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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Nurs . 2026 Mar 5;25:350. doi: 10.1186/s12912-026-04504-3 Search in PMC Search in PubMed View in NLM Catalog Add to search Critical care nurses’ knowledge, attitude, and practice regarding hypothermia management during continuous renal replacement therapy: a cross-sectional study Qingqing Sheng Qingqing Sheng 1 Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 China Find articles by Qingqing Sheng 1, # , Yufeng Tan Yufeng Tan 1 Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 China Find articles by Yufeng Tan 1, # , Xiaoqun Huang Xiaoqun Huang 1 Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 China Find articles by Xiaoqun Huang 1, # , Tingting He Tingting He 1 Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 China Find articles by Tingting He 1, # , Xiaoxia Li Xiaoxia Li 1 Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 China Find articles by Xiaoxia Li 1 , Yao Huang Yao Huang 1 Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 China Find articles by Yao Huang 1 , Liting Zeng Liting Zeng 1 Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 China Find articles by Liting Zeng 1 , Xinning Wang Xinning Wang 2 School of Nursing, Guangzhou Medical University, 195 Dongfeng West Road, Guangzhou, 510000 China Find articles by Xinning Wang 2 , Mengmeng Xu Mengmeng Xu 1 Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 China Find articles by Mengmeng Xu 1, ✉ , Shuqin Zhang Shuqin Zhang 1 Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 China Find articles by Shuqin Zhang 1, ✉ , Lihua Chen Lihua Chen 1 Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 China Find articles by Lihua Chen 1, ✉ Author information Article notes Copyright and License information 1 Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 China 2 School of Nursing, Guangzhou Medical University, 195 Dongfeng West Road, Guangzhou, 510000 China ✉ Corresponding author. # Contributed equally. Received 2025 Oct 27; Accepted 2026 Feb 25; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13072486 PMID: 41787344 Abstract Background Hypothermia is a relatively common complication during CRR and affects patients’ decisions of clinical management, ICU length of stay, and clinical outcomes. It is important for critical care nurses to understand hypothermia during CRRT and implement management to prevent it. Methods A multicenter cross-sectional survey was conducted in 13 hospitals in Guangdong province, China, from June to July 2024. A self-made structured questionnaire was used for data collection. Descriptive statistics, Mann-Whitney U test, Kruskal-Wallis test T-tests, multiple linear regression, and Spearman correlation coefficient tests were employed. Results A total of 741 eligible questionnaires were received for data analysis. The median scores of knowledge were 9.0 (IQR: 8.0–10.0), with mean scores of 8.6 and scoring rate of 66.2%; The median scores of attitude were 25.0 (IQR: 24.0–25.0), with mean scores of 23.9 and scoring rate of 95.6%; The median scores of practice were 48.0 (IQR: 44.0–53.0) with mean scores of 48.0 and scoring rate of 80.0%. There was a positive and significant relationship between knowledge, attitude and practice. Multiple linear regression analysis indicated that education level and head nurse independently affected the knowledge; marital status independently affected the attitude; ICU working years, education level, technical title and casual/contracted type independently affected the practice. Conclusions In the study, critical care nurses generally have inadequate knowledge, positive attitude and good practice regarding hypothermia management during CRRT. There is room for improvement in knowledge and practice compared to attitude. Trial registration Not applicable. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-026-04504-3. Keywords: Hypothermia, Knowledge-attitude-practice, Intensive care unit, Nurse, Cross-sectional study Background Continuous renal replacement therapy (CRRT) is a standard therapy for critically ill patients with acute kidney injury, severe fluid overload, and electrolyte disturbances in the intensive care unit (ICU) [ 1 ]. A multinational study has shown that over half of all critical ill patients had AKI and 23.5% of these patients required CRRT [ 2 ]. Complications associated with CRRT have received attention and been studied gradually to improve practical benefits [ 3 , 4 ]. Hypothermia is a relatively common complication during CRRT because of the heat loss of extracorporeal blood circulation [ 5 ]. A retrospective study has showed that 57.2% CRRT patients still experienced significant hypothermia despite the heating system of the equipment [ 6 ]. The definition of hypothermia during CRRT remains inconsistent but generally accepted to occur when core body temperature (BT) is less than 36.0 ℃ [ 7 – 9 ]. Hypothermia extends far beyond discomfort to patients, directly affecting multiple organ systems. Specifically, it is associated with risk of bradycardia and arrhythmia, impaired pharmacodynamics, coagulopathy, and subsequent transfusion requirements [ 10 ]. Besides, hypothermia can also mask fever potentially, delay infection diagnosis and the antibiotic initiation, leading to prolong the length of ICU stay and compromise patient outcomes [ 5 , 11 ]. A meta-analysis involving 10,834 patients across 42 studies confirmed that hypothermia patients with sepsis have a significantly higher mortality compared with those with normothermia or fever [ 12 ]. The hypothermia during CRRT should be paid more attention, rather than merely focusing on fluid balance, metabolism, anticoagulants [ 5 , 13 , 14 ]. Our previous evidence summary has indicated that hypothermia during CRRT was influenced by multiple factors, including patient-related factors, machine and parameter-related risk factors, and environmental-related risk factors [ 15 ]. To date, standardization protocols and guidance for hypothermia management during CRRT remains limited [ 16 ]. It is vital to take active and passive measures to maintain patients warmth throughout the entire CRRT [ 15 , 17 ]. Study have indicated that heating replacement fluid can safely and effectively reduce the incidence of hypothermia in CRRT patients [ 18 ]. Besides, a recent study from Swedish found that the novel TherMax warmer technology protected against hypothermia and was significantly more accurate than the Barkey warmer [ 19 ]. As the first direct caregivers of critically ill patients, critical care nurses’ KAP regarding hypothermia management can improve the quality and safety of nursing care. However, there is a scarcity of published literature examining the critical care nurses’ KAP regarding hypothermia management. When available, they were often comprehensive surveys of CRRT management [ 20 , 21 ], with little focus on temperature monitoring and warming inventions. Therefore, we have developed a knowledge, attitude, and practice (KAP) questionnaire regarding hypothermia during CRRT. The study aimed to evaluate the KAP regarding hypothermia management during CRRT among critical care nurses and analyze the factors affecting the KAP regarding hypothermia management. Methods Study aim The aims of the study were to (a) evaluate the critical care nurses’ KAP regarding hypothermia management during CRRT in Guangdong province, China; (b) analyze the factors affecting the critical care nurses’ KAP regarding hypothermia management during CRRT. Study design A cross-sectional online survey with self-reported questionnaires was used in this study. Study setting The study was conducted in 13 hospitals from Guangdong province with a convenience sampling method from June 2025 to July 2025. Each hospital is a tertiary-A hospital or a teaching hospital affiliated with one of Sun Yat-Sen university, Guangzhou Medical University, or Jinan University. Participants All participants met the following inclusion criteria: (a) obtain a Nursing Practice Certificate issued by the Ministry of Health of China; (b) provide care for patients with CRRT; (c) volunteer to take part in the study. Nurses who self-reported less than 12 months of work experience were excluded. Sample size It is generally accepted that the sample size should be at least 5–10 times the number of independent variables included in a multiple linear regression [ 22 ]. The number of independent variables was expected to be 14 in the study. Considering 20% attrition rate, the sample size should be at least 84–168 participants. Study instrument The questionnaire was developed based on researchers’ extensive literature review and evidence summary [ 15 ]. The final version of the questionnaire was divided into two sections after three rounds of group discussion. The first section included age, gender, clinical working years, education level, technical title and position. There were also three ancillary questions regarding temperature measurement for patients with CRRT. It was only designed to elicit suggestions for future research and not included in the statistical regression analysis. The second sections consisting of 30 questions is a self-made questionnaire, and focused on the KAP survey regarding hypothermia during CRRT among critical care nurses. The knowledge dimension included 13 items of questions, with one point for correct responses, and zero points for incorrect and unclear responses. The score range was 0–13 points. Regarding the attitude dimension, it included 5 items and was evaluated using a 5-level Likert scale (1= “highly disagree” to 5= “highly agree”), allowing a score range of 5–25 points. Similarly, the practice dimension evaluated using a 5-level Likert scale from (from 1= “never” to 5= “always”). With a total of 12 items, the score range was 12–60 points. Higher scores for each dimension would indicate higher level of critical care nurses’ KAP regarding hypothermia during CRRT among ICU nurses. The scoring rate for each dimension = mean scores/theoretical maximum × 100%, and a scores ≥ 80% is regarded as possessing adequate knowledge, attitude and practice for delivering safe and effective nursing care. Validity Five intensive care experts who had more than 15 years of critical care experience were invited to evaluate the relevance, clarity, and appropriateness of the questionnaire of knowledge, attitude and practice regarding hypothermia during CRRT. No significant changes were suggested. To confirmation content validity of the KAP regarding hypothermia during CRRT, the 4-point scale from “not relevant” to “most relevant” was used to assess the relevance of each item. The total Scale Content Validity Index in the questionnaire was 0.927, demonstrating good content validity. Ethical issues The ethics committee of the First Affiliated Hospital of Guangzhou Medical University approved the study (Ethical Approval Number: ES-2023-132-01; Date:2023-08-14). All participants were informed about the purpose of the study, the procedures and their rights in the beginning of the questionnaire, and completion of the survey was considered “consent to participate” (see Related File 1). Data collection In the study, the electronic questionnaire was used to collect data by Wenjuanxing platform, a free and open online survey website. Prior to the survey, consent and cooperation from ICU nursing department leaders in each hospital were obtained, and professional hyperlinks and QR codes were sent through Wechat. Then, each nursing department head sent an electronic questionnaire to all eligible nurses in their department. A standardized guideline outlining the study’s aims and significance on the first page of the electronic questionnaire. Each IP address was restricted to a single submission and each question was designed to require a response to avoid missing items. Participants could end the survey at any time. If participants closed the link or did not submit the survey, and their data would not be retained. The questionnaire could not be revoked after submission. Data analysis Data analysis was performed using SPSS 25.0 (see Supplementary File 1 ). The Kolmogorov-Smirnov test and Shapiro-Wilk test were applied to assess normality, revealing the scores of knowledge, attitude, and practice were not a normal distribution ( p < 0.05). As a result, a nonparametric statistical test was used. Frequencies and percentages, median with interquartile range (IQR) were used to represent the data. Spearman correlation coefficient was used to examine the relationship among knowledge, attitude, and practice. To examine the variations in KAP scores based on critical care nurses’ characteristics, the Mann-Whitney U test and Kruskal-Wallis test were used. The characteristics of P-values less than 0.1 were included in the multiple linear regression model to analyze the factors affecting the KAP scores. P-values less than 0.05 were considered statistically significant. Results Participants’ characteristics A total of 833 questionnaires were received. Of theses, 92 were further excluded because of the response times less than 120 s, leaving 741 eligible questionnaires for data analysis. Majority of participants were female (80.5%) and married (65.1%). 49.2% participants were 20 to 30 years old in the ICU. In terms of ICU working years, 41.8% participants were 1–5 years. The detailed demographic characteristics were presented in Table 1 . Table 1. Demographic characteristics associated with knowledge, attitude, and practice of hypothermia during CRRT among critical care nurses ( n = 741) Demographics Number(%) Median knowledge[Q1-Q3] P value Median Attitude[Q1-Q3] P value Median Practice[Q1-Q3] P value Age (year) 20–30 years 311(41.9%) 9[8,10] 0.766 b 25[23,25] 0.318 b 48[44,54] 0.818 b 31–40 years 347(46.8%) 9[8,10] 25[24,25] 48[44,52] > 41 years 83(11.2%) 9[8,10] 25[24,25] 48[44,53] Gender Male 144(19.4%) 9[8,9] 0.849 a 25[24,25] 0.219 a 49[44,56] 0.219 a Female 597(80.5%) 9[8,10] 25[24,25] 48[44,53] Marital status Married 483(65.1%) 9[8,10] 0.565 a 25[24,25] 0.039 a 48[45,53] 0.375 a Unmarried 258(34.8%) 9[8,10] 25[23,25] 48[44,53] ICU working years 1–5 years 310(41.8%) 9[8,10] 0.439 b 25[23.75,25] 0.951 b 48[44,54] 0.011 b 6–10 years 173(23.3%) 9[8,10] 25[24,25] 48[45,52] 11–15 years 150(20.2%) 9[8,10] 25[23,25] 47[43,51] ≥ 16 years 108(14.5%) 9[8,10] 25[24,25] 50[45,54] Education level College or below 74(9.9%) 9[7,10] 0.045 b 25[24,25] 0.059 b 47[42.75,53] 0.081 b Bachelor 656(88.5%) 9[8,10] 25[23,25] 48[44,53] Master or above 11(1.4%) 9[9,10] 25[25,25] 53[48,56] Technical title Primary 390(52.6%) 9[8,10] 0.987 b 25[23,25] 0.200 b 48[45,54] 0.038 b Moderate 306(41.2%) 9[8,10] 25[24,25] 47[44,51] Senior 45(6.0%) 9[7,10] 25[25,25] 48[44,53] Contract type Permanent 250(33.7%) 9[8,10] 0.660 a 25[24,25] 0.901 a 47[43.75,51] 0.003 a Casual/Contracted 491(66.2%) 9[8,10] 25[24,25] 48[45,54] Specialist nurse No 94(12.6%) 9[8,10] 0.132 a 25[23,25] 0.445 a 48[44,53] 0.481 a Yes 647(87.3%) 9[8,10] 25[24,25] 48[44,52] Head nurse No 713(96.2%) 9[8,10] 0.011 a 25[23,25] 0.078 a 48[44,53] 0.764 a Yes 28(3.7%) 9[9,10] 25[25,25] 50[44,52.75] Open in a new tab Abbreviations: ICU, intensive care unit a p -value is calculated using the Mann-Whitney U test b p -value is calculated using the Kruskal-Wallis test Temperature measurement for patients with CRRT Majority of participants (98.9%) reported to routinely monitor temperature when caring for patients with CRRT. However, only 441 (59.5%) critical care nurses reported that their unit had tools for measuring core body temperature. Further investigation using multiple-choice question revealed that the most commonly body site of measuring temperature for patients undergoing CRRT was axilla (730, 98.5%), followed by bladder (99, 13.3%), rectum (47, 6.3%), oral (17, 2.2%), ear (8, 1.1%), inguinal region (7, 0.9%), else sites including blood, back, neck (6, 0.8%). Critical care nurses’ knowledge regarding hypothermia during CRRT The median scores were 9.0 (IQR: 8.0–10.0), with mean scores of 8.6 and scoring rate of 66.2%, showing overall inadequate knowledge regarding the hypothermia during CRRT. The items with highest scoring rate were the questions including maintaining warmth during CRRT (96.4%) and keeping consistency in the measurement site and method (95.8%). However, it was found that majority of critical care nurses were not aware of the heating temperature for the irrigation fluid (19.4%), the replacement fluid (23.1%) and the common cause of low hypothermia (33.3%). The detailed scoring rate of each item of knowledge dimension were shown in Table 2 . Table 2. Critical care nurses’ knowledge attitude and practice of hypothermia during CRRT ( n = 741) Items Score rate (%) Knowledge K1. It is classified as hypothermia when a patient’s core body temperature is lower than 36℃ during CRRT 86.1 K2. The common cause of low hypothermia during CRRT is the insufficient warmth 33.3 K3. The CRRT mode of patients is a risk factor for low hypothermia 70.7 K4. The low temperature during CRRT should be judged based on the patients’ core body temperature 81.5 K5. The highest accuracy sites for measuring core body temperature is the intravascular (such as pulmonary artery, internal jugular vein, femoral artery, etc.) 79.5 K6. The bladder, esophagus or anal are usually selected as the measurement part for core temperature in the clinical work 53.0 K7. It is necessary to ensure that the measurement site and method are consistent each time for temperature measurement to keep the accuracy during CRRT 95.8 K8. The infusion tubing heating is the most effective heating methods among the common infusion tubing heating, the replacement fluid heating, and the warming blanket machine heating during CRRT 90.3 K9. Maintaining patient warmth should be throughout the entire CRRT 96.4 K10. The temperature of the irrigation fluid should be heated to 40–42 °C during rinsing therapy 19.4 K11. It is necessary to heat to 38 °C when the volume of intravenous infusion and blood products administered exceeds 1,000 m during CRRT 42.8 K12. If the replacement fluid is heated, the heating temperature is usually 38 °C during CRRT 23.1 K13. The patient with hypothermia may have arrhythmia during CRRT 91.0 Attitude 95.7 A1. Temperature is an important monitoring indicator for patients during CRRT 95.1 A2. Regular temperature measurements are extremely important for patients during CRRT 96.4 A3. Critical care nurses’ nurses need to master the knowledge about hypothermia management during CRRT 96.8 A4. Hospitals or departments should provide regularly training sessions on hypothermia management during CRRT for critical care nurses 95.2 A5. I want to learn more about the knowledge related to hypothermia management during CRRT 95.0 Practice P1. I will proactively monitor the body temperature of patients undergoing CRRT during shift change. 91.4 P2. I will conduct temperature monitoring for the patient throughout the entire CRRT 92.9 P3. I will prefer to use axilla or foreheads as the site for temperature measurement during CRRT (Reverse scoring) 26.7 P4. I will prefer to use blood, bladder, esophagus or anal as the site for temperature measurement during CRRT 60.9 P5. I will prefer to use blood, bladder, esophagus or anal as the site for temperature measurement, when patients experience hypothermia during CRRT 63.5 P6. I will monitor the patient’s body temperature at interval 4 to 6 h during CRRT 93.5 P7. During the warming up for patients with hypothermia, I will monitor the patient’s temperature each 30 min to assess the warming effect 87.7 P8. I will pay attention to the patient’s vital signs, skin temperature, skin color, and state of consciousness during CRRT, so as to identify patients with hypothermia in time 94.1 P9. I will proactively cover the patient with thick cotton blankets and insulation blankets to keep them warm during CRRT 94.7 P10. When CRRT patients experience hypothermia, I will use inflatable warming devices and conduction heating devices to keep them warm 89.2 P11. I will heat the replacement fluid to quickly raise patients’ temperature when patients experience hypothermia during CRRT 75.8 P12. I will pay attention to the complications of hypothermia when patients experience hypothermia during CRRT 90.5 Open in a new tab Abbreviations: CRRT, continuous renal replacement therapy Critical care nurses’ attitude regarding hypothermia during CRRT The median scores were 25.0 (IQR: 24.0–25.0), with mean scores of 23.9 and scoring rate of 95.6%. The range of scoring rate was 95.0% to 96.8% in attitude dimension, showing a overall positive attitude regarding the hypothermia during CRRT. The detailed scoring rate of each item of knowledge dimension were shown in Table 2 . Critical care nurses’ practice regarding hypothermia during CRRT The median scores were 48.0 (IQR: 44.0–53.0) with mean scores of 48.0 and scoring rate of 80.0%. Overall, intensive care nurses’ practice for hypothermia during CRRT is good, and the scoring rate of 63.6% (7/11) items were above 80%. The item with the lowest scoring rate was the reverse scoring item using axilla or foreheads as the site for temperature measurement (26.7%), indicating that the axilla or foreheads were the common sites for temperature measurement among critical care nurses. Also, the item of using blood, bladder, esophagus or rectum as the site for temperature measurement was only the 60.9% for the scoring rate. The detailed scoring rate of each item of practice dimension were shown in Table 2 and Supplement file 2 . Correlation analysis of critical care nurses’ knowledge, attitude and practice regarding hypothermia during CRRT Spearman coefficient tests showed a significantly positive correlations between knowledge and attitude ( r = 0.116, p = 0.002), knowledge and practice ( r = 0.206, p = 0.000), and attitude and practice ( r = 0.355, p = 0.000). Detailed data were presented in Table 3 . Table 3. Correlations of knowledge, attitude, and practice of hypothermia during CRRT among critical care nurses ( n = 741) r -value p -value The knowledge and attitude 0.116 0.002 The knowledge and practice 0.206 0.000 The attitude and practice 0.355 0.000 Open in a new tab Factors affecting the critical care nurses’ knowledge, attitude and practice regarding hypothermia during CRRT After multiple linear regression analysis, we found that education level, head nurse independently affected intensive care nurses’ knowledge regarding hypothermia during CRRT. Marital status independently affected intensive care nurses’ attitude regarding hypothermia during CRRT. ICU working years, education level, technical title, contract type independently affected intensive care nurses’ practice regarding hypothermia during CRRT. Detailed data were presented in Table 4 . Table 4. Multiple linear regression analysis of knowledge, attitude and practice of hypothermia during CRRT patients among ICU nurses ( n = 741) Dependent variables Independent variables B Std. error β t value 95CI P -value Knowledge score a Constant 7.817 0.365 21.412 7.100-8.533 0.000 Education level 0.411 0.188 0.080 2.183 0.041–0.781 0.029 Head nurse 0.653 0.324 0.074 2.015 0.017–1.289 0.044 Attitude score b Constant 24.494 0.496 49.430 23.521–25.467 0.000 Marital status -0.362 0.151 -0.089 -2.391 -0.658–0.065 0.017 Practice score c Constant 42.744 1.896 22.547 39.022–46.465 0.000 ICU working years 0.700 0.264 0.130 2.653 0.182–1.218 0.008 Education level 1.424 0.671 0.079 2.120 0.105–2.742 0.034 Technical title -0.978 0.492 -0.101 -1.987 -1.945–0.012 0.047 Casual/Contracted type 1.575 0.556 0.126 2.836 0.485–2.666 0.005 Open in a new tab Abbreviations: ICU, intensive care unit Knowledge score a : R = 0.114; R 2 = 0.013; adjusted R 2 = 0.010; F = 4.874; P = 0.008 Attitude score b : R = 0.108; R 2 = 0.012; adjusted R 2 = 0.008; F = 2.855; P = 0.035 Practice score c : R = 0.160; R 2 = 0.026; adjusted R 2 = 0.020; F = 4.858; P = 0.001 Discussion The study is the first to examine to the current level of critical care nurses’ KAP regarding hypothermia management during CRRT and the variables that affect them. Overall, the findings showed that there was room for further improvement in critical care nurses’ knowledge and practice regarding hypothermia management during CRRT compared to the attitude in the study. It should be given priority to increased theoretical and practical training of hypothermia management during CRRT for critical care nurses. However, the findings of this study required cautious interpretation due to the absence of reliability testing of the self-developed KAP questionnaire, and future studied should employ well-validated instruments to confirm these findings. In the knowledge dimension, critical care nurses generally showed proficiency in keeping warmth and temperature measurement, but their knowledge of the heating temperatures for the irrigation and replacement fluids remained notably deficient. This discrepancy may be due to the fact that critical care nurses only have a good grasp in routine operational knowledge, but they lack in-depth and comprehensive knowledge regarding CRRT management. CRRT management is a dynamic and complex processes [ 21 ]. As the primary users of the equipment, the nursing quality during CRRT is closely linked to the level of expertise possessed by nurses [ 23 , 24 ]. Therefore, it is suggested to develop various continuing education platforms such as theoretical training, lectures, and workshops to enhance critical care nurses’ comprehensive knowledge regarding hypothermia management during CRRT. Overall, intensive care nurses’ practice regarding hypothermia management during CRRT is good, except for the selection of measurement site. We also found that the most common site of body temperature measurement for patients undergoing CRRT was axilla, followed by bladder, anal, oral in the present study, similar to the findings of a prior study [ 25 ]. These findings are likely because axilla temperature is easy to collect, and conventional oral or anal temperature monitoring methods are often not suitable for the critical ill patients [ 25 , 26 ]. A systematic review and meta-analysis has showed that most commonly peripheral thermometers do not have clinically acceptable accuracy for estimating body temperature [ 27 ]. Measuring temperature from an intravascular site is considered the gold standard. However, this measurement is difficult to obtain routinely in the ICU [ 28 ]. In the study, only 441 (59.5%) critical care nurses reported that their units had tools for measuring core body temperature. Therefore, it is recommended to establish the specific protocols to standardize procedures of temperature monitoring and hypothermia management for critical ill patients with CRRT. According to the results of the present study, there was a statistically significant correlation between the critical care nurses’ knowledge, attitude, and practice scores regarding hypothermia management during CRRT, suggesting that knowledge and attitude could influence practice regarding hypothermia management. This result can be supported by the viewpoint that integrating intrinsic knowledge and positive attitude can be converted into extrinsic behaviors [ 21 ]. The caregiver’s behavior will directly impact how the patient’s illness is treated and how rapidly their physiological functions recover [ 29 ]. Therefore, it is necessary to assess nurses’ training needs and develop structured education program to improve the knowledge, attitude, and practice regarding hypothermia management. The present study showed that critical care nurses with higher educational level usually had a higher knowledge and practice scores in hypothermia management during CRRT. The finding is not a surprise, as the ACCCN recommended a post graduate nursing qualification for nurses employed in ICU [ 30 ]. Nurses with high education level usually were given more chance and exhibited a heightened learning capacity, leading to more knowledge and practice ability regarding hypothermia management during CRRT. Furthermore, our findings showed that there was a significantly higher knowledge scores towards hypothermia management among head nurse. ICU is a highly specialized clinical setting, where head nurses require higher role competence in management and patient care to develop nursing care plans for patients with complex conditions [ 31 , 32 ]. Furthermore, as first-line nursing managers, head nurses are also responsible for improving leadership ability to motivate nurses to pursue continuous learning and professional competence [ 33 ]. The study showed that there was a notably proactive attitude towards hypothermia during CRRT among married nurses. This result might be explained based on the theory of role accumulation [ 34 ]. The theory recognizes that playing role in work and family simultaneously can relieve the stress caused by one of the two roles. The experience of interpersonal communication and emotional support in family have a positive impact on the attitude in work of individuals [ 35 ]. The study revealed that ICU working years of critical care nurses had significant association with their practice scores. The theory of competency development noted that professional competence is a dynamic developmental process from the basic to the advanced level [ 36 ], which explains why critical care nurses with more years of ICU working years have a higher capacity in hypothermia management. Interestingly, our findings showed that critical care nurses with higher technical title had significantly lower practice scores. This may be attributed to critical care nurses with lower technical title being predominantly responsible for monitoring vital indicators and basic daily clinical care. In contrast, critical care nurses with higher technical title mainly focus on supervising the clinical nursing quality and handling emergency situations. Furthermore, in the present study, casual/contracted nurses had higher practice scores than permanent nurses. In China, nursing employment can be divided into permanent and casual/contracted employment [ 37 , 38 ]. Contract-based positions do not have lifetime employment and might experience lower incomes and limited benefits. Therefore, contract-employed nurses believe that outstanding working ability and sufficient service behaviour can help to renew the employment contract when their current contract expired [ 39 ]. Limitations The present study has several limitations. The data were collected by convenience sampling with self-report methods, which might lead to information bias owing to concealment or potential social desirability preference. In addition, the self-developed questionnaire was lack of reliability testing and attention-check items, and the findings may require cautious interpretation. Wilcoxon rank sum test (Mann-Whitney U test and Kruskal-Wallis test) was the main statistical methods in the study because of non-normally distributed data. This approach did not fully utilize the information contained in the data, leading to relatively lower test efficiency than parametric tests. Given the large sample size in this study, the test efficiency of Wilcoxon rank sum test results was ensured to some extent in the study. Conclusion In the study, critical care nurses have inadequate knowledge, positive attitude and good practice regarding hypothermia management during CRRT in Guangdong province, China. In addition, there is room for improvement in knowledge and practice compared to attitude. Nursing managers, educators, and administrators should establish standardize protocols for hypothermia management, and provide more structured education program to improve nurses’ ability on hypothermia management during CRRT. Moreover, there is a need for clearer and concise guidelines to standardize measurement and management of hypothermia management for critical ill patients with CRRT. Supplementary Information Below is the link to the electronic supplementary material. Supplementary Material 1 (624.9KB, pdf) Supplementary Material 2 (15.3KB, docx) Acknowledgements We also wish to express a special thanks to all participants in this study and the medical staff for help us to implement the study. Abbreviations IQR Interquartile Range ICU Intensive Care Unit CRRT Continuous Renal Replacement Therapy KAP Knowledge, Attitude and Practice Author contributions QS, LC, YT, SZ, and TH designed the study and write the research protocol; QS, LC, SZ, MX, TH, and XL did the literature, quality control, collected and checked the data; QS, XH, YT and YH analyzed the data, interpretation of data; QS, XW, YT, TH and LZ prepared the manuscript; QS, YT, LC, SZ, TH and MX did the revision. All authors read and approved the final manuscript. Funding This work was supported by the Science Foundation of Guangdong Province (grant numbers A2024371, B2025680); Guangzhou Health Science and Technology General Guidance Program (grant numbers 20261A010088, 20261A011066). Data availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate This study was approved by the ethics committee of the First Affiliated Hospital of Guangzhou Medical University (ES-2023-132-01, Date:2023-08-14) and adhered to the Declaration of Helsinki. All participants provided informed consent after they were informed about the study. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Qingqing Sheng, Yufeng Tan, Xiaoqun Huang and Tingting He are joint first authors. Mengmeng Xu, Shuqin Zhang and Lihua Chen are joint first corresponding authors. Contributor Information Mengmeng Xu, Email: [email protected]. Shuqin Zhang, Email: [email protected]. Lihua Chen, Email: [email protected]. References 1. Zhou Z, Liu C, Yang Y, Wang F, Zhang L, Fu P. 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[ DOI ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Supplementary Material 1 (624.9KB, pdf) Supplementary Material 2 (15.3KB, docx) Data Availability Statement The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. 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