with postoperative complications such as infection, bleeding, cardiac events and changes in drug metabolism, patient discomfort, and increased length of hospital admission (McSwain et al, 2015).
It is satisfying to know that nurses had robust basic knowledge of the physiology of thermoregulation, which is a crucial factor for the prevention and management of hypothermia in surgical patients. Results showed that nurses had a relatively low rate of correct answer to statement regarding perioperative warming devices. The result of a meta-analysis on the effectiveness of forced-air warming devices for the prevention of unintentional perioperative hypothermia in surgical patients showed that forced-air warming is more effective in the prevention of perioperative hypothermia than passive insulation and circulating-water mattresses; however, when forced-air warming devices were compared with circulating-water garments, resistive heating blankets, and radiant warming systems, the results showed no statistically significant difference (Nieh and Su, 2016).
Preoperative unintentional hypothermia prevention awareness
With regard to the statements on preoperative hypothermia prevention domain, nurses had the frequent correct answer to the statement regarding special attention to the comfort of patients having difficulties to express themselves. Patients with the inability to express themselves may not contribute or adhere to teachings when being prepped for surgery. Surgical patients should be thoroughly assessed to identify communication barriers and implement certain communication techniques to counter this effect.
Intraoperative unintentional hypothermia prevention awareness
Regarding intraoperative hypothermia prevention domain, nurses had the most frequent correct answers to the statements regarding fluid warming devices and covering of the patient throughout surgery. Warming intravenous fluids and blood products before administering to patients will help maintain normothermia, protecting them from harmful negative consequences associated with hypothermia. Also, covering patients during the operative period will help to prevent heat loss and maintain normothermia. The result of a systematic review on the role of perioperative warming in surgery showed that warming surgical patients perioperatively was effective in mitigating wound pain, wound infection, and shivering. Warming of surgical patients was also associated with less perioperative blood loss by preventing hypothermia-induced coagulopathy (Sajid et al, 2009).
Postoperative unintentional hypothermia prevention awareness
With regard to the postoperative hypothermia prevention, it is satisfying to note that the majority of nurses demonstrated good knowledge on active warming, patient covering, and the frequency of temperature measurement during this phase of the perioperative cycle. These are consistent with the AORN (2016) and NICE (2008) perioperative hypothermia prevention guidelines. However, it is very disappointing to note that, regarding the postoperative hypothermia prevention, majority of nurses had wrong knowledge about the frequency of temperature measurement. This is in contrast with the NICE (2008) perioperative hypothermia guideline, which recommends that surgical patients' temperature be measured every 30 minutes while in the theater and every 15 minutes while in the recovery room. This result shows the nurses' need for education on unintentional perioperative hypothermia preventive devices, to warming the irrigation fluids, active warming, and frequency of the temperature measurement.
Practices of nurses on unintentional perioperative hypothermia prevention
With regard to the practices of nurses on unintentional perioperative hypothermia prevention, results showed low mean score of correct/always practice. A majority of participants chose the “never” answer for the statements regarding the use of warming devices, documentation of the temperature measurement, and advising patients to stay warm before surgery. In line, a qualitative study performed with nurse anesthetists and operating theater nurses showed that, taking the temperature and measures against inadvertent hypothermia perioperatively are not always systematically implemented (Honkavuo and Loe, 2020). However, effectiveness of preventive practices against unintentional perioperative hypothermia is well known. The results of a systematic review on the effectiveness of prewarming to prevent perioperative hypothermia showed that using force-air warming devices was effective in reducing hypothermia when used for warming surgical patients (de Brito Poveda et al, 2013).
Results of another systematic review and meta-analysis on the efficacy of air-free warming systems on perioperative hypothermia in total hip and knee arthroplasty showed that air-free warming system was as efficient as forced-air warming system in patients undergoing joint arthroplasty (Liu et al, 2019). The result of the study also showed that most nurses had “sometimes” answers for the statements regarding warming intravenous and irrigation fluids, warming the patients, care planning for unintentional perioperative hypothermia prevention, and thermoregulation in your hand-over report. These findings are in contrast with the AORN (2016) and NICE (2008) guidelines for perioperative hypothermia prevention. As shown by the overall always practice score, a majority of nurses demonstrated poor practice regarding unintentional perioperative hypothermia prevention. This poor outcome might be due to the nonexistence of clinical practice guideline or absence of forced air warming devices at the hospital.
Results showed that there was no correlation between the overall awareness correct answers score and practice scores of nurses. Nurses had satisfying awareness and knowledge; however, there was failure in unintentional perioperative hypothermia prevention practices. This could be due to absence of unintentional perioperative hypothermia guidelines, or absence or malfunctioning temperature measuring and warming devices. As shown from a study on 139 nursing staff from a general hospital in United Kingdom on the practice and awareness of nurses with regard to temperature monitoring of patients, nurses had a poor level of awareness and practice in the use of infrared tympanic thermometry to monitor patients' temperature levels (Evans and Kenkre, 2006).
Comparison of the descriptive characteristics and the overall knowledge and practice mean scores of nurses on unintentional perioperative hypothermia prevention showed that, higher age affects their awareness and longer working experience affects their practices positively. Since the majority of nurses have ≤5 years of working experience, it is crucial that they undergo training on unintentional perioperative hypothermia prevention.
Limitations
There are limitations in this study that need to be addressed. First, this is a single-center study and the results cannot be generalized. Second, obtaining data on nurses' unintentional perioperative hypothermia prevention practices using the questionnaire without an observational method can be considered another limitation.
Conclusion
The results of this study showed that nurses had a high level of awareness/knowledge of unintentional perioperative hypothermia prevention. This is however not translated into practice. This may be due to an absence of guidelines, and active and passive warming devices, and inadequate training on unintentional perioperative hypothermia prevention. Preventing unintentional perioperative hypothermia is a main patient safety concern of perioperative nurses. Therefore, members of the perioperative team should receive training on hypothermia preventive practices. Up to date, perioperative hypothermia guidelines such as the NICE (2008) and AORN (2016) should be implemented to help prevent and manage perioperative hypothermia. Nurses should work with other health care personnel throughout the perioperative cycle to help mitigate, if not eradicate, inadvertent unintentional perioperative hypothermia, which would result in improved outcomes for their patients.
Authors' Contributions
This study was designed and conceptualized by O.J. and N.B. Data collection, analysis, interpretation, and writing the full article of were performed by O.J. and N.B. O.J. and N.B. reviewed, revised, agreed, and approved the final version of the article.
Ethics Statement
The study was conducted according to the Declaration of Helsinki. Ethical approval was obtained from Institutional Review Board (IRB) of Near East University (2020/78/1036) and Institutional Review Board of the Edward Francis Teaching Hospital before conducting the study. All nurses were given adequate information about the research and its aim and objective, and consent was obtained to ensure the willingness to voluntarily participate in the study.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
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