Effects of comfort warming on preoperative patients. AORN

Effects ofComfort Warniing

on Preoperative Patients

Doreen Wagner, RN; MichelleByrne, RN; Katharine Kolcaba, RN

Temperature is an integral compo-nent of a patient's perception ofwell-being during the periopera-

tive experience. Memories of thermalcomfort or discomfort during surgeryhave an effect on a patient's overallsatisfaction with surgical care." Begin-ning in the preoperative phase of sur-gery, patients often remark that theyfeel cold. The most common nursingapproach for addressing this patientdiscomfort is to cover the patient withwarmed cotton blankets. After placinga warm blanket on a patient, the nurseoften hears appreciative statementssuch as "I love getting these warmblankets before surgery. It reallyhelps." The nurse recognizes an in-crease in overall patient comfort as aresult of this warming interventionand, of equal importance, often per-ceives a decrease in patient anxiety im-mediately after the patient receives theblanket.

People respond holistically to com-plex stimuli, so the sensation of feelingcold produces discomfort and can trig-ger anxiety about• the impending surgery,• the anesthesia,• expected pain, and• being immobilized.'lnterventions to prevent or treat a pa-tient's feeling of being cold, therefore,often have a positive effect on how thepatient perceives other threats. Such in-terventions thereby may reduce a pa-tient's anxiety The problem addressedin this study is how nurses can inter-vene successfully to increase thermalcomfort and decrease anxiety in the pre-operative setting.

WARMINGRecent research has documented the

therapeutic effects of wanning preoper-ative patients.'••'•' Prewarming raisesmean body temperature by increasingthe energy content in the peripheralthermal compartment of the body. Thisis important because it is difficult to treatcore hypothermia that occurs from aninternal core-to-peripheral redistribu-tion of body heat immediately after in-duction of general and regional anesthe-sia.""' Anesthetic agents decrease thevasoconstriction threshold to a levelbelow the current body temperature andthus open arteriovenous shunts. This re-distribution is not a clear exchange ofheat with the environment, but rather aflow of heat from the body's core to theperiphery, thereby reducing the coretemperature.'"' The redistribution ofbody heat can be prevented, however,with prewarming interventions in the

ABSTRACT• THERMAL COMFORT IS ONE DIMENSIONof overall patient comfort, and it usually is ad-dressed by covering the patient with warmed col-ton blankets.

• WARMING HELPS A PATIENT maintain nor-mothermia and appears to decrease patient anxiety.

• AN STUDY WAS CONDUCTED in a preoper-ative setting to compare the effects of preoperativewarming with warmed cotton blankets versus pa-tient-controlled warming gowns on patients' per-ceptions of thermal comfort and anxiety.

• BOTH WARMING INTERVENTIONS had apositive effect on patients' thermal comfort andsense of well-being. Patients who used the patient-controlled wanning gown also experienced a sig-nificant reduction in preoperative anxiety. AORN J84 (September 2006) 427-448. © AORN, Inc, 2006.

e AORN, Inc, 2006 SEPTEMBER 2006, VOL 84, NO 3 • AORN JOURNAL • 4 2 7

SEPTEMBER 2006, VOL 84, NO 3 Wagner — Byrne — Kolcaba

Higher levels of anxiety are linked to tachycardia, hypertension,

arrhythmias, and increased levels of pain, which adversely

affect patient health and healing.

preoperative setting.'^'Traditionally, nurses have used

warmed blankets to provide thermalcomfort for patients in the preoperativesetting. Unfortunately, the warmth fromheated cotton blankets dissipates within10 minutes.' Other passive and tradi-tional approaches to providing thermalcomfort include the use of insulative-type coverings such as reflective blan-kets, the placement of socks and headcoverings on preoperative patients, anda manual increase in room temperature.

Warming a patient preoperatively ismore effectively accomplished by us-ing an active warming method.'' Ex-amples of active warming methods in-clude the use of convective (ie, warmedair) warming blankets and fluid warm-ing to maintain or increase a patient'sbody temperature. Active warming tothe overall body and to localized areasalso has been found to be an effecti\ einter\'ention for reducing patient's anx-iety and complaints of pain in severalrecent studies.'*" Perioperative nursesfrequently use preoperative warmingboth as a warming intervention and asa means of providing comfort. Thereare no published research reports,however, that focus on the benefit ofpreoperative warming as both a com-fort intervention and as a method ofdecreasing patient anxiety.

ANXIETYIt has been recognized for more than

40 years that patients experience differ-ing levels of anxiety when faced withimpending surgery.'-'" Preoperative anx-iety is commonly associated with• loss of independence or control,• anesthesia concerns,• unwanted diagnoses,• postoperative pain, and• fear of death.Preoperative anxiety is reported tooccur in 11% to 80% of adult patients.'"'Higher levels of anxiety have been

linked to tachycardia, hypertension, ar-rhythmias, and increased levels of pain,which can affect the entire perioperativeperiod of patient care.'"'' Hormonal ac-tivity, known as the stress response, iswidely believed to compromise recov-ery and includes an iiicrease in circulat-ing cortisol, adrenaline, noradrenaline,oxytocin, antidiuretic hormone, andprolactin.''-

Anxiety was defined by Spielberger^'as a group of behavioral expressionsthat can be divided into trait and stateanxiety Trait anxiety is a lifelong pat-tern of anxiety that is a personality char-acteristic. People with trait anxiety gen-erally are nervous, hypersensitive tosituational stimuli, and psychologicallymore reactive. State anxiety refers toacute and situationally driven episodesof anxiety that do not continue beyondthe situation that triggers them.'"''' Animpending surgical experience is a goodexample of state anxiety State anxiety isemotionally transitory and consists offeelings of tension, apprehension, andnervousness with heightened activity inthe autonomic nervous system. Thiscondition varies in intensity and canfluctuate during the specific experience.The definition of state anxiety used inthis study is the unpleasant, self-awarefeeling of tension and apprehension ac-companied by arousal of the autonomicnervous system that is evoked in indi-viduals who interpret a situation as per-sonally threatening.

THE BENEFITS OF REDUCED ANXIETY. A patientwho is less-anxious is medically desir-able because of the physiological impli-cations of stress. A significant aspect ofthe perioperative nurse's role is to recog-nize that preoperative anxiety is a com-mon and distressing problem for mostsurgical patients. Addressing psycholog-ical needs is a valuable contribution toholistic patient care. Simple anxiety man-agement plans are beneficial because ofthe reduced amount of time available to

4 2 8 • AORNJOURNAI.

Wagner — Byme — Kolcaba SEPTEMBER 2006, VOL 84, NO 3

nurses and the high turnover of patientsin the perioperative arena.

Unfortunately, some health care pro-viders may assume that a surgical pa-tient's preoperative anxiety and periop-erative hypothermia are unavoidableand to be expected. Conventional nurs-ing interventions regarding anxiety andperioperative hypothermia, moreover,may not be best suited to the care of sur-gical patients. Established beliefs mayneed to be revised.

Perioperative nurses could be more ef-fective in handling both the patient's pre-operative warming needs as well as thepatient's preoperative anxiety if therewere more evidence on which to base in-terventional decisions. The purpose ofthis study was to compare the effects oftwo warming interventions—traditionalwarmed cotton blankets versus a patient-controlled warming gown—in enhanc-ing thermal comfort and relieving patientanxiety. The following research questionswere asked.• What is the effect of warming meth-

ods on the patient's self-report ofthermal comfort?

• What is the effect of warming meth-ods on self-reported preoperativeanxiety?

REVIEW OF LITERATURE

There are several nursing standardsof practice for temperature monitoringthat address thermal comfort. In its mon-itoring standard, the American Societyof Anesthesiologists was the first organi-zation to formalize the evaluation of thepatient's temperature when clinicallysignificant changes are intended, antici-pated, or suspected.-"' The standard doesnot specifically address hypothermia,however. The American Association ofNurse Anesthetists (AANA) recom-mends body temperature monitoring forall patients receiving local, regional, andgeneral anesthesia.^^ Again, no specificinformation is given in the AANA stan-

the

dards regarding what to do when hy-pothermia occurs. AORN's "Recom-mended practices for safe care throughidentification of potential hazards in thesurgical environment" addresses the im-portance of temperature monitoring andprovides perioperative nurses withsome basic interventions for preventinghypothermia.'" These recommendations,however, do not provide the practitionerwith specific clinical information thatmight impress upon nurs-es the importance of man-aging normothermia.

The first clinical guide-line for the prevention ofunplanned perioperativehypothermia was pub- effeCtS Oflished by the AmericanSociety of PeriAnesthesia traditionalNurses (ASPAN) in 2001.-'The purpose of the guide warmed blanketsline is to give periopera-tive practitioners an ap- VSrSUSproach to preventing andmanaging patients at riskfor developing unplannedhypothermia. The guide- Warming gownsline provides patient as- . . .sessments, interventions, 7/7 enhanongand evaluations with ex- r -».pected outcomes in addi- thermal COmfOrttion to well-defined terms ,of thermoregulatory man- and relievingagement. It covers the en- *,• *tire perioperative period patientbeginning with the preop-erative phase to phase 11recovery postoperatively.

THERMAL COMFORT RESEARCH. In a thermallycomfortable environment, no heat or coldstress should be experienced. When inthermal neutrality, a person will take nodeliberate action to maintain the properheat balance of the body^ Environmentalengineers began to study thermal comfortin the early 1900s with the realization thathumans have widely varied reactions tothermal conditions, Fanger,-' a renowned

AORN)OURNAI • 4 2 9

SEPTEMBER 2006. VOL 84, NO 3 Wagner — Byrne — Kolcaba

In 2003, nurses

at the AORN

Congress and

the American

Of

Nurses

researcher in thermal comfort, developeda thermal comfort model in the late 1960s,which is widely used and debated intoday's thermal comfort studies.-" In hishook Thermal Comfort: Analysis Applica-lioiis in Environmental Engineering, Fangerdefined thermal comfort for a person as"that condition of mind which expressessatisfaction with the thermal environ-

ment."-"''"' Fanger provid-ed a detailed analysis ofthe parameters affectingthermal comfort. He wrotethat the thermal balance ofthe body is influenced notonly by the environmentalparameters of

• air temperature,• mean radiant temper-

ature,• relative air velocity, and• relative humiditv;but also hy the personalparameters of, activity level.

convention cited

patient warmthnc tho tnnUb ine Wp

'^^ discomfort, warm orcool conditions, or the un-

concern 8 ^concern. ^^^ ^ particular part of the

body.""" In other words,thermal comfort is multi-

sensory and a subjective experience oftemperature that is affected by theenvironment.

Kolcaba and Wilson^ stated that thephysical comfort of the surgical patientalso includes thermal comfort, Theyidentified preoperati\-e warming as atechnical comfort measure that alsoprevents complications in later stagesof perioperative care. They concludedthat comfort interventions such as pre-emptive warming should be used toregain and maintain the patient'shomeostatic state.

Fossum et al' conducted an experi-mental study to determine differences intemperatures on arrival in the postanes-thesia care unit (PACU) between pa-tients who were warmed preoperativelywith forced-air warming blankets andpatients who were warmed with tradi-tional cotton blankets. They found thatpatients in the forced-air warming grouphad significantly higher temperatures onarrival in the PACU than patients in thewarm blanket group {P = .000). They alsoreported that 66% (n = 33) of the forced-air treatment group reported a comfortlevel of zero, with zero being most ther-mally comfortable and 10 being the mostthermally uncomfortable. These findingsindicated that active preoperative warm-ing pro\-ides a high level of thermalcomfort. As an incidental finding, pa-tients expressed that they were less anx-ious when they were warm. Fossum et alstated that temperature is important inthe patient's perception of comfort dur-ing a surgical experience and that in-creased patient satisfaction will occur ifnurses advocate for patients throughthermal-comfort measures.

In 2003, Wilson and Kolcaba" con-ducted a survey of nurses who attendedthe annual conferences of ASPAN andAORN. A total of 722 nurses completedthe suA'ey in which they were asked fortheir perceptions of the top three comfortconcerns of perioperative patients.Warmth was cited most often (ie, 33.3%)as the top comfort concern, followed bypain management after surgery {ie,18.3%), position during and after surgery(ie, 12.2%), and all others (ie, 36.2%). Par-ticipants also were asked how often theyconsidered temperahare to be a comfortissue for their patients. Tlie majority (ie,7Vy<>) responded that cold is often a com-fort issue; 25"/. reported that cold issometimes a comfort issue; and only 4%responded that cold is rarely a comfortissue. These results demonstrate theneed for patient-warming interventions.

4 3 0 • AORN ]f)URNAL

SEPTEMBER 2006, VOL 84. NO 3 Wagner — Byrne — Kolcaba

defined cold

QS an

both in the clinical context of maintain-ing normothermia and as a means of in-creasing overall patient comfort in theperioperative setting.

In an interventional study, Robinsonand Benton'- examined the comfort pro-vided by warmed blankets to older adulthospitalized patients and found that thelevel of discomfort after a patient re-ceived a blanket was significantly less(P < .001). As in numerous other studies,thermal comfort was not defined; but theresearchers addressed cold as an uncom-fortable sensation that can increase rest-

lessness, aggravate pain,and decrease overall pa-

Researchers in ^̂ "̂̂ satisfactionIn a study in which the

study researchers investigatedthe relative contribution^^ ™^̂ ^^^ ^î" tempera-tures to thermal comfortsnd autonomic responses,Bulcao et aP̂ stated that

uncomfortable thermal comfort is re-sponsible for the initia-

that tion of behavioral ther-moregulation, in which

increase individuals usually areable to control both ambi-ent temperature and thelevel of body-surface in-

pain, sulation. These researchersfound that skin tempera-

decrease ture contributed greatly to, subjective thermal com-

patient fort, whereas core temper-ature predominately regu-lated a person's autonomicand metabolic responses.

In the perioperativesetting, patients usually

are not able to control the ambient tem-perature or the level of body-surface in-sulation. Active warming, whether byuse of warmed blankets or forced-airwarming methods, therefore should beused to prevent and protect patientsfrom hypothermia.

4 3 2 - AOKN JOURNAL

PREOPERATIVE ANXIETY RESEARCH. G r i e v e -

conducted a qualitative study of 150patients in an outpatient surgery set-ting and suggested that nurses lackawareness of the therapeutic potentialof the nurse-patient relationship in anx-iety reduction. He argued that anxiety-reduction interventions disproportion-ately emphasize the provision ofpreoperative information when otherinterventions may be more appropri-ate, depending on both the patient'spersonality (ie, if he or she exhibits traitanxiety) and coping style.

Mitchell'' reviewed 34 studies to as-sess the level of knowledge about and in-terventions used to treat surgical patientanxiety. The studies that were reviewedwere conducted between 1990 and 2002and included data from 3,754 patientsundergoing surgery. Mitchell found thatpreoperative anxiety began at least 12hours before surgery, and both femaleand first-time surgical patients weremore anxious than others, although thiswas not always statistically significant. Aconsistent finding of this review was thatincreased anxiety levels were associatedwith a patient's lack of preoperative in-formation and with the patient undergo-ing nonvoluntary surgery. The inductionof anesthesia also strongly provokedanxiety in many patients. Mitchell alsofound that

• increased patient anxiety levels wereassociated with the need for an in-creased level of anesthesia,

• reduced patient anxiety was viewedas clinically more desirable, and

• anxiety was closely related to person-ality type.Measuring preoperative anxiety was

a major challenge for the researchers inthe studies that Mitchell re\'iewed, andthe researchers employed a mixture ofsubjective and objective measurements(eg, visual analogue scales; skin conduc-tance showing sympathetic nerve activ-ity; several types of lengthy, self-report


SIDEBAR

The Cost of Cotton BlanketsIn a benchmaTking report on the costs of cotton blan-

kets, Senn' surveyed 25 US health care facilities andfound that the average cost of one blanket, factoring intheft. Loss, and cleaning expenses, was $1.08 per use;and an average of nine cotton blankets are used duringa patient's perioperative experience. This corresponds toan average cost of $9.72 per patient. With this in mind,i t also is important to remember that there are othercosts associated with the use of cotton blankets {eg,nursing time spent filling blanket warmers and retrievingblankets for patients, warming cabinet purchase and up-keep, electricity, laundry staff member labor, storage).The average Life span of a cotton blanket is 22 washings,with an average replacement cost of $4.80 per bLanket.Senn found that the cost of a forced-air warming bLanketwas approximateLy $9 and was a proven optimaL warmingapproach for perioperative patients.

1. G F Senn, "Some cold, hard facts about warmed cottonblankets," SSM 8 (June 2002) 19-25.

questionnaires). With patients general-ly spending shorter times in preopera-tive settings, Mitchell concluded thatthere should be a more clinically viahleapproach to measuring preoperativeanxiety.

Mitchell identified anxiety manage-ment including anxiolytic medicationsand distraction techniques as the mainmanagement approaches taken in thepreoperahve setting. Most of the studieslisted premedication with anxiolytics asa positive management regimen. Thestudies did not estahlish an associationhetween extended postanesthesia careand benzodiazepine premedication,however. Pharmacological managementof anxiety is gauged hy physiological as-sessments and is a focus of the medicalmodel of care. Distraction methods (eg,music, television viewing, relaxation) arepresented as having a positive effect onpreoperative anxiety.

SUMMARY. For decades research has fo-cused on preoperative anxiety, but it re-mains clear that additional research isneeded to identify appropriate interven-tions and best practices suitable for careof the surgical patient. Thermal comfortalso is a complex and perhaps incom-pletely defined concept in perioperative

nursing. The evidence favors use of ther-mal comfort measures in the preoperativesetting. Preoperative warming has beenshown to provide basic comfort, decreaseanxiety, and possibly prevent postopera-tive complications. Further research isneeded regarding thermal comfort in thepreoperative setting, including examina-tions of the cost-effectiveness of warmingmethods and examinations of patient out-comes such as comfort and overall satis-faction with perioperative care.

CONCEPTUAL FRAMEWORKThe conceptual framework for this

study was derived from Kolcaba's Com-fort Theory." Kolcaba proposes an impor-tant relationship between patient com-fort, a patient's behaviors that move himor her toward a state of well-being, andthe institutional outcomes that are rele-vant in a particular research setting. Kol-caba developed a general comfort ques-tionnaire (GCQ) to measure comfort. TheGCQ is a 48-item questioiinaire with asix-point, Likert-type response format.The GCQ was pilot tested with 256 par-ticipants who were randomly selectedfrom the community and diverse hospitalgroups, which included the population ofinterest for this study, The data from thepilot test were factor analyzed, and theanalysis revealed three factors. These fac-tors were semantically consistent with thetypes of comfort in Uie taxonomie struc-ture and were named:

• relief,• ease, and• transcendence.^'For preoperative care, the Comfort Theo-ry states that the multidimensional out-come of patient comfort is increasedthrough the nurses' attention to the pa-tient's anxiety, the patient's expectation ofpostoperative pain and bleeding, and theprevention of shivering and chills, as wellas other standard nursing-care measures.

The Comfort Theory is best under-stood when divided and described in

4 3 4 • AORN JOURNAL

Wagner — Byrne — Kolcaba SEPTEMBER 2005, VOL 84, NO 3

Nurses assess the physical, psychospiritual, sodocultural, and

environmental comfort needs of patients and implement a variety

of interventions to meet those needs.

three parts. Part one states that nurses as-sess the holistic (ie, physical, psycho-spiritual, sociocultural, environmental)comfort needs of patients in all settings.Nurses further implement a variety of in-terventions to meet those needs andmeasure or assess patients' comfort levelsbefore and after those inter\'entions. Thisaspect of the Comfort Theory also de-scribes positive and negative interveningpatient variables over which the nursehas little control but which have a consid-erable impact on the success of comfortinter\'entions.'' Examples of interveningvariables considered in this study were

room temperature,baseline vital signs and temperature,preoperative medications and prepa-rations,

comorbid medical problems,routine home medications, andprognoses.Part two of the Comfort Theory states

that enhanced comfort strengthens pa-tients to consciously or subconsciouslyengage in behaviors that move them to-ward a state of well-being. These behav-iors are called "health-seeking behaviors"and provide a rationale for implementingcomfort interventions. For patients in thisstudy, the health-seeking behaviors un-der consideration were• decreased anxiety,• normothermia, and• stable vital signs.Both parts one and two of the ComfortTheory were tested in this study.

In part three of the Comfort Theory,health-seeking behaviors are related the-oretically to institutional integrity, whichis defined as

the qiinlity or state of health care or-ganizations in terms of being com-plete, whole, sound, upright, profes-sional, and ethical providers ofhealth

Many indicators are used to measure in-

stitutional integrity, including• cost of care;• length of stay;• turnover rates for staff members; and• patient, nurse, and staff-member

satisfaction.Part three was not tested in this study,but recommendations for doing so areincluded in the "Suggestions for FutureResearch" section of this article.

METHODSThe researchers used a pretest/

posttest experimental design for thestudy, which was conducted during afive-month period in a large public hos-pital in the southeastern United States.The study received approval by the in-stitutional review boards at NorthGeorgia College and State University,Dahlonega, Ga, and the research com-mittee at Wellstar Kennestone Hospital,Marietta, Ga. The hospital is a 455-bed,acute care facility with 20 operatingsuites. A separate preadmission testingarea was used to provide privacy andconfidentiality during interactions withpatients who participated in the study.The preoperative area is sectioned into40 private rooms. This area also servesas the discharge area for same day sur-gery patients.

SAMPLE. Norwood's computations''were used to determine sample size.Power analysis was based on a type Ierror rate of .03, a type 11 error rate of .2,and a medium effect size for the thermalcomfort instrument based on Kolcaba'spast research.*" This power analysis de-termined that 62 data sets were neededin each group to demonstrate significantdifferences between the two interven-tions for thermal comfort and anxiety.The inclusion criteria were ability toread, write, and hear English; mentalcompetency; being 18 years of age orolder; and being scheduled for surgeryon a day that a researcher was available.Patient exclusion criteria were paralysis.

AORN JOURNAL* 4 3 5

SEPTEMBER 2006. VOL 84, NO 3 Wagner — Byrne — Kolcaba

FIGURE 1

Flow Diagram of ParticipantStatus During the Study

Participants includedin the study {N = 126)

Assigned to controlgroup (n = 64)

Lost in Time 2follow-up (n = 6)

Included in analysis(n = 58)

Assigned to treatmentgroup (n = 62)

Lost in Time 2follow-up (n = 2)

Included in analysis(n = 60)

presence of known paresthesia, or fever(ie, a temperature above 37° C [98.6° F]).The final sample included 126 patientsbetween 18 and 80 years of age. Therewere missing data when a patient wastaken to the OR before Time 2 data couldbe retrieved. Researchers did not delaysurgery to complete data retrieval, andonly complete data sets were used foranalysis (ie, treatment group n - 60, con-trol group n = 58 [Figure 1]).

iNSrRUMENTS. Room temperatures weretaken by indoor thermometers with a dig-ital readout. Researchers also recorded• start times for warming interventions

with the patient-controlled warminggown for the treatment group;

• time for placement of warmed blan-kets for the control group;

• blanket warmer temperatures;• pulse oximetry; and• vital signs, including measurement of

body temperature.Identical study thermometers were pur-chased to increase the reliability of read-ings, and these were used to take oraltemperature measurements throughoutthe study. The facility's engineering de-partment inspected and approved allstudy devices before their use. Docu-mentation of preoperative medicationand IV fluid administration also was in-cluded on the second questiomiaire.

THERMAL COMFORT. The thermal comfortinventory (TCI) tool that was used was a

composite questionnaireconcerning a patient'ssubjective sensation ofbody temperature. Theresearchers created theTCI tool by modifyingKolcaba's original GCQ,""which has been adaptedfor many comfort studiesin diverse populations.^'The TCI tool consisted of13 questions on a Likert-type scale of one to six,where one was "strongly

disagree" and six was "strongly agree"with a statement. Eight of the statementswere directly related to temperature per-ception. In addition, one statement fo-cused on the patient's perception of thenurses' care for him or her, and one state-ment addressed the patient's level ofanxiety. The total possible range of an-swers to the TCI tool was 13 to 78. Afterthe statements that were negativelyworded were reverse scored, the higherscores represented a greater level of ther-mal comfort.

A second instrument that was usedto measure a patient's thermal comfortwas a numeric visual analog scale(NVAS). Scores for thermal comfortranged from zero (ie, extreme cold) to10 (ie, extreme heat). Thermal neutrality(ie, thermal comfort) was identified bythe midrange mark of five. Participantswere asked to place a dot on the NVAScorresponding to their perception oftheir thermal comfort.

Thermal comfort NVASs have beenused in numerous studies to evaluatethe subjective thermal comfort of pa-tients in comparison with physiologicmeasurements to establish a correla-tion between them.^'"'''''" The NVAS forthermal comfort was expected to be neg-atively correlated with anxiety (ie, it wasexpected that higher thermal comfortwould be associated with less anxiety).The NVAS was implemented in this


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study, although no documentation of itsreliability had been reported in previousstudies'"'"^" or in the current study.

ANXIETY, An NVAS for anxiety also wasused to measure a patient's level of anx-iety. Participants were asked to place adot on the NVAS corresponding to theirperception of their anxiety at that time.

The subjective scores foranxiety ranged from zero(ie, no anxiety) to 10 (ie,extreme anxiety) on the

significant and ^X^^^J^J::proven positive

correlation

between the w r . ,agree) to six, (le, stronglyagree). Lastly, anecdotalinformation from the pa-tient regarding anxietyand thermal comfort wasdocumented on the com-ment section of the form tofurther validate a patient'sresponses.

sponded on the six-pointLikert-type scale, ranging

Anxiety Inventory

and the visual

analog scale for

anxiety*

three main instru-ments used by researchersto measure anxiety are theAmsterdam PreoperativeAnxiety and InformationScale (APAIS), the Spiel-

berger State-Trait Anxiety Inventory(STAI), and the anxiety visual analogscale (VAS).-"-"'̂ ' The APAIS is a six-question, Likert-type inventory that fo-cuses on fears of anesthesia and sur-gery. The STAI has demonstratedreliability and validity in previous stud-ies;̂ " however, it is a 20-question instru-ment and therefore is cumbersome asan anxiety screening tool in the preop-erativG area. The VAS has shown tohave significant and positive correla-tion with the STAI (r = 0.64; P = .0001="and r = 0.55; P < .01'").

Elkins et al,"' studied the utility of a

numeric visual analog anxiety scaleusing a zero to 10 scale when identifyingpreoperative anxiety in patients sched-uled for colorectal surgery. Participants(n = 36) completed both the NVAS andthe STAI. This visual analog scale instru-ment correlated significantly with theSTAI instrument (P < .0001). On the basisof this evidence of the measurement reli-ability and validity, the researchers inthis study decided to use an NVAS tomeasure anxiety in surgical patients.

PROCEDURESSurgical nurses and OR staff mem-

bers participated in an inservice pro-gram about the study. Surgeons andanesthesia care providers were in-formed through letters of intent outlin-ing the purpose of the study Data col-lection forms were pilot tested byrepresentatives of the target popula-tion—a sample of approximately 10% ofthe desired sample size (ie, 12 data col-lection sets)—to determine the usabilityand clarity of the forms.

After the principal investigator in-structed the coinvesti gator and a hireddata collector on the data collection pro-cedures and forms, the coinvesti gatorand data collector observed one anotherduring pilot data collection and com-pared observational notes to establishstructured approaches to data collection.No interrater reliability statistical analy-sis was performed.

PARTICIPANT SELECTION. Patients typicallyarrived at the preadmission and testingdepartment several days to one weekbefore their scheduled surgery date. Onthe days and during the hours that re-search investigators were available, allsurgical patients in the preadmissiontesting area were given a printed flyerbriefly describing the nursing studyand asking for interested participants. Ifa patient indicated an interest in partici-pating in the study, an investigator ap-proached the patient to further describe

4 3 8 • AOKN JOURNAL


Participants in the treatment group used a patient-controlled

warming gown which they put on approximately 30 to 60

minutes before the anticipated start of the surgical procedure.

the study and to ascertain if the patientmet the inclusion criteria. When appro-priate, informed consent and demo-graphic information then were obtained.

On the day of surgery, when the pa-tient arrived in the preoperative holdingarea, he or she was randomly assigned toone of two groups through the use of aset of computer-generated blocks of ran-dom numbers. Randomization was notbased on prior gender separation. Theassignments were kept in sealed, se-quentially numbered envelopes untilused. From the block randomizationnumbering, the envelopes were markedcither with blue dots to designate thecontrol group or red dots to designatethe treatment group. Colored forms alsowere used to maintain organization andto ensure that Time 1 and Time 2 docu-ments were clearly distinguishable.

For both groups. Time 1 vital signs, in-cluding temperature measurements, theTCI tool, and both the thermal comfortand anxiety NVAS tools were collectedimmediately before the commencementof the warming intervention. Time 2 datawere gathered after a minimum of 30minutes but before the patient enteredthe OR suite or underwent anesthesia in-duction. Patients again completed theTCI and both NVAS tools for thermalcomfort and anxiety, and physiologicaldata also were collected. Throughout thest^dy, the researchers kept a journal doc-umenting their decision-making process-es, contextual variables, and the partici-pants' anecdotal comments.

TREATMENT GROUP. After the initial set ofmeasurements (ie. Time 1), those in thetreatment group put on identical patient-controlled warming gowns, which weredonated by the manufacturer. This oc-curred approximately 30 to 60 minutesbefore the anticipated start of the surgicalprocedure. The patient then was coveredwith one nonwarmed, cotton blanket, ifhe or she desired. After it was initiated,the warming gown was used until just

before the patient was transferred to theOR. The gown's warming level was doc-umented at the start of treatment and atthe time of the second data collection (ie.Time 2). The patient controlled the warm-ing gown, and if he or she chose not toturn on the gown to receive any warmingtreatment, this was documented at eachmeasurement time. Subsequent anesthe-sia and surgical-management decisionswere made at the discretion of the attend-ing physicians.

CONTROL GROUP. After Time 1 measure-ments were taken, patients in the con-trol group put on a regular cotton hos-pital gown approximately 30 to 60minutes before the anticipated start ofsurgery, and they were covered withone warmed blanket from one of twowarming cabinets. Time 2 data weregathered at least 30 minutes after Time1 measurements. Temperature readingsof the specific warming cabinet weredocumented on the patient's datasheet. Tf a patient asked for anotherblanket, a warmed cotton blanket wassupplied as requested. This was theusual practice at the facility. The totalnumber of warmed blankets that wereprovided to a patient was documented.If a patient chose not to receive anywarming treatnient, this also was docu-mented at each measurement time.

DATA ANALYSISData analysis was performed using a

computer-based spreadsheet analysisprogram, with the exception of Cron-bach's alpha and descriptive statisticsdata, which were computed using acomputer-based statistical and dataanalysis system. By combining all cate-gory responses, the reliability of theTCI instrument was assessed usingCronbach's alpha. All analyses were per-formed on an intention-to-treat basisusing two-sided P values (P < .05). To ob-tain additional information, relativechange was computed for individual

AORNJOUKNAI.* 4 3 9

SEPTEMBER 2006, VOL 84, NO 3 Wdgncr — Byrne — Kolcaba

TABLE 1

Partidpant Characteristics

Characteristic

MaleFemaleAgeHeight (inches)Male height (inches)Female height (inches)Weight (lbs)Male weight (lbs)Female weight (lbs)Body surface area (m )̂Body mass index (kg/m-)Narcotic medicationsPsychotropic medications

Controlgroupn = 64

1054

48 ± 1565 ±371 ±264±2

174 + 53205 ± 20169 ± 55

1.86 ± 0.2628.7 ± 8.1

716

Treatnientgroup

1745

50 ±1367 + 371 ±265 ±2

184 ±55195 ± 31180 ± 61

1.94 ± 0.2529.6 ± 8.8

620

items on the TCI. These data were notnormally distributed, so nonparametricanalyses with continuity correction wereconducted. Data frt)m the composite TCIwere normally distributed; data fromthe NVAS tools were not. Nominal datawere compared using a chi-square test,and numeric measures were comparedusing Student's / test. For analyses of theNVAS tools, the nonparametric Wilcox-on rank sum test was used. Differencedata between the TCI and NVAS toolswere not normally distributed, so aWilcoxon rank sum test was used withcontinuity correction to compute signifi-cance levels. To evaluate the variablesmore extensively, comparisons weremade of the relative changes within eachvariable from Time 1 to Time 2 values.

FINDINGSTable 1 illustrates the baseline char-

acteristics of the study participants ac-cording to group. Women comprisedapproximately 73% of the entire sam-ple. There were no significant differ-ences between the two groups exceptfor height. When this was analyzedseparately for men and women, heightwas not found to be significantly dif-ferent between the treatment and con-trol groups.

Cronbach's alpha for the TCI was .82,showing respectable internal consisten-cy and reliability for a new instrument.

At Time 1, the range ofdata on the TCI was from25 to 78, and the standarddeviation was 10.7. AtTime 2, the range of dataon the TCI was from 38 to78 and the standard devi-ation was 9.2. Table 2summarizes the reliabili-ty contribution of eachLikert-type scale item ofthe TCI instrument.

The sigiiificance levelsfor the relative change for

all the individual scale iten\s on theNVAS and TCI are shown in Table 3. Asignificant value {P - .014) was found inthe anxiety NVAS with the treatmentgroup experiencing less anxiety thanthe control group. Significance wasnoted between groups with four itemson fhe TCI Likerf-type scale scores,demonstrating that the treatment grouphad higher levels of thermal comfort inrelation to• their overall body temperature (P =

.016),• room temperature (P - .049),• shivering (P ^ .010), and• chest warmth (P ^ .003).

Mean TCI scores are shown in Table4. A number of the individual scoresdemonstrated the same trend as thepopulation comparisons. There were nosignificant differences between the ini-tial and final "I am anxious" scores be-tween the two groups (control P - .01and treatment P = .00); however, therewas a trend toward decreasing anxietyin both groups. The same trend was seenin the NVAS anxiety scores.

Table 5 shows that the mean values forthe TCI and NVAS for thermal comfortwere significantly different at baseline;however, anxiety scores were similar.Specifically, at Time 1, the two groups ex-perienced significant initial differences intheir TCI (t = 2.07, P = .04) and NVASthermal comfort scores {t = 2.24, P = .034),

4 4 0 • AOKN JOURNAL

Wagner — Byrne — Koicaba SEPTEMBER 2006, VOL 84, NO 3

Reliability Analysis (

Patient-reportedvariableBody temperature

feels fineChair/bed feels coldRoom temperature

is warm enoughFeels confidentHas enough privacyIs shiveringArms are coldFeels that nurses

are caringFeels anxiousFeet are coldChest is warmFeels cold in generalFeels out of control

Item values

Mean4.83

4.874.24

4.965.385.464.405.67

3.554.414.774.655.21

Standarddeviation

1.31

1.471.61

1.220.931.121.700.75

1.721.731.441.581.24

TABLE

jf the

Totalmean57.55

57.5258.14

57.4357.0156.9257.9956.71

58.8357.9857.6257.7357.17

2Thermal

If thisTotal

standarddeviation

9.38

9.409.17

9.699.989.599.13

10.10

9.549.329.729.009.89

Comfort ]index

item is omitted (SC)

Coeffidentalpha0.80

0.800.79

0.810.820.800.790.82

0.820.810.820.780.82

Correlationtotal0.63

0.530.63

0.420.260.560.610.18

0.340.480.310.760.24

Otheritems0.48

0.380.56

0.400.420.400.530.31

0.250.390.190.720.21

Relative

Variable(Time 1 - Tune 2)/Time 1Thermal comfort/numeric visual

analog scale (NVAS) scoreAnxiety NVAS scoreThermal comfort inventory score

TABLE 3Change for Individual Scale Items

Controlgroup

(n = 58)mean-0.26

-0.03-0.09

Treatmentgroup

(n = 60)mean-0.27

0.27-0.13

Thermal Comfort Inventory Likert-type scale scoresMy body temperature feels fineThe chair/bed feels cold

-0.32-0.01

The room temperature is warm enough -0.31I feel confident1 have enough privacyI am shiveringMy arms are coldThe nurses care about meI am anxiousMy feet are coldMy chest area is warmIn general, I feel coldI feel out of control

-0.23-0.05-0.11-0.15-0.020.000.11

-0.010.15

-0.16

-0.470.11

-0.49-0.060.020.15

-0.03-0.120.160.00

-0.430.23

-0.19

*Wilcoxon rank sum test with correction for ties and continuity (difference <df =121)** Significant values

Z value*-0.059

2.466-0.759

-2.403-0.099-1.9691.7140.3622.5621.3620.8641.608

-0.507-2.9850.623

-0.904

P.953

.014**

.448

.016**

.921

.049**

.0865

.718

.010**

.173

.388

.108

.612

.003**

.534

.366

> 0 lie, a tiw-taikd analysis];

AORN JOURNAL" 4 4 1

SEPTEMBER 2006. VOL 84. NO 3 Wagner — Byrne — Kolcaba

TABLE 4

Differences in Thermal Comfort Index Scores Between Groups

Variable

Time 1ThermalComfort

Indexmean'*'

Time 1standarddeviation


Indexmean*


My body temperature feels fineControl GroupTreatment Group

4.44.50.6

.573

1.51.5

4.85.53.9#

.000*

1.20.7

1.65.4

The chair/SeJleels coldControl GroupTreatment Group

.1067

.0000*

2.8 1.72.2 1.62.1*

P .035*The temperature in the room is warm enouglTControl Group 3.8 1.6Treatment Group 4.2 1.7(** 1.4P .1531 feel confidentControl GroupTreatment Group

2.11.53.2*

.002*

1.30.9

3.23.7

4.15.03.3*

.001*

1.61.3

1.34.2

4.55.22.9"

.004*

1.41.1

4.95.21.9.065

1.01.2

2.61.1

I have enough privaq^

.0022*

.0005*

.2088

.0001'*

.0118*

.2617

Control GroupTreatment Group

r*pI am shivering

5.35.40.3

.788

1.00,9

5.45.40.3

.751

0.91.0

1.71.4

.0994

.1806

Control GroupTreatment Group(**PMv arms are coTd"

1.91.51.6.108

1.41.2

1.71.04.9*

.000*

1.10.2

0.04.0

Control GroupTreatment Group

3.02.61.6.123

1.71.8

2.82.03.1*

.003*

1.71.5

0.82.4

1.0000.0002*

.4192

.0193*

with the treatment group scores beinghigher. There was no difference, howev-er, in the anxiety scores (t - 0.596, P =.746) or other initially measured vari-ables. At Time 2, the treatment grouphad scores that were significantly loweron anxiety (f = 1.87, P - .06), higher onNVAS thermal comfort (f = 2.84, P =.005), and higher on the TCI (f - 3.77, P- .0002). On relative change, the treat-ment group experienced a significantlygreater relative reduction in NVAS anx-iety scores compared to the control

group (/ = 2.77, P - .007). The controlgroup did not experience a significantreduction in anxiety scores [t = 0.790,P = .431). The relative change in boththe NVAS thermal comfort {t - 0.047, P= .963) and TCI {t = 0.913, P = .363) werenot significant.

There were no significant differencesbetween groups when compar ingchanges in outcome variables. Therewere no significant differences ob-served in body temperatures betweenthe two groups, even when they were



TABLE 4

Differences in Thermal Comfort Index Scores Between Groups (Continued)

VariableThe nurses care aboutControl GroupTreatment Group

PI am anxiousControl GroupTreatment Groupt**PMy feet are coldControl GroupTreatment Group

pMy chest area is warmControl GroupTreatment Groupt**PIn general, I feel coldControl GroupTreatment Group

r*p

I feel out of controlControl GroupTreatment Groupt**P

H m e lThermalComfort

Indexmean*^

me5.65.60.8

.422

3.83.70.3

.728

3.02.90.6

.555

4.74.60.2

.851

3.32.33.4*

.001*

1.81.62.0

.053


0.70.8

1.71.7

1.81.9

1.21.5

1.71.6

1.21.2


Indexmean*

5.75.70.5

.596

3.42.91.8

.067

2.22.30.1

.890

4.55.34.0#

.000*

2.41.34.9*

.000#

1.91.71.2

.240

rime 2standarddeviation

0.70.8

1.71.6

1.51.6

1.51.4

1.50.7

1.31.2

tvalue**

1.50.8

2.54.5

3.62.6

0.53.7

4.15.1

0.31.7

P

.1389

.4103

.0143

.0000*

.0007*

.0107*

.5964

.0004"

.0001*

.0000*

.7306

.0927

* Mean Thermal Comfort Index (TCI) scores (d( = 721)** Nonpaired t test to compare TCI responses between groups; paired t test to compare TCI responses vnthin groups* Significant values

normalized to body mass index, bodysurface area, or body mass. Of interest,there was a slight increase in tempera-ture found in both groups. The numberof blankets received by the controlgroup averaged just slightly more thantwo, which is considerably fewer thanwas obsen'ed in a study by Senn.̂ - Last-ly, there were no significant differencesbetween the initial ambient room tem-peratures between groups. The ambienttemperature, however, changed signifi-cantly (ie, an increase in Time 2 room

temperature reading) for the treatmentgroup {I - 3.05, P - .0007).

DISCUSSIONThe treatment group experienced a

significant decrease (ie, t = 3.85, P =.0002) in anxiety compared to the con-trol group. This effect demonstratedthat the patient-controlled warminggown had psychological effects in addi-tion to providing thermal comfort. Itmay be that the patient-control featureof the gown contributed to the decrease

AORN JOURNAL • 4 4 3


MeanTime

VariableTime 1

TABLE 5

Values of Scores1 versus Time 2

Control Treatmentgroup group

Thermal comfort numeric 4.24visual analog scale (NVAS)

Anxiety NVAS 4.5Thermal comfort inventory 57.8Time 2Thermal comfort NVASAnxiety NVASThermal comfort inventory

* Significant value

4.884.23

61.9

4.8

4.3461.7

5.493.35

67.7

P

.034-̂

.746

.04*

.005*

.06*

.0002*

in anxiety, although the treatment andcontrol groups did not demonstrate dif-ferences on the items related to confi-dence (treatment group: t = 1.1, P =.2617; control group: t - 2.6, P = .0118)or feelings of control (treatment group:t = 1.7, P = .0927; control group: t = 0.3,P = .7306).

Relative change in each item on theTCI provided further information aboutthe effects of the patient-controlled gownon subfactors related to total comfort. Ofparticular interest is ihat the treatmentgroup demonstrated a greater relativeimprovement on four important items:

• self-perception of body temperature,• perception of room temperature,• shivering, and• warmth in the chest area.This seems to indicate that the patient-controlled gown has the desired effecton the subfactors most closely as-sociated with holistic thermal comfort.These effects were somewhat diluted inthe total score by other items that hadno apparent effect on the total score.

Another interesting observation isthat participants who were assigned tothe treatment group experienced signif-icantly higher levels of thermal comfortand TCI scores even before the warmingunit was activated. This finding sug-gests that the patient-controlled warm-ing gown itself produces significantlygreater levels of thermal comfort andpreoperative satisfaction. Another pos-sibility related to this finding may be

that the control g roupparticipants expressed de-creased thermal comfortdue to a compensatory ri-valry effect. Brink andWood""̂ describe compen-satory rivalry as when re-spondents in the controlgroup believe they are re-ceiving a less-desirabletreatment than the exper-imental group and thus

are motivated to compete for equity.The knowledge that they did not havethe "new technology" for warmingmay have been a contributing factor tomore negative responses on the s tudyinstruments.

The TCI instrument demonstratedstrong reliability as evidenced by mod-erately strong internal consistency (ie,alpha - 0.82); and all of the items ap-parently integrated well. Examiningchanges in each individual item pro-vided a greater unders tanding of theunique and specific effects of the patient-controlled gown. Both NVAS tools dis-played concurrent validity with the anx-iety and total comfort scores on the TCIat both time points.

STUDY LIMITATIONS

Reliability of the NVAS tools forthermal comfort was not tested beforestudy was conducted. The NVAS for-mat, however, has been tested by Kol-caba on her web site,^ and these resultshave been published. '̂' The NVAS wasfound to be moderately sensitive to self-report. Additional testing of the tool'svertical, 10-cm format is indicated. Inthe current study, the NVAS toolsdemonstrated the same results as theTCI, which provided preliminary evi-dence of concurrent validity. In design-ing this study, the researchers may havegiven unciue credit to the holistic effectsof the patient-controlled gown by in-cluding questions not directly related to



thermal comfort (eg, privacy, nurses' car-ing, confidence); however, all patients inthe study were told that the research wasthe evaluation of a new thermal therapy,not an anxiolytic therapy.

Another study limitation is the possi-bility of compensatory rivalry as a threatto internal validity. This may explain thehigher level of thermal comfort at thestart of Time 1 in the treatment group.This was not a double-blind study and itwas obvious that new technology wasreplacing the usual gown, so the controlgroup was aware that they were not re-ceiving the experimental treatment. Ran-domization was used to assign individu-als to either the control or treatmentgroups, and patients in the treatmentgroup scored higher on both total ther-mal comfort and the NVAS for totalcomfort at Time 1 than patients in thecontrol group. These differences at Time1 render findings about total comfort in-conclusive. The fact that there were nosignificant differences in the relativechanges of the thermal variables may beexplained by compensatory rivalry; butbecause the participants were told thatthe research was evaluating a new ther-mal therapy, it is less likely that biasplayed a role in the evaluation of anxiety.

The significant difference in ambi-ent room temperature at Time 2 for thetreatment group also is a limitation ofthis study. The small preopera t iverooms are enclosed spaces, so it is pos-sible that the use of the warming unitand the warm air flow coming fromthe warming gowns actually changedthe environmental temperature. Thisunknown variable was not accountedfor in the study design, but it shouldbe considered in future studies.

SuGGESnONS FOR FUTURE RESEARCHFuture research might be better served

by a quasiexperimental design, where pa-tients on day A receive only one type ofthermal comfort inter\'ention (eg, usual

care) and patients on day B receive onlyanother type of thermal comfort inter-vention (eg, the patient-controlled heatedgown), A third type of comfort interven-tion (eg, warmed IV fluids) then could beoffered on day C. This rotation could berepeated until the desired sample size foreach group is achieved. This would re-duce the possible compensatory rivalryeffect on patients that may have beenpresent in the current study

The relationship between preopera-tive warming, intraoperative normoth-ermia, and postoperative normothermianeeds to be examined aswell. In doing so, it will beimportant for all meas-ures of body temperatureto be conducted with thesame type of equipmentand with the same cali-bration protocol. It wouldbe helpful to track otheroutcomes of interest, suchas postoperative infec-tions, bleeding, pain, andother complications relat-ed to perioperative hy-pothermia in any or all ofthe perioperative phases.Further studies also arewarranted to address ther-mal comfort as a nurse-sensitive and institutionaloutcome, and to measure the impact ofthermal comfort on

• overall patient satisfaction with pre-operative care,

• improved outcomes, and• shorter length of stay in the PACU.

Kolcaba's'' Comfort Theory is basedon the assumption that patient comfortis germane to the discipline of nursingand health care. In this study, the imme-diate outcome of enhanced thermalcomfort in the preoperative setting wasassessed. Specific relationships betweenpreoperative interventions for thermalcomfort, intraoperative normothermia.

Future studies

are warranted to

address thermal

comfort as a

nurse-sensitive

and

institutional

outcome.

AORN JOURNAL- 4 4 5


and postoperative normothermia needto be explored further. Future studies arewarranted to test the theoretically posi-tive relationship between thermal com-fort and other relevant health-seekingbehaviors, such as a quick and unevent-ful recovery from surgery and anesthe-sia, as well as the desirable institutionaloutcomes of• patient satisfaction with care as re-

vealed by institutional patient caresurveys,

• fewer complications or readmis-sions, and

• shortened length of stay in the opera-tive and postoperative areas.

The specific relationships between pre-operative interventions for thermal com-fort, intraoperative normothermia, andpostoperative normothermia also needto be explored. A comparison of thetypes of inter\'entions and their relation-ship to health-related and institutionaloutcomes has not yet been undertaken.

iMPLianONS FOR PERIOPERAnVE NURSINGThis study was conducted to deter-

mine the effects of preoperative warm-ing with patient-controlled warminggowns versus warmed cotton blanketson a patient's perception of thermalcomfort and anxiety in the preoperativesetting. Findings suggest that comfortwarming is a positive intervention forboth temperature management and anx-iety reduction. Both types of comfortwarming inter\'entions demonstrated apositive effect on thermal comfort andthe general sense of well-being of pre-operative patients. Tliough body tem-perature was not significantly differentbetween the groups as an outcomemeasure, measurements obtained dur-ing Time 2 of both groups were higherthan the initial readings. This corrobo-rates other research that has shown thatprewarming patients can be a therapeu-tic inter\'ention in perioperative temper-ature management.'""'*^^ Only the treat-

ment group experienced a significant re-duction in preoperative anxiety, howev-er. This finding suggests that there is abenefit to using new technology and de-vices that provide a patient with morecontrol over their thermal comfort toboth decrease anxiety and potentially in-crease overall patient satisfaction. Awider knowledge base concerning thebenefits of thermal comfort measuresperioperatively could potentially pro-vide evidence for best practices duringthe entire perioperative experience. •

Doreen Wagner, RN, MSN, CNOR,is an assistant professor. North Geor-gia College and State University,Dahlonega, Ga.

Michelle Byrne, RN, PhD, CNOR, isan associate professor. North GeorgiaCollege and State University,Dahlonega, Ga.

Katharine Kolcaha, RN, PhD, is anassociate professor. University of AkronCollege of Nursing, Akron, Ohio.

The researchers thank the perioperntiveRNs ofWellstar Keniiestonc Hospital.Marietta, Ga, for their support and inter-est in this study. The researchers alsogratefully acknozuledge the assistance ofMoim Hatch, RN, Wellstar KeunestoueHospital, Marietta, Ga,for data collection.

Editor's note: This research was fniancial-h/ and lechukalhj supported by ArizantHealthcare, Inc, Eden Prairie, Minn.

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4 4 6 • AORNJOURNAL


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32. S Robinson, G Benton, "Warmed hlan-kets: An intervention to promote comfort forelderly hospitalized patients," Geriatric Nurs-ing 23'(November/December 2002) 320-323.33. C F Bulcao et al, "Relative contributionof core and skin temperatures to thermalcomfort in humans," journal of Thermal Bi-ology 25 no 1-2 (20(H)) 147-150.34. M Mitchell, "Patient anxiety and mod-ern elective surgery: A literature review,"journal ofChnical Nursin'^ 12 (November2003)806-815.35. K Kolcaba, Comfort Theory and Practice:A Vision for Health Care and Research (NewYork; Springer Publishing Co, 2003) 45-47.36. K Y Kolcaba, "Holistic comfort: Opera-tionalizing the construct as a nurse-sensitiveoutcome," Advances in Nursiw^ Scie)UY 15(September 1992)1-10.37. S I. Norwood, Research Strategies for Ad-vanced Practice Nurses (Upper Saddle River,NJ: Prentice Hall Health, 2000).38. A J M Lopez-Cepero et al, "Anxietyduring the performance of colonoscopies:Moditication using music therapy," Euro-pean journal of Gastroenterolo<^y and Hepatol-og}/16 (November 2004) 138^-1386.39. C H Kindler et al, "Tlie visual analogscale allows effective measurement of pre-operative anxiety and detection of patients'anesthetic concerns," Anesthesia and Analge-

sia 9ii (Mixrch 2000) 70e-7U.40. C Elkins et al, "Use of numeric visualanalog anxiety scale among patients under-going colorectal surgery," Clinical NursingResearch 13 (August 2004) 237-244.41 . N Moerman et a\, "Tlie Amsterdampreoperative anxiety and information scale(APAIS)," Anesthesia & Analgesia 82 (March1996)445-451.42. G F Serin, "Some cold, hard facts aboutwarmed cotton blankets," SSM 8 (June2002)19-25.43. PJ Brink, MJ Wood, Adva)!ced Design inNursiu'^ Research, second ed (Tht.)usandOaks, Calif: Sage Publications, Inc, 1998) 37.44. K Kolcaba, "The comfort line," TheComfort Line-Kathy Kolcaba PhD, RN,The University of Akron, http'.llwww.thecomfortline.comi (accessed 12 July 2006).45. K Kolcaba, R Steiner, "Empirical evidencefor the nature of holistic comfort," journal ofHolistic Nursing 18 (March 2000) 46-62,46. S M Vanni et al, "Preoperative com-bined with intraoperative skin-surfacewarming avoids hypothermia caused bygeneral anesthesia and surgery," journal ofClinical Anesthesia 15 (March 2003) 119-125.47. P Kiekkas, M Karga, "Prewarming: Pre-venting intraoperative hypothermia,"British journal of Perioperative Nursin*^ 15(October 2005) 444-451.

Hospitals Develop Methods to Improve Patient Hand Offslew procedures are being developed to addressI the communication breakdown that sometimes

occurs when a patient is transferred between unitsor during a shift change, according to a June 28,2006, article from The Wall Street Journal Online.There is evidence that this breakdown in communi-cation is the single greatest source of medical er-rors that occur in health care settings.

The Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) has begun re-quiring hospitals to implement formal standardsfor communicating patient information duringhand offs. If a health care facility fails to respondto JCAHO's directive, it risks losing accreditation.Health care organizations are starting to respond,but few facilities have an established, compre-

hensive transfer-of-care system in place.The Institute for Healthcare Improvement has

developed a communication tool for the healthcare industry known as SBAR (ie, situation, back-ground, assessment, recommendation). This hand-off program was developed from one used in mili-tary applications and can be used by nurses andphysicians to organize and convey a patient's crit-ical information in approximately 60 seconds. An-other available solution is the use of electronicmedical records with automated transfer logs, butfacilities with access to this technology are rare.

L Landro, "Hospitals combat errars at the 'hand-off,'" TheWaU Street Journal Online, 28 June 2006, http://onLine.wsj.com (accessed 28 June 2006).


Documents

Effects of comfort warming on preoperative patients. AORN