Barriers and enablers to the implementation of perioperative hypothermia prevention practices from the perspectives of the multidisciplinary team: a qualitative study using the Theoretical Domains Framework

Figures & data

Table 2 TDF domains less likely to inform interventions to improve perioperative hypothermia prevention practices

TDF domain	Specific belief	Example quotations	Frequency out of 12
Intention	I/we intend to implement practices to prevent perioperative hypothermia	Oh, it’s something I try and think about every time I anesthetize a patient. (A2)	4
Emotion	I do not feel any strong emotion regarding prevention of perioperative hypothermia	Not really. I don’t have any emotion attached to that. (S9)	1
	I feel positive towards using interventions to prevent perioperative hypothermia	Totally. Yeah, I am all for it. So, like my motivation is tops, yeah. But, I haven’t really done a proper formal sort of analysis but I think all staff would agree that it is an important thing and would be on top of that as well. (CF8)	1
Behavioral regulation	We need to monitor and plan to implement perioperative hypothermia prevention practices	… I think we all need to be so much more mindful of positioning and you know, Bair Huggers and warm fluids and so forth. (S10)	4
	If temperature management practice were standardized within the hospital, I would be more likely to manage perioperative hypothermia	If there was some sort of, same sort of thing applied, you know if it was like, when the patient comes in, make sure they have a warm blanket on during the procedure, make sure … I don’t know, if they have a temp probe catheter and all that sort of stuff, monitoring that like there was … which I mean, I guess … (SN4)	4

Table 3 COM-B model and TDF domains: suggested intervention strategies to improve perioperative hypothermia prevention

TDF domain	COM-B	Intervention function	BCT taxonomy	Individual BCT	Strategy example
Knowledge	C (Psychological)	Education	Goals and planning Feedback and monitoring Associations	Information about consequences Feedback on behavior and outcome of behavior Prompts/cues Self-monitoring	Audit and feedback of key prevention activities (temperature monitoring, warming – behavior) and rates of hypothermia (outcomes) Reminders of prevention activities in all key clinical areas; computerized reminders
Memory, attention, and decision processes	C (Psychological)	Training	Shaping knowledge	Demonstration of behavior Feedback on behavior and outcome of behavior Self-monitoring Behavioral practice/rehearsal	Education: when to monitor; how to monitor; when and how to warm; how to document Education: scenarios that allow for practice and feedback
		Environmental restructuring	Associations Antecedents	Adding objects to the environment Prompts/cues Restructuring of physical environment	Reminders (see above) Ensure monitoring is visibly obvious with reminders
		Enablement	Goals and planning Feedback and monitoring Antecedents	Social support (unspecified and/or practical) Goal-setting (behavior and/or outcome) Adding objects to the environment Problem-solving Action planning Self-monitoring of behavior Restructuring of physical environment Review behavior and outcome goal(s)	Identified champion to monitor and provide encouragement Monthly agreed goals (based on audit and feedback) Reminders and equipment (see above) Provide hypothermia prevention pathway
Skills	C (Physical)	Training	Shaping knowledge Feedback and monitoring	Demonstration of behavior Feedback on behavior and outcome of behavior Self-monitoring Behavioral practice/rehearsal	Education (see above) Audit and feedback (see above)
Social/Professional Role and Identity	M (reflective)	Education	Shaping knowledge Feedback and monitoring Associations	Information about consequences Feedback on behavior and outcome of behavior Prompts/cues Self-monitoring	Make information available about consequences of not monitoring, warming, and outcomes of condition Prompts (see above) Audit and feedback (see above)
		Persuasion	Comparison of outcomes Natural consequences Feedback and monitoring	Credible source Information about social, environmental and health consequences Feedback on behavior and outcome of behavior	“High status” professional to provide information/education re importance of prevention Patients’ perspective of condition (and consequences) Audit and feedback (see above)
		Modeling	Comparison of behavior	Demonstration of behavior	Provide demonstration of prevention pathway (ie, film/poster)
Beliefs about capabilities	M (reflective)	Education	Shaping knowledge Natural consequences Feedback and monitoring Associations	Information about consequences Feedback on behavior and outcome of behavior Prompts/cues Self-monitoring	Make information available about consequences of not monitoring, warming and outcomes of condition (as above) Prompts (see above) Audit and feedback (see above)
		Persuasion	Comparison of outcomes Natural consequences Feedback and monitoring	Credible source Information about social, environmental, and health consequences Feedback on behavior and outcome of behavior	High status’ professional to provide information (as above) Patients’ perspective of condition (and consequences) Audit and feedback (see above)
		Modeling	Comparison of behavior	Demonstration of behavior	Provide demonstration of prevention pathway (ie, film/poster)
		Enablement	Social support Goals and planning Antecedents Goals and planning Feedback and monitoring	Social support (unspecified and/or practical) Goal-setting (behavior and/or outcome) Adding objects to the environment Problem-solving Action planning Self-monitoring of behavior Restructuring of physical environment Review behavior and outcome goal(s)	Identified champion to monitor and provide encouragement Monthly agreed goals (based on audit and feedback) Reminders and equipment (see above) Provide hypothermia prevention pathway
Optimism	M (reflective)	Education	Shaping knowledge Feedback and monitoring Associations	Information about consequences Feedback on behavior and outcome of behavior Prompts/cues Self-monitoring	Make information available (as above) Prompts (see above) Audit and feedback (see above)
		Persuasion	Comparison of outcomes Natural consequences Feedback and monitoring	Credible source Information about social, environmental, and health consequences Feedback on behavior and outcome of behavior	High status’ professional to provide information (as above) Patients’ perspective of condition (and consequences) Audit and feedback (see above)
		Modeling	Comparison of behavior	Demonstration of behavior	Provide demonstration of prevention pathway (ie, film/poster)
		Enablement	Social support Goals and planning Antecedents Goals nd planning Feedback and monitoring	Social support (unspecified and/or practical) Goal-setting (behavior and/or outcome) Adding objects to the environment Problem-solving Action planning Self-monitoring of behavior Restructuring of physical environment Review behavior and outcome goal(s)	Identified champion to monitor and provide encouragement Monthly agreed goals (based on audit and feedback) Reminders and equipment (see above) Provide hypothermia prevention pathway
Beliefs about consequences	M (reflective)	Education	Goals and planning Feedback and monitoring Associations	Information about consequences Feedback on behavior and outcome of behavior Prompts/cues Self-monitoring	Make information available (as above) Prompts (see above) Audit and feedback (see above)
		Persuasion	Comparison of outcomes Natural consequences Feedback and monitoring	Credible source Information about social, environmental, and health consequences Feedback on behavior and outcome of behavior	High status’ professional to provide information (as above) Patients’ perspective of condition (and consequences) Audit and feedback (see above)
		Modeling	Comparison of behavior	Demonstration of behavior	Provide demonstration of prevention pathway (ie, film/poster)
Goals	M (reflective)	Education	Goals and planning Feedback and monitoring Associations	Information about consequences Feedback on behavior and outcome of behavior Prompts/cues Self-monitoring	Make information available (as above) Prompts (see above) Audit and feedback (see above)
		Persuasion	Comparison of outcomes Natural consequences Feedback and monitoring	Credible source Information about social, environmental, and health consequences Feedback on behavior and outcome of behavior	High status’ professional to provide information (as above) Patients’ perspective of condition (and consequences) Audit and feedback (see above)
		Incentivization	Feedback and monitoring	Feedback on behavior and outcome of behavior Monitoring of behavior, and/or outcomes of behavior, by others, without evidence of feedback Self-monitoring of behavior	Audit and feedback (see above)
		Coercion	Feedback and monitoring	Feedback on behavior and outcome of behavior Monitoring of behavior, and/or outcomes of behavior, by others, without evidence of feedback Self-monitoring of behavior	Audit and feedback (see above)
		Modeling	Comparison of behavior	Demonstration of behavior	Provide demonstration of prevention pathway (ie, film/poster)
		Enablement	Social support Goals and planning Antecedents Goals nd planning Feedback and monitoring	Social support (unspecified and/or practical) Goal-setting (behavior and/or outcome) Adding objects to the environment Problem-solving Action planning Self-monitoring of behavior Restructuring of physical environment Review behavior and outcome goal(s)	Identified champion to monitor and provide encouragement Monthly agreed goals (based on audit and feedback) Reminders and equipment (see above) Provide hypothermia prevention pathway
Reinforcement	M (automatic)	Training	Shaping knowledge Feedback and monitoring	Demonstration of behavior Feedback on behavior and outcome of behavior Self-monitoring Behavioral practice/rehearsal	Education: when to monitor; how to monitor; when and how to warm; how to document Education: scenarios that allow for practice and feedback
		Incentivization	Feedback and monitoring	Feedback on behavior and outcome of behavior Monitoring of behavior, and/or outcomes of behavior, by others, without evidence of feedback Self-monitoring of behavior	Audit and feedback (see above)
		Coercion	Feedbackand monitoring	Feedback on behavior and outcome of behavior Monitoring of behavior, and/or outcomes of behavior, by others, without evidence of feedback Self-monitoring of behavior	Audit and feedback (see above)
		Environmental restructuring	Associations Antecedents	Adding objects to the environment Prompts/cues Restructuring of physical environment	Prompts (see above) Provide hypothermia prevention pathway
Environmental context and resources	O (physical)	Training	Shaping knowledge Feedback and monitoring	Demonstration of behavior Feedback on behavior and outcome of behavior Self-monitoring Behavioral practice/rehearsal	Education: when to monitor; how to monitor; when and how to warm; how to document Education: scenarios that allow for practice and feedback
		Restriction	No BCTs	No BCTs
		Environmental restructuring	Associations Antecedents	Adding objects to the environment Prompts/cues Restructuring of physical environment	Prompts (see above) Provide hypothermia prevention pathway
		Enablement	Social support Goals and planning Antecedents Goals and planning Feedback and monitoring	Social support (unspecified and/or practical) Goal-setting (behavior and/or outcome) Adding objects to the environment Problem-solving Action planning Self-monitoring of behavior Restructuring of physical environment Review behavior & outcome goal(s)	Identified champion to monitor and provide encouragement Monthly agreed goals (based on audit and feedback) Reminders and equipment (see above) Provide hypothermia prevention pathway
Social influence	O (social)	Restriction	No BCTs	No BCTs
		Environmental restructuring	Associations Antecedents	Adding objects to the environment Prompts/cues Restructuring of physical environment	Prompts (see above) Provide hypothermia prevention pathway
		Modeling	Comparison of behavior	Demonstration of behavior	Provide demonstration of prevention pathway (ie, film/poster)
		Enablement	Social support Goals and planning Antecedents Goals and planning Feedback and monitoring	Social support (unspecified and/or practical) Goal-setting (behavior and/or outcome) Adding objects to the environment Problem-solving Action planning Self-monitoring of behavior Restructuring of physical environment Review behavior & outcome goal(s)	Identified champion to monitor and provide encouragement Monthly agreed goals (based on audit and feedback) Reminders and equipment (see above) Provide hypothermia prevention pathway

Abbreviations: BCT, Behavior Change Theory; TDF, Theoretical Domains Network.

Table 1 TDF domains likely to influence the implementation of perioperative hypothermia prevention practices *denotes belief statements congruent with Boet et al.¹⁶

TDF domain	Specific belief	Example quotations	Frequency, out of 12
Knowledge	I am/am not aware that guidelines exist for the management of inadvertent hypothermia*	I am not aware of any official guidelines I must say, I don’t think I am aware of any guidelines per se, whether they be from the Australian College of Anesthetists or Surgeons or ACORN, I am sure they exist, but yeah. (A2) Not particularly any specific guidelines, I just know practices that improve the outcome and that’s what I do but I haven’t seen any written guidelines that have to be done every time. Are there such things? (SS5) Guidelines … I don’t … I am not aware of any Australian guidelines, there’s some British guidelines called NICE guidelines which are fairly strict. There is some auditing guidelines from the Australian anesthetic college, but they’re not actually guidelines on how to manage perioperative hypothermia, they are really just how to audit it. (A11)	11
	I/we have a lack of knowledge regarding the condition	Umm … it’s where their temperature drops, um and I know it can cause death, like well I know that’s malignant hyperthermia, is that the same or different? Okay, I don’t really know a lot then. (PN1) Again, it’s just getting to a number for discharge, I don’t think that the background knowledge of the actual importance of it being a certain range is there so I would just say that, because that was me you know when I still didn’t know all the ins and outs of it. (PN12)	9
	Education would assist me/us to increase our knowledge and awareness of managing perioperative hypothermia	Uh, probably education. You know for the surgical side because I think that we don’t get a lot of that in the training, we know it’s important but what steps, what checklists, we, I don’t think, well I haven’t. (S9) Information, just … Information, yeah knowledge, what works best, what’s the most economical, what’s readily available and … just what assists and then how patient outcomes at the end of the process, if you come out cold, is their stay in hospital another day, is their pain relief harder to deal with, is there, I’d like to just know those sorts of information so that I can use that information when I’m educating staff, new staff as well as older staff. (SS5)	11
	I know and understand the parameters for perioperative hypothermia	Right, well, I guess perioperative hypothermia refers to the patient’s body temperature being less than 36 degrees Celsius. Perioperative means it may be pre-op, intra-op ,or post-op. (A11)	2
	I understand how to monitor and prevent perioperative hypothermia	Warming blankets, hot dogs, warm clouds … Bair Hugger, all of those sort of interventions that we usually put in. Keeping the patient warm beforehand and on transport. (SS4)	3
Skills	The ability to monitor temperature is important in preventing perioperative hypothermia	To prevent it? To constantly be monitoring your patient, being aware of what their temperature is in theater. (PN1) And I think another thing that is very important is actually taking the preop temperature so that we know the baseline, where it is sitting. People sit in different temperatures … some high and some low, we cannot regulate everything, and we could end up with an even worse scenario or outcome. (AN3) So, knowing how to take someone’s temperature, knowing how to use the devices to keep them warm, that’s about it really, I think. I can’t think of anything else. (A11)	8
	I feel I have the skills necessary to manage and prevent perioperative hypothermia	My ability to perform the skills I would rate as high, my diligence and attendance to it is probably not quite as good as it should be at times. (A2) I’d say I’ve got basic skills … (PN1)	3
Social/Professional Role and Identity	I believe it is the responsibility of everyone in the operating room (including surgeons and nurses) to manage the patient’s temperature*	Every practitioner that sees the patient along their entire stay (is responsible for monitoring, managing and preventing perioperative hypothermia). (PN12) Uh I will just take you know, the usual, team effort approach. (S9) So, I think it is a multi-disciplinary responsibility, so it is surgeons, anesthetists, unit managers, educators, staff, all of those, yes. (8CF)	10
	It is predominantly the anesthetists‘ responsibility to manage the patient’s temperature*	Well, intraoperatively it’s the anesthetist, overall that’s a harder question to answer because the anesthetist has no control over many things outside the operating theater but I think at the end of the day it’s our role to keep all physiological variables as normal as we can and that’s one of them. (A2) Well I think the anesthetist has the primary role, the main role. Because we need to have a leadership role in theater to start off with. Obviously if the perioperative nurses and anesthetic technicians have a proactive attitude to it, it helps us but I would be taking the responsibility for the outcomes of the patients so, if they became hypothermic or had a complication, I would take that personally as my responsibility. (A11) Well the anesthetist is the one in the theater that is looking after that because they have the monitors there and they are able to tell us, and they’re monitoring the patients’ vitals and they can see that. They’ve also got the temperature probes, so they are basically taking on that responsibility and we can only assist them at that time, but once in recovery it’s the anesthetic, the recovery nurses and the team that have to monitor and keep the patients warm. (SS5)	10
	It is not a scrub scout nurses‘ responsibility to manage the patients‘ temperature	That’s not part of my role as a scrub/scout, I mean it is but its’ not my primary sort of thing, that is usually anesthetics or the anesthetist and stuff, but … I mean I still have a basic understanding of what we need to do, like keep them covered and all of that sort of stuff from uni even though I haven’t had direct training in it. Does that make sense? (SS4)	1
	It is/is not my role to manage the patients‘ temperature	My role is a bit of a, you know, you have … pretty primary. I am dealing with my patient face to face and so I feel as if I am responsible for their warmth and their care until they are handed over to the surgeon and the anesthetist in the theater. But I certainly will take them on as my responsibility from the time I pick them up until I get them into the anesthetic room and then into theater, so it is a primary carer at that time. (SS5) Um, yeah I can sort of passively delegate that pretty well, thank you. (S9)	6
Beliefs about capabilities	It is easy/challenging to manage my patient’s temperature*	Yeah, it’s easy, doable, achievable. (PN1) I would say it is easy for me to implement practices that would minimize hypothermia. There are times when during the procedure there is very little that you can do and then you need to spend some time to improve it at the end of the surgical procedure. (A2) Well, there’s certain surgical or cases that are more challenging than others for example prolonged laparoscopic cases can be very hard to keep the patient’s temperature up and major plastics cases like tram flaps. (A11)	12
	My ability to manage the patients‘ temperature effectively is limited by factors beyond my control*	Well there’s, sometimes if I’m scrubbed or if I’m … sometimes if I’m not going to be able to … like I can’t … (SS4) Right, so, some things are easy, some things are difficult. So, the things that I have direct control over are easy to do. So I can quite easily warm a patient in the induction bay and I can warm a patient in theater, so, and I can, and in recovery too, if I suggest to the recovery nurse that we need to warm this patient then they will do it, there is no barrier there. The main … probably the only time I don’t have much control is in the preoperative area where the nurses are admitting the patients and taking their obs and then letting them sit and wait for their surgery. (A11)	9
	I do/do not feel confident in my ability to manage patient’s temperature*	I wouldn’t say I am an expert at it (monitoring, managing & preventing perioperative hypothermia). (PN1)	2
Optimism	We are managing perioperative hypothermia effectively	Most of the time we are doing pretty well and the staff, with scrub/scout, recovery and holding bay, everyone, anesthetic … quite well. (AN3) I think as a department we’re pretty good, like a team. (SN4)	8
Beliefs about consequences	If perioperative hypothermia is not managed, this can result in adverse health outcomes*	Patient outcomes, poor patient outcomes, post op care and their recovery (will happen if we do not monitor, manage and prevent perioperative hypothermia). (PN1) Adverse outcomes, patient outcomes. It’s as simple as that. (CN7) … it contributes to all manner of adverse patient outcomes ranging from altered coagulation to impaired wound healing, patient discomfort, shivering, acidosis, eventually if you let people get cold enough, arrhythmias and even death. (A2)	12
	I/we do not know the impact of our efforts in preventing perioperative hypothermia*	I don’t really have any, it is a bit hard in recovery because you don’t see them. I don’t know what the long-term consequences really are, but I would say I guess it would have something to do with their long-term recovery, how they recover. (PN1) I think just in general the management of hypothermia is improving, in my opinion, um, and that maybe … feedback to the staff would be helpful, yeah like if it was, I don’t know patients, like pre-op, intra-op and post-op temperatures were recorded for a day and then they came back to a staff member and said hey your patients were really warm what did you do or your patients were really cold, that would help change and implement better practice. That’s about it. Yeah, because once the patients out of the theater you very rarely ever see them again so you are not aware if they are cold or if they’ve had a DVT or when they’ve gone home. So yeah we ‘re so isolated that I think acknowledgement of your care would help people I guess. (Prompt) I think that would apply to everyone, like every area yeah, maybe not so much with the pediatrics but with adults and obstetrics I think it would be noteworthy. (AN6)	3
Reinforcement	Awareness of the adverse outcomes associated with perioperative hypothermia acts as an incentive to manage the condition.	Data. I think, if you present staff, especially well-educated staff, which we should all be, here, if you present staff saying this is the data that says if you keep this patient’s temperature at this level the outcomes this … his statistically significant outcomes are going to be this. For me, that’s what I would think is an incentive. (CN7) Or maybe feedback would be good. So, for example, we always hear about cold patients but maybe if you hear about all the patients that are warm maybe that would be helpful, yeah, um, yeah that’s about all I can think of. (AN6) … some feedback in terms of, you know, how it is going over time and if it is getting better or worse and I think that is really helpful for people. Whether you strictly incentivise it or not … is I think questionable, but just trying to keep everyone in the team on board. (S10)	8
Goals	Perioperative hypothermia prevention practices are (very) important	Yeah well, I know I feel it’s … important and a high priority, that’s why I have it there set up ready to go. (PN1) Oh, it’s probably on the top five, yep. (CF8) Um, yeah, it’s an important concept I think, it’s when we um, particularly when we are operating for long periods we need to pay attention to keeping the patient normothermic, so maybe 37 degrees or above, um, yep. (S9)	8
	Other goals are more important than preventing perioperative hypothermia	… I guess one time which makes it difficult is in emergencies, yeah so like um, both in obstetrics and in adults like, the last thing you actually get to is the warming and I think that’s just in the hierarchy of needs yeah, and you’re playing catch up. (AN6) Yeah, I would have said it gets a relatively low priority for most anesthetists and theater teams. There’s is a couple of anesthetists here who are really big about it but others who are less so and the rest of us are probably somewhere in the middle. (A2)	7
Memory, attention, and decision processes	My attention to perioperative hypothermia prevention could sometimes be improved	To be honest, if anything when it is really, really busy. Yeah, if you’ve got other issues going on like pain and nausea, that would kind of, I feel, takes my priority away from, yeah, looking at their temperature and managing that, so I guess, that would be it. (PN1) So I think it is a priority but there are so many other things going on with a complex case that it’s easy to miss. (S9)	8
	I remind others to implement hypothermia prevention	Sometimes pretty good, sometimes really don’t, don’t have any perception that the patient may be cold, or exposed or anything like that, yeah, and that’s alright, that’s just education as well, all we need to do is just bring their attention to it, just say did you, you know, do you see this patient’s got a lot skin there we are waiting for the scrub team to wash their hands, I think we could cover them up for a bit longer, keep them, you know, it’s just participation, communication, and participation amongst the team members. I don’t think it’s any particular barriers, it’s just education … thoughtfulness. (SN4)	4
	I/others have processes or rituals in place to remind me to implement practices to prevent or manage perioperative hypothermia	I have my tray, my bedside tray, set up with my thermometer closest to the patient with a pen and piece of paper ready to go and that kind of triggers me to do it and record it straight away when the patient comes out. (PN1) Um, so I guess rituals would be from the start when I get the patient I always get them a warm blanket, I give it to them to hold, um, as we walk down to the induction room, and then when we are in the induction room I‘ll get them onto the trolley, the blanket goes on and then the dressing gown goes over it and then for monitoring, I always put the temperature probe um, there’s a little um, tray on the anesthetic machine where all the airway devices are and I have one underneath with the top blue part showing so it’s like a trigger for me to see it to get it, yeah. (AN6)	7
	Paying attention to keeping the patient covered is very important	Ok, um, so, first of all is keeping the patient warm and covered, um, not necessarily always by a warm blanket, like in the induction room, but just so they don’t um, radiate the heat, then we intraoperatively, you know, have bair huggers, warm fluids, um, for a lot of joints um if the bottom of the patient is exposed we wrap their head in a blanket or a towel, yeah, and using our monitoring as well obviously. (AN6)	2
Environmental context and resources	The availability/non-availability of resources affects my practice in preventing hypothermia*	The resources are all there ready to go and readily available. (PN1) They are … they are available here. Well, I see everything that is possible, maybe there’s something else that we can be doing – I don’t know. But everything that I know of, is available to us here. (SN5)	11
	Availability/non-availability of checklists and documentation affects my ability to record temperature and prevent hypothermia	If they’re concerned about it they should have a … something on the pre-op checklist, if they want us to initiate something preoperatively …because that’s basically our one piece of paper pre-op – and then during will have to be up to the anesthetist, and then post-op, I think it’s well done but if there’s improvement there then it should be identified and fixed on the PACU post-op form. (CN7) Again, some guidelines as to how to manage that and then some sort of established monitoring process and then someone who owns that, takes responsibility for that would be really helpful. (S10)	7
	Control of ambient temperature impacts upon our management of perioperative hypothermia	Fix the air con, make it more adjustable, which they are doing now, but we have not seen the result of that yet. (AN3) Well I guess as I eluded to before, the individual control of operating theater temperature is unreliable and my understanding is that’s not limited to here – that that’s a result of the way the buildings are engineered, but a smarter building design with better ability to control the temperature more precisely would be useful particularly in a place that does pediatric anesthesia as well. Yes … can’t think of any other environmental … we could just open the windows on a day like today! Oh, that’s right – we don’t have windows. (A2)	6
	The environmental layout and organization assists/impedes my ability to prevent perioperative hypothermia	So, intraoperatively and postoperatively there is good support. Preoperatively I don’t think it is existing, and I think the problem is that it is hard to come up with rock solid effort and space. Look here it is, because lots of hospitals do their little pilots and you get different results from different hospitals, some say yay and others say no. Because our layout is not that easy, people just sit and watch morning TV, while they wait. (CF8)	5
	There is a lack of communication in the workplace regarding perioperative hypothermia	I think generally people are pretty good with it, I think it is just that there’s not a lot of communication about it. I think that’s the biggest thing. I don’t think it is necessarily ignored by anyone, it’s just that there’s not really a lot of communication … (SN4)	1
	I have concerns regarding the accuracy of the temperature monitoring devices that are available to us	… temperature monitoring and would probably better in recovery if we had monitors that monitor … thermometers that were accurate, very inaccurate sometimes and they call them random number generators from time to time, so that’s a little bit tricky. (SN5)	3
Social influence	Other team members support/impede my temperature management practices	There is some resistance from surgeons to some warming methods so some, especially orthopedic surgeons, they worry about increasing infection rates so they don’t like using a device like the Warm Cloud. Most surgeons don’t like us turning the forced air warmers on before they have finished prepping and draping which can take a long time and the prepping is one of the things that can make the patient cold very quickly. So, there’s a couple of barriers there, but otherwise it is pretty straight forward. (A11) So, ah, I guess either awareness to start off with, I think it’s a team effort, so you know a lot of times surgeons, we probably don’t think about it as much as we should but you do see nursing staff a lot more active, anesthetists a lot more active in that part. (S9) Oh, I think people are very supportive once you initiate it and there’s some anesthetist particularly advocative of preoperative warming. (CN7)	12

Abbreviations: DVT, deep vein thrombosis; PACU, Post-Anesthetic Care Unit; TDF, Theoretical Domains Network.

Boet S, Patey AM, Baron JS, et al. Factors that influence effective perioperative temperature management by anesthesiologists: a qualitative study using the Theoretical Domains Framework. Can J Anesth. 2017;64(6):581–596. doi:10.1007/s12630-017-0845-928211002

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Data availability

The datasets generated and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.