Staff-Perceived Barriers and Facilitators

Patients rely on nurses for positioning and assistance with sitting and walking in the intensive care unit (ICU). Little information is available about how nurses evaluate patients’ readiness for progression from in-bed activity to out-of-bed mobilization. Understanding the barriers and facilitators to clinical practice may promote implementation of a protocol for progressive mobility when this activity is not common practice in a setting. Barriers and facilitators are defined as factors that prevent or enhance behavioral change.1 One barrier to adopting early, progressive mobility may be nurses’ perceptions of patients’ readiness for activity.2–4 This report describes the results of staff interviews collected during an investigation into the feasibility of a protocol to implement early, progressive activity among surgical and medical ICU patients who received mechanical ventilation for more than 48 hours.This descriptive study examined nurses’ perceptions of the barriers to and facilitators of use of progressive mobility. Data were collected with a semistructured interview that preceded any activity related to patient mobility.All nurse-participants provided direct care to a subsample of patients involved in a larger study that included a mobility intervention in several ICUs in an academic medical center. Both ICUs are closed units, with all admissions receiving care from an intensivist. Neither unit has a unit-based physical therapist or lift team, so most patients are mobilized with the nursing staff or the assistance of 1 or 2 patient care assistants. Characteristics of the 49 chronically critically ill patients who were the recipients of the interviewees’ care are summarized in Table 1; all patients were physiologically stable at the time of the interview. Before the study, neither unit used a systematic approach to mobility, and out-of-bed activity among ventilator patients was uncommon.The interview form was created by the principal investigator, who used a change framework6 to guide the development of a tool along with pilot data from 4 staff nurses who were asked to identify all factors that contributed to the decisions around making a plan for activity for a chronically critically ill patient in the ICU. Three content experts provided content validation after tool construction; reliability was not tested. Before the protocol phase of the study, nurses in the units were shown a diagram of the protocol7 at a staff meeting; however, specific questions about the protocol were not included in the interview process.A total of 33 nurses participated in 49 interviews. Although some nurses were interviewed more than once, second interviews were associated with a unique patient and responses in the first interview were not related to responses in the second interview (r = 0.12, P = .28; data not shown). Nurses in this study were mostly female and had a mean of 5 years of ICU experience. Ten interviews with 8 unique participants occurred before the protocol was implemented, and 39 interviews with 25 unique nurse participants occurred after the protocol phase of the larger study was implemented. Characteristics did not vary significantly between the nurses who participated before and the nurses who participated after the protocol was implemented, so demographic data are aggregated (Table 2).Of the 49 activities planned for patients on the day of interview, 41 were limited to in-bed activity, including frequent manual turning or passive range of motion exercises. Only 1 nurse planned active range-of-motion exercises. For these bedfast patients, unstable vital signs (24/41 or 59% of interviews) and low respiratory and energy reserve (each 19/41 or 46%) were identified as the most common reasons for restricting activity. Fourteen nurses (34% of interviews) also cited safety concerns, related to either fear of the patient falling or risk to tubing or catheter integrity. Eleven nurses (27% of interviews) reported sedation and an additional 3 nurses each reported low level of consciousness or agitation as important barriers to out-of-bed activity. Additional findings are reported in Table 3.Nine nurses planned out-of-bed activity, with the majority (7/9) making those plans during the protocol phase. The most common facilitator identified by these nurses was “the patient is cooperative today” (9/9 or 100% of interviews with planned out-of-bed activity). Both “good oxygen reserve” and “physician order” were facilitators of out-of-bed activity in 4/9 (44%) interviews. Four nurses volunteered that they were placing the patient in an in-bed chair position to evaluate the patient for standing and walking “because we have new beds that make this so easy.” The new bed allowed a true chair position with backrest, hips, and knees all angled at 90°.Plans to keep a patient in bed or to progress a patient to out-of-bed activity were not associated with the nurses’ sex, age, or experience or to the type of ICU (Table 3). When the periods before and after the protocol are compared, an association is apparent between the presence of the protocol and planned out-of-bed activity. During implementation and evaluation of the protocol, out-of-bed activity increased and occurred on day 6 compared with day 9 among patients with long ICU stays (Table 1). Another factor correlated with out-of-bed activity was a score of 10 or greater on the Glasgow Coma Scale.Neither the numbers of staff nurses, nursing assistants, or physical therapists (r = 0.04, P = .9) nor the patient’s admitting diagnosis (χ2 = 0.2, P = .60) were related to either in-bed or out-of-bed planning for activity. Five of the 49 patients had a physical therapy consultation. Physical therapists typically see ICU patients about 3 days a week in this setting. No associations were found between available equipment and the planned activity. Generally, nurses did not cite physician orders as either a barrier or facilitator; in this setting, 5 of 49 or 10% of the patients had an activity/activity restriction order. All of the interviewees described the plan for activity as moderate-to-high priority or an average of 3.5 on a scale from 0 (not a priority) to 4 (high priority), and higher prioritization was positively associated with out-of-bed activity.This study had several limitations. The study was done at a single institution with a convenience sample. Although this setting and sample may be representative of other academic medical centers, it may not apply to community hospital settings or among staff with different attributes. In addition, the design did not examine whether the protocol caused a change in nursing behavior; only associations are reported. However, this study does provide unique data about nurses’ perceptions of patients’ readiness for mobility activity and how assessment is linked to progression of mobility in the ICU.Clinicians in several ICUs who incorporate early progressive mobility suggest that an interdisciplinary team is needed to promote mobility interventions.2,8 Although progression of mobility activities is challenging, progressive mobility activities are used by ICU nurses and can be implemented independently as well as interdependently.9 Nurses in this study indicated that in-bed and out-of-bed progressive mobility was important to patient care, and neither staff availability nor equipment contributed to decisions about activity implementation. When a protocol was incorporated into care, patients were more likely to experience out-of-bed activity, supporting expert opinion that culture influences mobility interventions in the ICU.10Similar to other reports,11,12 nurses in our study reported decreased consciousness as the most common barrier to progressive mobility in the ICU. Physical therapy consultations were uncommon in this setting, and this finding was not unusual, according to a report13 of the range of physical therapy in ICUs in the United States. Physician prescription for progressive mobility also was uncommon in this setting, but when an order for out-of-bed activity was present, the order facilitated progressive mobility.Equipment to progress mobility appeared to be somewhat underused. For example, we anticipated that the use of a bed with a “true” chair position that allows patients to place feet on the floor to progress to weight-bearing would promote progressive mobility, but it did not. Beds that ease egress from the bed were newly purchased and being used after in-service training in 30 of the 49 patients. Caregivers were able to report the presence of features that facilitated activity, but they may not have acquired a high degree of comfort in using those features.This study suggests that the presence of a protocol can act as a facilitator in implementing progressive mobility and that a culture of valuing activity for patients is important to activity progression.10 Coaching about patient readiness by the research nurse who provided in-bed activity and assisted with out-of-bed activity before and after implementation of the protocol also may have influenced adoption of early, progressive mobility in this setting.In this sample, nurses were unlikely to plan out-of-bed activity among chronically critically ill patients receiving mechanical ventilation. Concerns about patients’ condition, particularly the level of consciousness, stability of vital signs, and respiratory status, were identified as barriers to patient readiness for progressive activity. The presence of both a protocol and a champion (ie, coaching by the research nurse) facilitated increased frequency of out-of-bed activity and established a trend to earlier out-of-bed activity in patients at high risk for prolonged bed rest and the complications associated with inactivity. Results of this study suggest that ICU nurses can successfully initiate early, progressive mobility with limited resources by using a protocol to guide decisions about patients’ readiness for activity.The authors would like to acknowledge Dr Emily Chiou-Fang Liou, project manager, and Drs Daly, Hejal, and Rowbottom, who were coinvestigators in the portion of their study that examined patient-related data. They also thank the ICU nurses who were interviewed.