Background
The MyTEMP trial
Behavioural diagnostics of barriers and facilitators to clinical behaviour change
Methods
Participants
Recruitment and procedure
Interview topic guide development
Data analysis
Codebook development and coding to TDF domains
Results
Participants
Inter-rater reliability
Overall themes and TDF domains for setting and prescribing IDTs
Themes | Sub-theme | Belief statement | Frequency (out of 18) | Theoretical Domains Framework, domain(s) |
---|---|---|---|---|
Theme 1: awareness of clinical guidelines and how IDT fits with local policies | Awareness of guidelines | - We don't use guidelines for individualized cooler dialysate temperatures | 14 | Knowledge |
- There are no guidelines for dialysate temperature | 5 | |||
Potential for conflict of IDT with local policies | - Individualized cooler dialysate temperatures will/may conflict with local policies | 3 | Knowledge/Goals | |
Theme 2: benefits and motivation to use IDT | Not a priority | - It’s a little priority at this point | 10 | Goals |
No rewards in place | - I can’t think of any rewards | 8 | Reinforcement | |
Motivation limited to subset of patients | - I am more motivated to set or prescribe cooler dialyste temperatures when my patients have hypotension on dialysis | 6 | Intention | |
- I am not inclined to use individualized cooler dialysate temperatures for patients doing well on current dialysate temperatures | 5 | |||
- You have to weigh the benefits of preventing hypotension with patient complaints of feeling cold | 3 | |||
Theme 3: IDT alignment with usual prescribing and setting practices and roles | Currently not individualizing dialysate temperatures at each treatment | - We don't individualize dialysate temperatures | 10 | Nature of the Behaviour |
- When setting or prescribing cooler dialysate temperatures it is usually 0.5 degrees below standard | 8 | |||
Sometimes individualize the dialysate temperature | - I occasionally or rarely prescribe or set cooler dialysate temperatures | 11 | Social Professional Role and Identity/Nature of the Behaviour/ Beliefs about Capabilities | |
Nurses require physicians' order for permanent change in dialysate temperature | - We need a global order/ policy change/ medical directive so nurses can set individualized cooler dialysate temperatures | 7 | Social Professional Role and Identity/Social Influences | |
- We would need a doctor's order to set individualized cooler dialysate temperatures | 5 | |||
- I need an order from the doctor for a permanent change in dialysate temperature beyond one treatment session | 3 | |||
Theme 4: thermometer availability/ accuracy and dialysis machine characteristics | Outdoor temperature and drinks can influence temperature reading | - Climate in winter or summer can impact accuracy of core body temperature readings | 3 | Environmental Context and Resources |
- Consumption of warm beverages or ice can impact accuracy of core body temperature readings | 3 | |||
Thermometer availability | - Potential limited thermometer availability | 2 | Environmental Context and Resources | |
Dialysis machine can be adjusted in 0.5 or 0.1 increments up to 35 degrees Celsius | - Can adjust dialysate temperatures by 0.5 increments | 2 | Environmental Context and Resources | |
Theme 5: impact on workload | Negative impact on workload | - Physicians say nurses’ workload will increase | 6 | Beliefs about Capabilities/ Beliefs about Consequences |
- My workload will increase | 4 | |||
Theme 6: patient comfort | Negative clinical management consequences | - Patients may feel too cold on cooler dialysate temperatures | 11 | Beliefs about Consequences |
- It is common for patients to feel cold on dialysis | 7 | |||
Coping plans that lead to increased dialysate temperature | - If patients are really complaining of being cold we may increase dialysate temperature by 0.5 | 9 | Behavioural Regulation | |
- I may increase the dialysate temperature for someone with hypertension to see if that decreases their blood pressure | 2 | |||
- If patients are feeling cold and have no issues with blood pressure or fever and request an increase in dialysate temperature I would not have evidence to deny their request | 2 | |||
Emotions related to patient comfort | - I may feel worried or concerned if patients are feeling cold | 6 | Emotion | |
Theme 7: forgetting to prescribe or set IDT | Potential to forget | - I may forget to prescribe or set an IDT if I am busy | 9 | Memory, Attention and Decision Making /Emotion |
- We would need reminders for IDTs | 6 | |||
- It may be easy to forget in emotional or tense situations | 2 |
Theme | Sub-theme | Belief statement | Frequency (out of 18) | Theoretical Domains Framework, domain(s) |
---|---|---|---|---|
Theme 1: awareness of clinical guidelines and how IDT fits with local policies | Awareness of need for more evidence | - It needs to be studied | 18 | Knowledge |
Awareness of evidence | - An intervention that’s been studied for which there’s reasonable evidence of benefit | 10 | ||
Awareness of guidelines | - There are guidelines for dialysis treatment | 7 | ||
Link with existing policies | - Individualized cooler dialysate temperatures will not conflict with local policies | 12 | Goals | |
Centres have existing temperature standards | - Centre standard is 36.5 or higher | 10 | Knowledge/Goals | |
- Centre standard is less than 36.5 | 6 | |||
Theme 2: benefits and motivation to use IDT | Positive clinical management consequences | - Cooler dialysate temperatures can help manage or prevent hypotension during dialysis | 17 | Beliefs about Consequences |
- Cooler dialysate temperatures can help with fluid removal during dialysis | 7 | |||
Positive potential long-term consequences | - Individualized cooler dialysate temperature may lead to better cardiovascular outcomes | 8 | Beliefs about Consequences | |
- Individualized cooler dialysate temperatures may lead to a reduction in morbidity and mortality or increase longevity | 3 | |||
- Individualized cooler dialysate temperatures may preserve cognitive function | 2 | |||
Optimistic | - Based on what I'm hearing, I'm quite optimistic | 16 | Optimism | |
Patient benefit is inherently reinforcing | - If you can prevent symptomatic hypotension for your patients, that’s rewarding | 11 | Reinforcement | |
Priority | Setting/prescribing IDTs is a priority because we need to know the answer | 7 | Goals | |
Theme 3: IDT alignment with usual prescribing and setting practices and roles | Procedures and roles specific to physicians | - The physician would order or prescribe individualized cooler dialysate temperatures | 14 | Social Professional Role and Identity/Nature of the Behaviour/Beliefs about Capabilities |
- Physicians are responsible for prescribing dialysate temperatures | 11 | |||
- Prescriptions are applicable over all treatments until changed again | 8 | |||
- I would have to be able to prescribe IDTs in a way that I wouldn't have to review every treatment because that would not work | 5 | |||
Procedures and roles specific to nurses | - We usually measure core body temperature before and after treatment | 8 | Social Professional Role and Identity/Nature of the Behaviour/Beliefs about Capabilities | |
- Nurses can modify dialysate temperature during treatment | 5 | |||
- Dialysate temperature is set automatically or is a default | 5 | |||
- We usually accept treatment parameters | 3 | |||
Influences among health care professionals | - Nurses follow the doctor's orders or prescription | 12 | Social Professional Role and Identity/Nature of the Behaviour/Beliefs about Capabilities | |
- Nurses influence physicians when prescribing dialysate temperature | 10 | |||
It will be easy to prescribe or set IDTs | - I am confident that I will be able to prescribe IDTs for all my patients | 10 | Beliefs about Capabilities | |
- It will be easy to set individualized cooler dialysate temperatures | 8 | |||
- It will be easy to prescribed IDTs | 8 | |||
Theme 4: thermometer availability/accuracy and dialysis machine characteristics | Dialysis machine can be adjusted in 0.5 or 0.1 increments up to 35 Celsius | - Can adjust dialysate temperature by 0.1 increments | 3 | Environmental Context and Resources |
Theme 5: Impact on workload | Impact on workload | - My workload will increase minimally | 10 | Beliefs about Capabilities/Beliefs about Consequences |
- Reducing episodes of hypotension during dialysis can decrease workload | 7 | |||
- My workload will not increase | 6 | |||
Theme 6: patient comfort | Tolerability | - Patients are not likely to notice the cooler temperature/not likely to be side effects/generally well-tolerated | 8 | Beliefs about Consequences |
Coping plans for patients who say they are cold | - We give blankets to patients who feel cold on dialysis | 12 | Behavioural Regulation | |
- For patients who feel cold on dialysis, we suggest that they wear warm clothing and bring blankets | 5 | |||
No emotion related to IDTs | - I don’t or I won’t have any emotions related to dialysate temperature | 6 | Emotion | |
Theme 7: forgetting to prescribe or set IDT | Unlikely to forget | - I won’t forget | 7 | Memory, attention and decision making |
To my knowledge, there are no guidelines that recommend a given temperature. There are certainly practices that apparently vary from place to place. (Physician #9)
Do you use any guideline recommendations for prescribing individualized cooler dialysate temperatures? (Interviewer)I mean this initiative is so new. I’m trying to think if there’s a hard [guideline] at the moment. A lot of the work that are nephrology research is all done - is all published in scientific journals. I know there’s discussion about the temperature. I don’t think there’s a guideline per se about it. (Physician #18)
Well, currently we have a standard temperature so it is in conflict with that so that would have to be altered. (Nurse #9)
If the patient is becoming more hypotensive or you see a decline in systolic pressures, we will decrease the temp within reason in the hopes of, obviously, vasoconstriction to help maintain the blood pressure as we pull fluid from the vascular space. (Nurse #11)
You might go “Wait a minute. Why does everybody have to be cold if only 30% of people are going to drop their blood pressure?” (Physician #6)Well, if the patient is okay with the set temperature, I wouldn’t touch anything. (Nurse #1)
These dialysis orders are recurrent, meaning that they are valid until there’s another change. If there’s a change to another parameter then all of the other parameters stay the same. I could change one day the temperature. In three days if I change the potassium or the temperature, it’s going to remain whatever it was set at. (Physician #1)
I’m not going to have nurses call me with the temperature and write the temperatures of all the patients. That would never fly. Okay. You will get too many pages. […] So, it will have to be standard. It will have to be core temperature is this, subtract that much and that’s the dialysis temperature with some parameters. (Physician #7).If I have to write an order on every patient every time, it would influence my workload tremendously. I would not have the time and I think it would falter and not order it. (Nurse with prescribing role #9)
You just do it once and say that the dialysate temperature is supposed to be 0.5 less than their core temperature and that would stand forever until I discontinued it. (Physician #6)
They would because they (nurses) can change it manually for that treatment but if they decided this patient today, I’m going to drop them to 35.5, they can do it for that treatment but unless they go in and change that patient’s order in [Dialysis charting software], the next treatment, they would come back in at 36.5. (Nurse #5)
The individualized in every treatment is very different from what I’ve ever done. (Nurse #5)Once they have their first treatment, we have memory cards that memorize like codes data for the treatment. So we set it initially and then we wouldn’t change it unless we had an order to change the temperature. So once you put the card in and if you accept all the treatment parameters, usually we’re not changing it. (Nurse #10)
There’s not a lot of people who actually look at the core patient’s temperature to decide what they’re going to set the dialysis temperature. It’s more, let’s say patients having recurrent low blood pressure. You look at their prescription. They’re at 36.5. You’ll say let’s drop it to 36. We’re not going to look at what their core temperature is. We’re just going to say, “Let’s drop them by a .5 or a one degree towards the cooler side.” (Physician #1)
A nurse, usually because our nurses will interact a lot more with our patients on a day-to-day basis than we do so a nurse may suggest, oh, Mr. So and so is feeling cold. Do you mind raising the temperature or vice versa? Do you mind decreasing the temperature? We might say, “Yes, sure. That’s a good idea. Let’s do it.” (Physician #1)I think you’re always in conjunction with your doctor, right? If you see this as something that chronically needs to be ordered and brought forward, definitely a team, and of course you do sometimes seek others opinions or give reports saying “This is what I’ve done,” but primarily it’s the nurse and in conjunction with the doctor, if you see that is being a permanent change. (Nurse #11)
Yes. So it would just automatically be done because they have protocols in place for so many other things like what their potassium number is, often there's a protocol in place where the nurses will change the dialysate potassium without notifying the physician. So it's something like that where the physician could be bypassed. (Physician #13)
No, we’re not playing around with the temperature. (Nurse #10).
They would because they (nurses) can change it manually for that treatment but if they decided this patient today, I’m going to drop them to 35.5, they can do it for that treatment but unless they go in and change that patient’s order in [Dialysis charting software], the next treatment, they would come back in at 36.5. (Nurse #5)
I don’t think I would do it on my own. I would still need the doctor’s permission or his or their knowledge that I’m doing it. I am not authorized to change the temperature ad lib, so to speak. (Nurse #6)
It is when we have an adequate amount of thermometers around. Right now we do but every once in a while one may go down and sometimes two. In which case, staff is doing more running around the unit looking for available thermometers. I think the availability and the number of thermometers that are available close to where the patients are may impact as well people taking temperatures. (Nurse #8)
Yes because they come in from the cold and you might not even want to set it because it might be quite cold, but an hour later. They’ve got blankets on and they’re warming up a little bit. Even a dialysate temp at 36 might be warming them up compared to what they are when they came in. Do we set them? Keep them that cold for the whole run or do we do temperatures hourly or an hour later and then set it? (Nurse #8).
What I see as a potential difficulty of the study is a number of our patients miss out in their pre-dialysis temperature because they’re already chewing on ice as they come in the door. So we’re going to have to try and figure out how we can get around that. So we do get a pre-dialysis temperature on everybody. (Nurse #7)
I can put whatever. It doesn’t have to be 0.5 degrees; it could be 0.7 degrees, 0.8 degrees. (Nurse #6)With these machines, the temperature you can only change it by 0.5. So if you had to do it like anything other - if you had to deal something like 36.8 and then make it 0.5 less, these machines won’t allow you to do that. (Nurse #10)
It would be a change of practice. It would be like in any other change in practice - you know first of all, making sure your temperature is accurate, the first one actually going through the steps in it. […] It would probably put another minute of work in putting somebody on. (Nurse #10)
If patients actually have fewer hypotensive episodes and really those are ones that were - if you’re talking from a unit perspective, those would be symptomatic hypotensive episodes that require intervention. From a unit perspective, if you have less symptomatic hypotension, then you have [to] intervene less, that’s less work. (Physician #6)
It would be like being in an air conditioned room with not a lot of clothes on […] and sitting there for four hours. It’s not like it’s just a short period of time, it’s a long period of time. (Nurse #10)
Most patients feel cold on dialysis irrespective of what temperature you’re giving them. (Physician #1)Some of them - the patients are always cold. It’s an ongoing problem. Even when their temperatures are normal they still feel cold so you definitely need to have some patient buy-in if you’re deliberately freezing them. (Nurse #12)
I worry about the people. I think that cute, little old lady’s already cold. I think I would feel a bit conflicted in doing that to her. (Nurse #12)
Some patients might find it cold but with the 0.5 degrees that we’re talking about for this study, that’s less likely to occur. Generally well-tolerated so I’m not very concerned. (Physician #10)
That would be the kind of advice that we would give is to maybe wear warm socks and warm clothing. The rest we would supply with blankets. (Nurse #7)
But there are some people who will complain of feeling cold and occasionally request warmer temperature. If they did not have problems with low blood pressure, I would not have enough evidence to deny their request. (Physician #9)
I suppose the scenario where you just happen to hit a week where you’re particularly busy with patient load that you get distracted from this prescription concept. (Physician #12)Then you forget to do things because you’ve got a patient saying, “I’m late being connected and my ride is at such and such a time” a lot of anxieties that the patient can put on the staff at times. So I think that could be a factor in it being forgotten. (Nurse #7)Well number one, people may actually forget to make the change, I guess. I mean intense situations; emotional situations could be for other reasons, right? So, people could forget I suppose. (Physician #18)