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Contents lists available at ScienceDirect

Intensive and Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Research article

Identifying barriers to early mobilisation among mechanically

ventilated patients in a trauma intensive care unit
Kari Johnson a,∗ , Jamie Petti b , Amy Olson b , Tina Custer b
a
Honor Health Thompson Peak Medical Center, 7400 E. Thompson Peak Parkway, Scottsdale, AZ, 85255, United States
b
Trauma Intensive Care Unit, Honor Health John C Lincoln Medical Center, 250 East Dunlap Avenue, Phoenix, AZ, 85020, United States

a r t i c l e i n f o a b s t r a c t

Keywords: Mechanically ventilated patients can be at risk for functional decline (Cameron et al., 2015). Early mobil-
Attitudes and beliefs isation of mechanically ventilated patients can improve outcomes after critical illness to prevent this
Critical care decline. Although registered nurses understand the importance of early mobilisation there are nurses
Early mobilisation
who are unwilling to mobilise patients.
Early mobility
Aim: The aim of this study is to examine whether nurses’ attitudes and beliefs are barriers for early
Functional decline
Nurses mobilisation and evaluate whether an education intervention can improve early mobilisation.
Mechanically ventilated patients Method: Pre-test, post-test intervention with registered nurses and charge nurses in a 22 bed trauma
intensive care setting.
Procedure: Pre-test, post-test survey assessed perceived barriers in knowledge, attitudes, and behaviours
followed by targeted education.
Results: Dependent Sample T-test revealed a statistically significant increase in post-test responses for
the subscales knowledge, attitudes, and behaviours with early mobilisation. This over-all increase in
post-test results support that understanding barriers can improve patient outcomes.
Conclusion: Use of structured surveys to identify barriers for early mobilisation among nursing can assist
in providing targeted education that address nurse’s perception. The education intervention appeared to
have a positive impact on attitudes but it is unknown if the difference was sustained over time or affected
participants practice or patient outcomes.
© 2017 Published by Elsevier Ltd.

Implications for Clinical Practice

• Early mobilisation in mechanically ventilated patients has been shown to be both achievable and safe. Despite evidence to support
early mobilisation there is difficulty including this into practice in critical care settings.
• The education intervention appeared to have a positive impact on attitudes, but it is unknown if the difference was sustained over
time or effected the participants practice or patient outcomes.

Introduction et al., 2015). This lack of mobility can lead to decreased mus-
cle strength, increased time of mechanical ventilation (MV), and
Critically ill patients who are hospitalised can experience a increased length of hospitalisation (Roberts et al., 2014). Mobil-
decrease in mobility placing them at a greater risk for functional isation can be defined as a “physical activity sufficient to elicit
decline (Bailey et al., 2009; Jolley et al., 2014; Li et al., 2013; Resnick acute physiological effects that enhance ventilation, central and
peripheral perfusion, muscle metabolism, alertness and are counter
measures for venous stasis and deep vein thrombosis” (Cameron
∗ Corresponding author.
et al., 2015, p. 664). Early mobilisation (EM) can be defined as “phys-
E-mail addresses: [email protected] (K. Johnson),
ical activity within the first two to five days of a critical illness or
[email protected] (J. Petti), [email protected] (A. Olson), injury” (Cameron et al., 2015, p. 664). The Institute for Healthcare
[email protected] (T. Custer). Improvement (IHI), (2012) identified physical deconditioning as a

http://dx.doi.org/10.1016/j.iccn.2017.06.005
0964-3397/© 2017 Published by Elsevier Ltd.

Please cite this article in press as: Johnson, K., et al., Identifying barriers to early mobilisation among mechanically ventilated patients
in a trauma intensive care unit. Intensive Crit Care Nurs (2017), http://dx.doi.org/10.1016/j.iccn.2017.06.005
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risk factor for hospitalised adults and developed a web based course Design
called “Mobility in the Intensive Care Unit” that presented both the
science and strategies for implementing a mobility program for an A pre-test/post-test intervention was chosen to measure nurses’
intensive care setting (IHI, 2012). The European Respiratory Soci- attitudes and beliefs for EM of MV patients to identify barriers
ety and European Society of Intensive Care Medicine Task Force to improve EM. The education intervention comprised of targeted
on Physiotherapy for Critically Ill Patients conducted a literature education that addressed concerns from the pre-test results and
review on the effectiveness of physiotherapy for acute and chronic education on the The Mobilisation of Ventilated Patients Early
critically ill adult patients (Gosselink et al., 2008). Recommen- (M.O.V.E.) protocol. The M.O.V.E. protocol provides safe EM guide-
dations included 1) standardising pathways for clinical decision lines for MV patients through assessing patients to determine the
making and education, 2) definition of a professional profile of appropriate mobility stage utilizing nursing, respiratory/physical
physiotherapy and 3) increased awareness and benefits of preven- therapy (physiotherapy), and occupational therapy assessments
tion and treatment of immobility and deconditioning for critically followed by the exercise intervention. The education was delivered
ill adult patients” (Gosselink et al., 2008, p.1188). The British Asso- by the trauma intensive care unit (TICU) co-investigators for all Reg-
ciation of Critical Care Nurses (BACCN) recommends physiotherapy istered Nurses (RNs) and charge nurses (CNs) employed in the TICU
as a consistent therapy for patients to provide physical activity through walking rounds for both shifts, nursing shift huddles and
for early mobilisation to prevent critical care acquired weakness education poster boards stationed through-out the unit.
(Schweickert et al., 2009; Schweickert et al., 2009; Bailey et al.,
2007). Setting

Background The setting was a 22 bed Trauma Intensive Care Unit at a 266 bed
Level One Trauma Rural Hospital in Central Phoenix, Arizona. The
Studies have been conducted to understand knowledge 22-bed ICU specializes in trauma and neuroscience critical care.
and perceived barriers towards EM in critically ill patients Patients admitted to the ICU are typically involved in a trauma
among healthcare providers (Eakin et al., 2015; Winkelman and and/or suffered from a neurological insult or injury. The unit is
Peereboom, 2010; Jolley et al., 2014; Garzon-Serrano et al., 2011; equipped to deliver care to patients involved in any type of trauma
Hoyer et al., 2015). Jolley et al. (2014) found the majority of nurses, with the most prevalent mechanisms of injury for trauma patients
physical therapists, and physicians understood the benefits of EM being motor vehicle collisions and falls.
and reported acceptance of EM for patients who were MV. Identi-
fied barriers included inadequate staffing and insufficient nursing Participants and sample
time. Eakin et al. (2015) Identified perceived barriers reported
by healthcare participants included increased staff workload and Inclusion criteria included part time and full time RNs and CNs
safety concerns for both the patient and the healthcare provider. employed in the TICU who worked 12 h shifts, either 7 a.m.–7 p.m.
Components identified for a successful EM program included a mul- or 7 p.m.–7 a.m., and who were willing to sign informed consent.
tidisciplinary team approach, opinion leaders, individual discipline Exclusion criteria included RNs and CNs who were not employed
champions, and adequate rehabilitation providers and equipment full or part time in the TICU. A total of 55 registered nurses (RN) and
(Eakin et al., 2015). Reasons for not mobilising patients by nurses charge nurses (CN) were invited to participate in the study with 33
included concerns for patient safety with falls or dislodging tubes who met inclusion criteria and agreed. Of the study sample (31/33)
or lines as reasons for not implementing EM (Winkelman and (94%) were staff nurses and two of the 33 respondents (6%) were
Peereboom, 2010). Nurse barriers included lack of training, lack CNs with two declining to participate.
of comfort, and not having enough time to mobilise patients. The
highest perceived barrier reported by nurses and rehabilitation Instruments and measures
therapists was “more work for the nurses” (Hoyer et al., 2015).
Nurse’s perception of barriers to mobilising hospitalised
Summary
patients were measured using a pre-test/post-test survey. The
Review of the literature identified that EM of MV patients is survey was developed by a multidisciplinary team of two physi-
safe and can improve muscle strength, improve or maintain func- cians, three physical therapists, one occupational therapist, two
tional status, reduce length of MV, and intensive care and hospital administrators and four nurses (Hoyer et al., 2015). Permission to
length of stay (Jolley et al., 2014; Li et al., 2013; Resnick et al., use the survey was obtained from the multidisciplinary team of
2015; Cameron et al., 2015). Even with literature to support this authors who developed the survey (Hoyer et al., 2015). The sur-
intervention, EM does not occur in patients who are intubated vey was designed to assess provider barriers to early mobilisation.
and ventilated (Winkelman and Peereboom, 2010; Eakin et al., Three main categories included barriers related to knowledge (four
2015; Jolley et al., 2014). Identified perceived barriers among crit- items), barriers related to attitudes (nine items), and barriers that
ical care nurses included an established ICU culture where EM influence behaviour (13 items) for a total of 26 items in the sur-
for mechanically ventilated patients is not practiced, increased vey (Hoyer et al., 2015). The knowledge subscale assessed provider
workload (time management), safety concerns for the patient and training and education on mobilising patients. The attitudes sub-
healthcare participant’s, and lack of equipment (Hoyer et al., 2015; scale assessed providers’ lack of agreement, lack of self-efficacy,
Garzon-Serrano et al., 2011; Jolley et al., 2014; Winkelman and lack of outcome expectancy and perceptions of other providers’
Peereboom, 2010, Eikin et al., 2015). attitudes. The behaviours subscale assessed factors and practice
barriers that may prevent the nurse from mobilising a patient
Methods (Hoyer et al., 2015). The survey collected demographic charac-
teristics, including professional discipline, age, years of practice,
Aim education, and shift worked. For all survey items, a 5-point Likert
response scale was used with the following options; 1) strongly dis-
The aim of this study is to examine whether nurses’ attitudes agree, 2) disagree, 3) neutral, 4) agree, and 5) strongly agree (Hoyer
and beliefs are barriers for EM and evaluate whether an education et al., 2015). To create consistency among participants and min-
intervention can improve EM. imise recall error, survey participants were instructed to answer

Please cite this article in press as: Johnson, K., et al., Identifying barriers to early mobilisation among mechanically ventilated patients
in a trauma intensive care unit. Intensive Crit Care Nurs (2017), http://dx.doi.org/10.1016/j.iccn.2017.06.005
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questions that reflected their opinions based on experience dur- All policies, regulations and guidelines set forth by the Research
ing the past one to two weeks. During pilot testing with 82 nurses Integrity and Assurance IRB at Scottsdale Healthcare Research Insti-
and 38 rehabilitation therapists, the Cronbach alpha coefficients of tute were adhered to. Surveys were anonymous and participation
internal consistency reliability were acceptable, at 0.72 or greater was voluntary. Upon publication of any results of this study data
for the overall scores and all subscales (Hoyer et al., 2015). Internal would be reported in aggregate form only so participants’ identity
consistency reliability, item consistency, and discriminant validity would not be revealed.
psychometric characteristics were acceptable (Hoyer et al., 2015).
Results
Procedure
Demographic characteristics
Recruitment and retention
Demographic characteristics for study participants are pre-
Recruitment was conducted by the co-investigators who were sented in Table 1. A total of 66 paired surveys were completed.
employed in the TICU. A study information letter was distributed to A total of 33 participants completed the pre-survey and 33 partici-
RNs and CNs in the TICU by the co-investigators. The study informa- pants completed the post-survey. Many of the participants were in
tion letter stated the purpose of the study, voluntary participation, the category of 25–34 years for age (n = 12, 36%). Ninety-one per-
the ability to decline to answer any particular question, and to dis- cent (n = 30) of participants were RNs. The majority of participants
continue participation without incurring any penalty. Participants fell into the category of Bachelor of Science in Nursing (BSN) for
who met inclusion criteria were asked to participate in the pre- education (n = 32, 97%). The majority of participants had one to ten
test/post-test survey. Education was mandatory for all RNs and CNs years of practice (n = 17, 52%).
as the M.O.V.E. protocol was standard of care for patients who met
critieria for the intervention in the TICU. Participants were given Perceptions of early mobilisation results
two weeks to complete the pre-test survey and to return the pre-
test in the EM return box located in the TICU. Upon completion Table 2 outlines results of the dependent samples T-test to com-
of the pre-test survey, the TICU co-investigators provided targeted pare means from paired pre-test/post-test results. For the question,
education addressing survey results and a review of the M.O.V.E. “I have received training on how to safely mobilise my patients”
protocol for all RNs and CNs employed in the TICU. To determine there was a significant increase in respondents answering “strongly
the effectiveness of the education intervention, study participants agree to agree” post-test education intervention (t-test = −2.317, DF
were asked to complete the same post-test survey which were (32), p = 0.027). For the question, “I understand which patients are
distributed in the same manner as the pre-test survey to study appropriate to refer to physical therapy” there was a significant
participants. increase in participants answering “strongly agree to agree” (t-
test = −2.248, DF (32), p = 0.032) post-test. There was a statistically
Data collection procedures significant increase in participants answering “strongly agree to
agree”, post-test (t-test = −2.620, DF (32), p = 0.013) for the question
Data collection was standardized across intervention and usual
“unless there is a contraindication, I educate my patients to exer-
care conditions for the study and took place in the TICU. Data were
cise or increase their physical activity while on my unit”. Table 3
entered into an electronic medical record (EMR) data base by the
outlines differences between pre-test/post-test results for survey
principal investigator (PI). Data from the EMR were then entered
variables.
into SPSS 23 spreadsheet by the PI.
Table 1
Treatment fidelity
Demographic Characteristics of Study Participants N = 33.

To maintain treatment fidelity and compliance the EM inter- Characteristic Frequency Percentage
vention was a standing agenda item at daily huddles on both shifts Age
for intervention review and clarification. Daily huddles were devel- 18–24 1 3.0%
oped by the unit and consisted of five-minute group meetings led 25–34 12 36.4%
by a nursing supervisor at the beginning of each shift where infor- 35–44 8 24.2%
45–54 6 18.2%
mation important to the daily function of the unit and the network
55–64 6 18.2%
is disseminated.
Education
Data management and analysis Master’s Degree Nursing 3 9.4%
Bachelor’s Degree Nursing 23 71.9%
Associate Degree Nursing 4 12.5%
Data from the survey were coded and analysed using a commer- Diploma Graduate 2 6.2%
cial software package (SPSS version 23.0; Chicago, IL). Statistical
Shift Worked
significance was set at (p < 0.05) for this analysis. Descriptive statis-
07.00-19.00hrs 14 43.8%
tics were used to summarise nursing demographic characteristics 19.00-07.00hrs 18 56.2%
and major variables of interest including age, years of practice,
Health Care Professional
health care profession, education degree and shift worked. Sum-
Registered Nurse 30 93.7%
mary measures of means (M), standard deviations (SD) and degrees Charge Nurse 2 6.3%
of freedom (DF) for variables were examined and described. Depen-
Years of Practice
dent sample T-tests and Chi-square tests were calculated to analyse 1–10 17 56.7%
group differences between mean scores pre-post survey. 11–20 5 16.7%
21–30 3 10.0%
Ethical considerations 31–40 4 13.3%
41–45 1 3.3%
An application to conduct the research study was submitted The survey was developed by a multidisciplinary team of two physicians, three
and approved by the Institutional Review Board (IRB) at Scottsdale physical therapists, one occupational therapist, two administrators and four nurses
Healthcare Research Institute in Scottsdale, Arizona, #770594-1. (Hoyer et al., 2015).

Please cite this article in press as: Johnson, K., et al., Identifying barriers to early mobilisation among mechanically ventilated patients
in a trauma intensive care unit. Intensive Crit Care Nurs (2017), http://dx.doi.org/10.1016/j.iccn.2017.06.005
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Table 2
Results of the dependent samples t-test to compare means from paired pre-post survey results.

Dependent Sample Statistics

Pre Survey Post Survey

Variable n M SD n M SD

I’ve received training to mobilise patients 33 1.70 0.637 33 2.18 1.2

I understand which patients are appropriateto refer to occupational therapy 33 1.55 0.564 33 1.91 0.7
I educate patients to exercise or increase physical activity 33 1.36 0.489 33 1.76 0.7
Leadership is supportive of patient mobilisation. 33 1.45 0.794 33 3.15 1
My patients are resistant to mobilisation. 33 2.85 0.939 33 3.39 0.9

Source; Hoyer et al. (2015).

Table 3
Differences between pre-post results for survey variables with statistically significant differences between pre-post results.

Paired Sample T-test

Variable T-test DF Sig.(2 tailed)

I have received training to safely mobilise patients. −0.059 32 0.027

I understand which patients are appropriate to refer to occupational therapy. −2.248 32 0.032
I educate patients to exercise or increase physical activity. −2.620 32 0.13
Department leadership is very supportive of mobilisation. −7.880 32 <0.001
My patients are resistant to mobilisation. −2.608 32 0.014

Source: Hoyer et al. (2015).

Discussion ence was sustained over time or affected participants practice or

patient outcomes.
Despite literature that validates the safety of EM there are
healthcare providers who hesitate to mobilise patients. A review of Appendix A. Supplementary data
the literature identified nurse barriers for EM included increased
workload (time management), lack of training, safety concerns Supplementary data associated with this article can be found, in
for the patient and healthcare participant’s, and lack of equip- the online version, at http://dx.doi.org/10.1016/j.iccn.2017.06.005.
ment (Hoyer et al., 2015; Garzon-Serrano et al., 2011; Jolley et al.,
2014; Winkelman and Peereboom, 2010, Eikin et al., 2015). Iden- References
tifying perceived barriers among critical care nurses for EM for
mechanically ventilated patients can assist in the design and imple- Bailey, P.P., Miller III, R.R., Clemmer, T.P., 2009. Culture of early mobility in mechan-
ically ventilated patients. Crit. Care Med. 37 (10), S429–S435.
mentation of an adequate educational intervention to meet the Cameron, S., Ball, I., Cepinskas, G., Choong, K., Doherty, T., Ellis, C.G., Martin, C.M.,
concerns that nurses have in safely mobilising patients. Mele, T.S., Sharpe, M., Shoemaker, J.K., Fraser, D.D., 2015. Early mobilization in
A targeted education intervention for EM revealed a significant the critical care unit: a review of adult and paediatric literature. J. Crit. Care 30,
664–672.
increase in post-test responses for the subscales knowledge, atti-
Eakin, M.N., Ugbah, L., Arnautovic, T., Parker, A.M., Needham, D.M., 2015. Imple-
tudes, and behaviours with EM. This over-all increase in post-test menting and sustaining an early rehabilitation program in a medical intensive
results support that understanding barriers to EM can improve care unit: a qualitative analysis. J. Crit. Care 30 (4), 698–704.
patient outcomes. Garzon-Serrano, J., Ryan, C., Waak, K., Hirschberg, R., Tully, S., Bittner, E.A.,
Eikermann, M., 2011. Early mobilization in critically ill patients: patients’ mobi-
lization level depends on health care provider’s profession. PM & R 3 (4),
307–313.
Limitations
Gosselink, R., Bott, J., Johnson, M., Dean, E., Nava, S., Norrenberg, M., Schonhofer, B.,
Stiller, K., van de Leur, H., Vincent, J.L., 2008. Physiotherapy for adult patients
A potential limitation with this study may be the relationship with critical illness: recommendations of the european respiratory society and
european society of intensive care medicine task force on physiotherapy for
between the co-investigators and the nursing staff as they were
critically ill patients. Intensive Care Med. 34, 1188–1199.
employed in the TICU and worked together. This may have influ- Hoyer, E.H., Brotman, D.J., Chan, K.S., Needham, D.M., 2015. Barriers to early mobility
enced survey results. Survey results may be unique only to the TICU of hospitalized general medicine patients: survey development and results. Am.
as all participants were employed in the TICU. Another potential J. Phys. Med. Rehabil. 94 (4), 304–312.
Institute for Healthcare Improvement (2012). Retrieved November 2016,
limitation is for further psychometric evaluation of the survey to http://www.ihi.org/education/WebTraining/Expeditions/MobilityintheICU.
support and expand the results presented, including further eval- Jolley, S.E., Regan-Baggs, J., Dickson, R.P., Hough, C.L., 2014. Medical intensive care
uation of its validity, test-retest reliability, and responsiveness to unit clinician attitudes and perceived barriers towards early mobilization of
critically ill patients: a cross-sectional survey study. BMC Anesthesiol. 14 (1),
change (Hoyer et al., 2015). Another limitation with this current 84.
study is a different setting compared to a previous study where the Li, Z., Peng, X., Zhu, B., Zhang, Y., Xi, X., 2013. Active mobilization for mechani-
same survey tool was used; which could affect generalisability of cally ventilated patients: a systematic review. Arch. Phys. Med. Rehabil. 94 (3),
551–561.
results. Resnick, B., Galik, E., Wells, C.L., Boltz, M., Holtzman, L., 2015. Optimizing physi-
cal activity among older adults post trauma: overcoming system and patient
challenges. Int. J. Orthop. Trauma Nurs. 19 (4), 194–206.
Conclusion Roberts, M., Johnson, L., Lalonde, T., 2014. Early mobility in the intensive care unit:
standard equipment vs. platform. Am. J. Crit. Care 23 (6), 451–457.
Use of structured surveys to identify barriers for EM among Schweickert, W.D., Pohlman, M.C., et al., 2009. Early physical and occupational ther-
apy in mechanically ventilated, critically ill patients: a randomized controlled
nursing can assist in providing targeted education addressing trial. Lancet 373, 1874–1882.
nurse’s perception for EM. A protocol for early mobility can guide Winkelman, C., Peereboom, K., 2010. Staff-perceived barriers and facilitators. Crit.
the intervention for EM. The education intervention appeared to Care Nurse 30 (2), S13–6.
have a positive impact on attitudes but it is unknown if the differ-

Please cite this article in press as: Johnson, K., et al., Identifying barriers to early mobilisation among mechanically ventilated patients
in a trauma intensive care unit. Intensive Crit Care Nurs (2017), http://dx.doi.org/10.1016/j.iccn.2017.06.005