J Adv
Nurs. Author manuscript; available in PMC 2012 Feb 1. Published in final edited form as: PMCID: PMC3038203 NIHMSID: NIHMS267523 The specific aims were to (1) define fever from the nurse’s perspective; (2) describe fever management decision-making by nurses and (3)
describe barriers to evidence-based practice across various settings. Publication of practice guidelines, which address fever management, has not yielded improvements in nursing care. This may be related to differences in ways nurses define and approach fever. The collective case study approach was used to guide the process of data collection and analysis. Data were
collected during 2006–7. Transcripts were coded using the constant comparative method until themes were identified. Cross-case comparison was conducted. The nursing process was used as an analytical filter for refinement and presentation of the findings. Nurses across settings defined fever as a (single) elevated temperature that exceeded some established protocol. Regardless of practice setting, interventions chosen by nurses were
frequently based on trial and error or individual conventions – ‘what works’– rather than evidence-based practice. Some nurses’ accounts indicated use of interventions that were clearly contraindicated by the literature. Participants working on dedicated neuroscience units articulated specific differences in patient care more than those working on mixed units. By defining a set temperature for intervention, protocols may serve as
a barrier to critical clinical judgment. We recommend that protocols be developed in an interdisciplinary manner to foster local adaptation of best practices. This could further best practice by encouraging individual nurses to think of protocols not as a recipe, but rather as a guide when individualizing patient care. There is value of specialty knowledge in narrowing the translational gap, offering institutions evidence for planning and structuring the organization of care. Keywords:
acute care, adult patients, case study, elevated temperature, evidence-based fever management, fever, nursing Fever in patients with neurological insults is associated with poor outcomes (Hajat et al. 2000,
Natale et al. 2000, Thompson et al. 2003, Wartenberg et al. 2006,
Adams et al. 2007, Kirkness et al. 2008) and should be avoided [Adelson et al. 2003,
Brain Trauma Foundation/American Association of Neurologic Surgeons (BTF/AANS) 2007]. Despite research that reveals an association between fever and poor outcomes, it is undermanaged in these patients (Albrecht et al. 1998,
Kilpatrick et al. 2000, Thompson et al. 2007b). Its management is often left to the discretion of the individual practitioner because evidence-based guidelines are not explicit
(Adelson et al. 2003, Adams et al. 2007, BTF/AANS 2007). In this article, we describe the findings from a study to define fever
from the nurses’ perspective, describe fever management decision-making and barriers to evidence-based practice (EBP) among nurses practising across various settings that care for patients with neurological insults. As neurotrauma is expected to become the third leading cause of death and disability worldwide (World Health Organization 2008), appropriate nursing management of these patients will
become increasingly important. BackgroundFever is a normal, coordinated response of the body to a perceived threat to the immune system, which includes autonomic, behavioural and neuroendocrine responses (Thompson et al. 2003). As part of this response, an elevated temperature occurs in response to endogenous stimuli to allow for improved functioning of the immune system (Cooper 1995, 2002). In most patients, fever is advantageous and does not require intervention. In certain populations, such as those with neurological insults, fever is associated with poor outcomes (Wartenberg et al. 2006, Kirkness et al. 2008) and should be avoided (Adams et al. 2007, Alexander et al. 2007, BTF/AANS 2007). Fever is a common human experience that is assumed to be universally understood. Nevertheless, its clinical interpretation is often remarkably individual and highly variable. Many authors in nursing and medical literature defined fever simply as an elevation of body temperature (Segatore 1992, Cairns & Andrews 2002, Schulman et al. 2005, O’Grady et al. 2008, High et al. 2009, Laupland 2009, Reaven et al. 2009). Furthermore, the specific temperature warranting the label of fever varies widely. Fever in the acute phase following traumatic brain injury (TBI), subarachnoid haemorrhage (SAH) and stroke is associated with unfavourable outcomes for patients. These outcomes include higher mortality rates, increased lengths of stay and decreased functional status (Hajat et al. 2000, Kilpatrick et al. 2000, Natale et al. 2000, Jiang et al. 2002, Stocchetti et al. 2002, Diringer et al. 2004, Greer et al. 2008). TBI, SAH and stroke guidelines state that maintenance of normothermia should be the standard of care (Adelson et al. 2003, Adams et al. 2007, Alexander et al. 2007, BTF/AANS 2007). Nurses frequently must manage the problem of fever in these populations as its prevalence is high in the acute phase (Childs et al. 2005, McIlvoy 2007, Thompson et al. 2007b, Kirkness et al. 2008). This management has a direct relevance to clinical outcomes and thus warrants study. Recent studies reveal wide variation in nursing practice and barriers to evidence-based fever management. In the United Kingdom (UK) and Ireland, the most common sites for temperature measurement in neurological ICU patients were the axilla and groin (Johnston et al. 2006), sites not recommended for monitoring temperature in critically ill adults (O’Grady et al. 2008). Previous studies in the United States (US) have shown that between 14% and 69% of febrile episodes in patients with neurological insults in the ICU are undertreated (Kilpatrick et al. 2000, Thompson et al. 2007b). Edwards et al. (2007) noted that Australian paediatric nurses generally consider fever to be a detrimental event requiring intervention with antipyretics. Grossman et al. (1995) evaluated nursing practices in the care and management of febrile patients on a mixed medical unit and found that only 59% of patients experiencing fever were treated appropriately by nurses. In studies conducted separately in three different countries (US, Sweden and Australia), all authors noted a lack of consistency in the way nurses described fever and the management of fever (Grossman et al. 1995, Emmoth&Mansson 1997, Edwards et al. 2001, 2007, Walsh et al. 2005). The gap between available evidence from patient outcomes research and data on bedside practice for fever management is a striking, widespread problem. In the context of high-risk outcomes, there is inconsistency in implementing EBP. As the nurse at the bedside is the primary decision maker on antipyretic interventions when there is an established fever management protocol in place (Emmoth & Mansson 1997, Thompson et al. 2007b), we undertook an inductive, qualitative study of nurses’ perspectives on fever management and clinical decision-making for patients and specifically for those with a neurological insult. The studyPurpose statement and specific aimsWe sought to understand perspectives of nurses on fever when caring for neurologically vulnerable patients across different settings. This study addressed the questions:
DesignA collective case study approach was used to identify how nurses across multiple practice settings define fever and subsequently decide how to care for neurologically vulnerable people. The case study method matched the study purpose of characterizing nurses’ perspective, definition and management of fever. In addition, the method enabled exploration of factors that influenced nurses’ behaviour and knowledge translation (Oeyen 2007) for a depiction of management decisions in a truly illustrative manner. ParticipantsProfessional nurses who cared for patients with neurological insults on five selected nursing units at two different US hospitals comprised a purposive sample of participants (N = 17). Nurses interested in participating were asked to identify themselves for inclusion. Nurses were recruited from both critical care (n = 11) and acute care units (n = 6), and from both dedicated neuroscience (n = 6) and mixed units (n = 11). Initially, maximum variation sampling was used until three to four nurses from each unit enrolled to ensure balanced representation across the units. Enrolment ceased when data saturation was achieved. Protection of participantsInstitutional Review Board Approval from the University of Washington was obtained for this study. The study was conducted in accordance with all established university policies for the conduct of research on humans. In addition, each hospital’s nursing research committee approved the study. Informed consent was obtained from all nurse participants. Nurse participants were informed that they did not have to answer every question and that participation was voluntary, confidential, and would not affect employment or performance evaluations. Participants received remuneration in the form of a $25 gift certificate for their time in participating. Participants were offered the option to review their interview tapes as a member check. A waiver of consent was granted by the institutional IRB for the direct observation of patient care and medical record review. Data collectionInterviewsAfter participants identified themselves and informed consent was obtained, tape recorded, semi-structured interviews were conducted in a quiet location convenient to the participants. Questions were developed by the primary investigator based on areas identified from the review of the literature and prior quantitative studies. The list of interview questions underwent pilot testing and refinement before their use in the current study. Sample questions during the interview included ‘how do you personally define fever?’ and ‘how do you decide what interventions to use for fever management?’ The primary investigator used reflective techniques before entering the study settings to bracket her perspective and assumptions about the phenomenon under study. Direct observationDirect observation of care delivery by study participants was conducted by the primary investigator on two units (one dedicated and one mixed unit) in the month immediately following completion of interviews. The primary investigator was present on the unit and observed care provided by five participants on normally scheduled day or evening shifts. Only care directly related to temperature assessment and management was of interest. The shift-based observation occurred until care for a febrile episode was observed (10 shifts total). Field notes were written about the observation and included descriptive information from the patient’s medical record to note nursing documentation of temperature assessment, assessment features that characterized the fever episode and care provided in response to fever. Observation targeted verification of interview data. Data analysisRecorded interviews were transcribed verbatim along with detailed field notes of the interviews and observations. Data were managed using the Atlas/ti 5.0 software program (Atlas.ti, Berlin, Germany). Using constant comparative technique, data were initially coded and preliminary categories were developed. Each case was initially analysed separately as data collection progressed. As transcripts were accrued, each interview was iteratively coded until themes were identified. As initial codes were collapsed or axialized, themes emerged. A subset of the cases were independently coded for verification by a trained graduate student. Crosscase comparison based on unit (specialty vs. mixed) was conducted only after individual case analyses were conducted as per the recommendation of Yin (2003). The nursing process (e.g. assessment and analysis, planning and implementation, and evaluation) was used as an analytical filter to refine and present the findings using a clustering approach (Miles & Huberman 1994, Rosenberg & Yates 2007). In this manner, emerging themes and patterns were examined and organized into a descriptive matrix (Rosenberg & Yates 2007). RigourTo allow for improved trustworthiness, data collection and analysis followed the three principles identified by Yin (2003): (1) using multiple sources of evidence; (2) creating a case study data base using computer software (Atlas/ti 5.0); and (3) maintaining a chain of evidence. The use of multiple data sources in this study allowed for data source triangulation and improved confirmability and credibility of the analysis (Guba 1981, Yin 2003). Verification was also employed to support credibility. The main study findings were presented to neuroscience nurses at a national meeting in April 2007 and to acute care nurse educators and researchers at a state of the science meeting in October 2008. These nurses verbally concurred with the study’s result, supported its value, and offered no alternative explanations or refutation. The use of nurses from a variety of patient care settings as participants supported trustworthiness by addressing the issue of transferability (Guba 1981). FindingsFindings were organized using the analytical filter of the nursing process: assessment/analysis, planning/implementation and evaluation. Assessment/analysisIn the context of assessment/analysis, themes of defining fever, fever vs. hyperthermia and patient assessment were identified (See Table 1 and Table S1). In the theme of ‘defining fever’, the definition of fever provided by most nurses was a single number or cut point. In all but one case, the temperature cited coincided with hospital protocols or physician orders: ‘typically 38·5…because that is how they ordered it’ and ‘what the medical community does is anything that is above 38·5’. Only after prompting by the interviewer to the question ‘Do you think of other symptoms when you think of fever’ did participants include other signs/symptoms such as: ‘they are warm’ ‘tachycardia’, ‘sweat’, ‘mental status changes’, ‘respiratory rate’ and ‘blood pressure’. This finding was confirmed by the review of documentation in the medical record during participant observation. In the context of the theme ‘fever vs. hyperthermia’, nurses were generally unable to describe how fever differed from hyperthermia regardless of practice setting: ‘I think of them as the same…so, I wouldn’t be able to distinguish whether someone was hyperthermic or have a fever’ (see also Table 1 and Table S1). Furthermore, in the theme of ‘patient assessment’, thermometer accuracy was seen as a large barrier to assessment as exemplified by the quote: ‘as far as I am concerned the machine can be very arbitrary I can get five machines in there and I can probably get five different temperatures’ (See also Table 1 and Table S1). Interestingly, participants on dedicated neuroscience units often reported mental status changes or confusion as a sign of fever (Table 1 and Table S1) and noted other specific causes of fever seen in patients with neurological disorders or injury such as a reaction to phenytoin and sympathetic storm. This finding was also confirmed during participant observation, where the presence of a change in level of consciousness prompted temperature assessment. Specific education on fever management was reported by nurses working on dedicated units: Table 1Meta-matrix of identified themes and supporting evidence
Planning/implementationThe themes identified in planning/implementation included rationale for choice of intervention, pharmacological interventions, non-pharmacological interventions, effect of physician, effect of protocol and total body/pan cultures. Many respondents reported doing ‘what worked’ for the individual patient in the past as rationale for choice of intervention (see also Table 1 and Table S1):
Others responded that they or their colleagues simply followed an available protocol or reported following a series of steps based on their own opinion, experience or philosophy: ‘I know there are a lot of people with a certain beliefs, I am kind of [like it] depends on how I am feeling that day’ (see also Table 1 and Table S1). Participants commonly reported using acetaminophen as a common first step: ‘First of all I check the order and find out do I have Tylenol’, often choosing to use it at a lower temperature threshold for fever than ordered (Table 1 and Table S1). This finding was confirmed during observation where acetaminophen was given by the nurse to treat a fever, but documented as given for pain as the temperature was lower than that for the fever order. Ibuprofen was commonly seen as working better than acetaminophen, but participants reported that it was not always available to them for use. Numerous non-pharmacological interventions were detailed including environmental changes (e.g. removing blankets, turning down thermostat, opening windows), physical cooling measures (e.g. ice packs, cooling blanket, bathing) and other interventions (e.g. mobilization, incentive spirometer use). Furthermore, many interventions seen as useful by some participants (e.g. ice packs, cooling blankets, fans, etc.) were seen as problematic by others (see also Table 1 and Table S1):
Available protocols were seen as including interventions deemed by many respondents as ‘aggressive’ or ‘extreme’ (Table 1 and Table S1). Furthermore, participants reported that some physicians did not treat fever in patients on an individual basis and that follow-up from cultures was poor. This was exemplified by the quote:
Most participants reported that they did not see a yield from ordered cultures and found them to be both resource- and time-consuming and potentially harmful to patients:
EvaluationWithin evaluation were the following themes: time interval for evaluating efficacy, efficacy, patient differences in response and barriers to treatment. A resolution of the patient’s temperature to a level below that in the fever protocol was defined as efficacy by participants. The interval for this assessment varied widely among participants, and when one intervention did not work, they would initiate another intervention as exemplified by the quote: ‘If it comes down, it comes down. If it doesn’t, I keep going until something works’. Paediatric patients were viewed as being very different from adults, and higher thresholds were set for concern. Lastly, while some participants reported no barriers to care, others reported that both the patient and availability of equipment were treatment barriers (Table 1 and Table S1). DiscussionWe sought to understand perspectives of nurses on fever when caring for neurologically vulnerable people across different settings, specifically examining how strategies are selected and barriers encountered. The study findings suggest that in the absence of protocols developed in an interdisciplinary manner, nurses chose rather to rely on trial and error or individual convention. The study identified that a barrier to care were the decisions made by nurses and their physician colleagues where, they are ‘doing their own sorts of things’ or what is ‘done at home’ without regard to EBP. This echoes previous findings from the US and Ireland and the UK where treatment decisions were based on opinion, resulting in dissatisfaction with treatment (Johnston et al. 2006) and perception of a barrier to best practice (Thompson et al. 2007a). Previous studies have found that collaborative development of protocols is critical for successful adaptation of protocols and for closing the translational gap (Oeyen 2007, Sinuff et al. 2007). Therefore, our findings support that fever management protocols need to be developed in collaboration with nursing to ensure best-practice is achieved. Furthermore, while protocols were seen as valuable by many participants in the present study, when not applied in a critical manner, they may also be practice-limiting as individual nurses do not think beyond the protocol to what is best for the individual patient. These findings suggest that there is a lack of detail in nurses’ descriptions of the febrile state and also a lack of consistency in determinations of when patients with fever should be treated. In previous studies, fever was defined by nurses as simply an elevation in body temperature, without further documentation of accompanying signs and symptoms of fever (Grossman et al. 1995, Edwards et al. 2001). Therefore, it is difficult to ascertain what role, if any, these signs and symptoms played in the decision to treat fever. Nurses caring for patients with a neurological insult who have fever commonly relied on multiple indicators that the patient indeed had a fever. These indications went beyond an elevation in temperature to include assessment findings and signs that may be specific to an individual patient, such as changes in the neurological assessment. These findings are often either not consciously noted or are not presented discursively in nurse–nurse communications (Thompson et al. 2007b). As a result, written communication about the patient’s unique experience of fever is often absent from the patient record. This could then lead to delayed or inappropriate fever management, which may have a significant impact on patient outcomes for patients with neurological insults. Thus, any ambiguity associated with fever in individual patients and its clinical interpretation have implications for patient care and outcome, particularly in vulnerable populations such as patients with neurological insults. Participants in the present study noted that at present, the medical record was a barrier to documentation of descriptive findings. Suggestions were made for improvement such as automatic documentation prompts in the electronic medical record. Emmoth and Mansson (1997) asserted that because descriptions of fever are very different, misunderstandings can result, and recommended the identification and use of clarified language in nursing documentation. The use of a prompt system, as suggested by participants in the present study, could provide some clarification. Our participants reported using interventions not supported by literature such as alcohol, ice packs to the groin and opening the windows in the intensive care unit to treat fever. During the chill phase of fever, use of ice packs is likely to lead to increased shivering as the temperature set point has been raised and the body is working to increase the temperature to the new threshold (Bruderlein et al. 2006). This concern is magnified when the ice is applied to the groin area which contains a large number of heat sensitive neurons. The use of alcohol to reduce fever is of unclear efficacy. While Polderman suggests that a combination spray is efficacious (Polderman 2009), there is little published evidence to support its use. Moreover, alcohol can be drying to skin, and alcohol toxicity has been reported with the use of 100% isopropyl or ethyl alcohol for sponge baths in both children and older adults (Axelrod 2000). There is a need for research to evaluate the use of the alcohol and water sprays in fever management. Several participants reported the use of an available ‘loophole’ for acetaminophen, administering it at lower temperatures than ordered for fever under its availability for pain, circumventing the system to keep fever down. This provides confirmation of findings from a previous study where 20% of acetaminophen doses were given at temperatures lower than was ordered for fever management purposes (Thompson et al. 2007b). In another study by Edwards et al. (2007), there was an apparent lack of understanding of the underlying pathophysiology of fever. This knowledge gap is also apparent in our findings as the majority of nurse participants could not distinguish hyperthermia from fever. Nurses should understand that fever plays a larger role in the outcome of neurological injury to make evidenced-based clinical decisions in managing these patients. Our results suggest that additional education is needed with regard to thermoregulation and the pathophysiology of fever, best practices for fever management and culture protocols and the implications of fever in different patient populations. Previous work has reported that a peer education programme can be an effective means of conveying information to nurses with regard to fever management in paediatric patients (Edwards et al. 2007). This method could be adapted to improve knowledge and EBP for patients with neurological disorders or injury. Of particular importance in the present study, nurses working in dedicated neuroscience units expressed that febrile patients needed to be treated differently and their assessment approach differed significantly from that of nurses working on mixed units. This further supports the value of specialty knowledge on dedicated nursing units, which should be considered by clinical administration. Study limitationsThe use of two academic medical centres may be viewed as a potential limitation of this study as nursing practices often vary widely based on type of practice setting (e.g. Lee et al. 1997); however, the two institutions serve very different purposes and populations. The descriptive credibility and relevance of the present findings to countries outside the US need to be confirmed. ConclusionsThese findings suggest opportunities to educate nurse to improve patient care, as there was a lack of understanding of temperature regulation and fever. While nurses reported doing ‘what worked’, this may not have always been based on best practice. Nurses chose fever intervention strategies that worked in part because there was a lack of collaboration with nursing in development of the institutional fever management protocol. This lack of interdisciplinary involvement in the development of patient care protocols probably served to create a barrier to their use. Implications for researchFurther research in other countries is needed to extend this work as nursing practices are often subject to regional trends. This work focused on nurses working with one vulnerable population: those with neurological insults. It would therefore be important to extend this work to other vulnerable populations such as those with cancer or burns to determine if similar issues arise and should be addressed. Implications for nursing practiceNurses need to understand fully the temperature regulation and febrile response to provide best practice. Due to the negative effects of fever in persons with neurological insult, nurses caring for these patients need to be vigilant in monitoring temperature and assessing for other signs and symptoms. Furthermore, the medical record frequently lacks detail with regard to individualized assessment of these signs and symptoms and successful management strategies. Nurses need to be more explicit in their documentation to assist future caregivers; this explicit documentation could improve the recognition and treatment of fever. To promote this, electronic or paper medical records could integrate documentation prompts or tools. Implications for nursing policyAs fever management is a collaborative enterprise, we recommend that protocols be developed with all team members represented to foster local adaptation of best practices. This may also further application of best practices by encouraging individual nurses to think of institutional protocols not as a recipe, but rather as a guide to care of the individual patient. Nurses working on neuroscience specialty care units articulated clear differences in the management of patients with neurological disorders or injury with fever compared with those working on mixed units. This finding endorses the value of specialty knowledge in narrowing the translational gap and offers institutions further evidence for planning and structuring the organization of care. Supplementary MaterialS1Table S1: Meta-matrix of identified themes and supporting evidence. AcknowledgmentsThis paper is dedicated to the memory of Deborah Webb, MSN, without whose assistance this study could not have been completed. Funding This work was supported in part by grants from the Integra Foundation/Neuroscience Nurses Foundation, the National Institutes of Health (T32NR007106; 1KL2RR025015) and the John A. Hartford Foundation Building Geriatric Academic Nursing Capacity Program (06-202). FootnotesConflict of interest No conflict of interest has been declared by the authors. Author contributions HT was responsible for the study conception and design, performed the data collection, obtained funding, provided administrative, technical or material support and supervised the study. HT and SK performed the data analysis, were responsible for the drafting of the manuscript and made critical revisions to the paper for important intellectual content. SK provided qualitative expertise. Contributor InformationHilaire J. Thompson, Biobehavioral Nursing and Health Systems, The University of Washington, Seattle, Washington, USA. Sarah H. Kagan, Lucy Walker Honorary Term Professor of Gerontological Nursing – Clinician Educator, The University of Pennsylvania, Philadelphia, Pennsylvania, USA. References
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A nurse is reviewing the medical record of a client who reports taking acetaminophen at home
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