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Contents lists available at ScienceDirect

Australian Critical Care journal homepage: www.elsevier.com/locate/aucc

Research paper

Barriers and facilitators to early mobilisation in Intensive Care: A qualitative study Elizabeth A. Barber B. Physiotherapy (Hons) a , Tori Everard B. Physiotherapy a , Anne E. Holland PhD a , Claire Tipping B. Physiotherapy (Hons) a , Scott J. Bradley PhD a , Carol L. Hodgson PhD b,a,∗ a b

The Alfred, Australia Australian and New Zealand Intensive Care Research Centre, Monash University, Australia

article information Article history: Received 18 August 2014 Received in revised form 24 November 2014 Accepted 27 November 2014 Available online xxx Keywords: Mobility Rehabilitation Intensive Care Unit Barriers Facilitators

a b s t r a c t Objectives: To determine the barriers and facilitators of early mobilisation in the Intensive Care Unit. Background: It is well established that mobilising critically ill patients has many benefits, however it is not occurring as frequently as expected. The causes and ways to change this are not clearly understood. Methods: A qualitative descriptive study involving focus groups with medical, nursing and physiotherapy clinicians, from an Australian quaternary hospital Intensive Care Unit. Results: The major themes related to barriers included the culture of the Intensive Care Unit; communication; and a lack of resources. Major themes associated with facilitating early mobilisation included organisational change; improved communication between medical units; and improved resources. Conclusions: Early mobilisation was considered an important aspect of critically ill patient’s care by all clinicians. Several major barriers to mobilisation were identified, which included unit culture, lack of resources, prioritisation and leadership. A dedicated mobility team led by physiotherapists in the ICU setting could be a viable option to address the identified barriers related to mobility. © 2014 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

1. Introduction It is now well established that mobilising critically ill patients in the Intensive Care Unit (ICU) is safe and may improve functional outcome.1–3 It may assist with earlier weaning of mechanical ventilation1,4,5 and its associated morbidities, thus improving patients’ quality of life.6 Despite this, mobilising patients in the ICU is not occurring as frequently as expected. Previous studies in Australian ICUs found

Abbreviations: ICU, Intensive Care Unit; M, medical; P, physiotherapy; N, nursing; ETT, endotracheal tube. ∗ Corresponding author at: Australian and New Zealand Intensive Care Research Centre, Epidemiology and Preventative Medicine, Monash University, Australia. Tel.: +61 3 9903 0598; fax: +61 3 9903 0071; mobile: +61 448 674 532. E-mail address: [email protected] (C.L. Hodgson).

that only 54% of all patient days involved mobility.7 Of those receiving mechanical ventilation, 95% are not mobilised within the first 72 h.7 Importantly, there is potential for these numbers to be greatly improved with simple management changes, such as changing the site for vascular access and improved timing of procedures.6 A point prevalence study completed in 2009–2010 observed mobilisation practices in 38 ICUs in Australian and New Zealand on a specific day. This showed that of 498 patients included in the study, 19% sat on the edge of the bed and 18% walked, however no mechanically ventilated patients sat out of bed or walked. The authors concluded that mobilisation practices in Australian ICUs were low.7 There remains a paucity of data to explain why studies supporting early mobility in ICU are not being translated into practice. A previous qualitative study has shown that the presence of a protocol and a champion facilitates mobility in ICU, however this was conducted in centres without physiotherapist involvement and only examined nursing staff attitudes.8

http://dx.doi.org/10.1016/j.aucc.2014.11.001 1036-7314/© 2014 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

Please cite this article in press as: Barber EA, et al. Barriers and facilitators to early mobilisation in Intensive Care: A qualitative study. Aust Crit Care (2014), http://dx.doi.org/10.1016/j.aucc.2014.11.001

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This study aimed to examine the main barriers and facilitators to mobilisation in ICUs, to inform strategies for better practice. The research questions for this study were: 1. What are the barriers to and facilitators of early mobilisation? 2. Are these issues similar or different amongst different clinician groups in the ICU? 2. Methods 2.1. Design The aims of this study were addressed using qualitative descriptive research methods.9 Qualitative research seeks to understand human experience and perceptions.10 Participants were identified and recruited using purposeful sampling by a clinical researcher (EB) from the ICU at the Alfred Hospital, Melbourne. Purposeful sampling is the process of identifying participants who appear to be valuable sources of information, as opposed to a random sample.10 We opted to recruit participants who not only fitted the inclusion criteria below, but who we believed would be able to openly discuss the challenges associated with delivering early mobilisation in the ICU setting. Focus group sample size was determined by current literature which suggests 6–12 participants per group.11,12 These numbers are suggested as they are optimal for facilitating effective discussion.11,12 Three separate focus groups were conducted (one each for medical, nursing and physiotherapy participants). This was done to reduce potential bias and influence on participants from different areas of expertise. Ten general questions were developed to guide the focus groups and to ensure that all three groups discussed similar topics (Appendix 1). However each facilitator allowed the discussion to develop depending on the participants, therefore giving scope for other areas to be discussed. All focus groups were digitally recorded and continued until the ten questions were discussed and participants had no new information to add. Two separate researchers conducted the focus groups to reduce the potential for bias. Researchers also made observational notes during the focus groups that were added to the data pool. Demographic data were collected at the time of the focus group from all participants regarding work discipline, years of clinical experience and years of ICU specific experience. Ethics approval for the project was granted from the Alfred Hospital Ethics Committee, Melbourne, Australia. Verbal informed consent was obtained from each subject prior to the commencement of each focus group. Responses were transcribed verbatim. 2.2. Characteristics of setting, participants and facilitators Participants were recruited from an Australian quaternary hospital with an ICU capacity of 45 beds and over 2000 admissions per year. Medical, nursing and physiotherapy clinicians were recruited. Participants were required to have greater than one year experience and work in the ICU environment. Potential participants were identified by the researches and were contacted via group email with an invitation to attend the focus group. Focus groups were conducted by two separate researchers, with clinical and research ICU experience. The facilitators may have known some of the participants in the focus groups; however they were not currently working with the participants. 2.3. Data analysis The data were analysed using qualitative content analysis methods. Qualitative content analysis is a dynamic form of analysis,

utilising all available data. It involves the simultaneous collection and analysis of data.9 The focus groups were conducted, and then transcribed. Each participant was assigned a code number for transcription and quotation to ensure de-identification of data. The data analysis process was completed independently by two researchers (CH and EB). This involved listening to audio, reading and re-reading transcripts and re-listening to the audio until the researchers had become familiar with the data and had reached a state of immersion in the data. Data were then analysed using line-by-line analysis and assigning codes to key thoughts and ideas which arose from the data. The codes were then organised into themes and categories which correctly reflected the data being analysed. The points of view of the participants during the focus groups were closely considered during the analysis process, and respected by linking key quotes with emergent themes and categories. The two independent researchers then met to discuss the findings and were in agreement with the themes and categories identified. 2.4. Trustworthiness and rigour There are four components to trustworthiness in qualitative research; credibility, transferability, dependability and confirmability.13 To enhance credibility the data were analysed independently by two researchers (CH and EB). Transferability was addressed by clearly outlining the data collection process, providing key descriptive information regarding the participants and detailed information regarding the data analysis process. This would allow the study to be completed in other similar or different population groups. Dependability of the results was improved by use of quote to back up each theme and sub categories. Confirmability of the results was enhanced by using two independent researchers to analyse the data and line-by-line coding was completed numerous times. Member checking was also completed, whereby the participants were sent the key themes and subcategories for review, this showed that all members agreed with the emergent themes and sub categories. Rigour in qualitative descriptive research is enhanced by four further components, authenticity, credibility, criticality and integrity.14 Authenticity was addressed by allowing and observing the participants speaking freely on all topics during the focus groups, using purposeful sampling and by conducting focus groups which tend to diminish the role of the researcher. Credibility was enhanced by using current ICU clinical staff which ensures an insider perspective is gained and criticality by critically reflecting on each research decision. Integrity was addressed by minimising researcher bias (two research completing focus groups and data analysis) and completing member checking. 3. Results A total of 25 ICU clinicians were included in the study. Three focus groups were conducted one for each discipline, medical (n = 12), nursing (n = 6) and physiotherapy (n = 7). Participants’ demographic data are outlined in Table 1. During each focus group Table 1 Demographic data.

N Age (years), mean (range) Male n, % Years of clinical experience, mean (range) Year of ICU experience, mean (range)

Medical

Nursing

Physiotherapy

12 47.4 (32–65) 11 (92) 23.3 (9–57)

6 34.8 (29–48) 2 (33) 9.3 (3–12)

7 31.9 (22–42) 1 (14) 7.5 (1–16)

6.6 (1–15)

4.6 (1–14)

16.5 (4–33)

Please cite this article in press as: Barber EA, et al. Barriers and facilitators to early mobilisation in Intensive Care: A qualitative study. Aust Crit Care (2014), http://dx.doi.org/10.1016/j.aucc.2014.11.001

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ten key areas were discussed. There was variability in the clinician’s age and level of experience. The facilitator of each focus group observed an appropriate level of open and detailed discussion by all participants on the barriers and facilitators to early mobilisation and observed no bias related to influence by the other members in the focus group or the facilitators. The data from the focus groups were analysed and three key themes emerged related to barriers to mobility and three key themes related to facilitators. The key themes and their subcategories are discussed below. All the themes which emerged during data analysis were raised by all groups of clinicians; however there was some variability in relation to the subcategories raised by each group. Tables 2 and 3 outline the themes and subcategories and the clinicians who raised them.

3.1. Major themes associated with barriers to mobility 3.1.1. Theme 1: culture All discipline groups identified that there were barriers to mobilising critically ill patients that related to the culture of the unit. Despite acknowledging that the presence of an endotracheal tube (ETT) was not a contraindication to mobility, it was perceived as a barrier by many participants: I think it’s the culture of the unit as I have worked in other units where we would get patients sitting in chairs with ETTs. (M) Patients with ETTs sometimes get put in the pink [ICU rehabilitation chair], but not mobilised all that often. (N) Two of the groups (N and P) stated that the sedation practice of the unit prevented mobilising patients:

Table 2 Themes related to barriers to mobilisation identified by each focus group. Major themes Culture Endotracheal tube Sedation Lines Low priority Communication Identifying and contacting the appropriate people Lack of accountability Not enough resources Staffing Equipment Training Increased effort and burden

Medical

Physiotherapy

Nursing

Yes No No No

Yes Yes Yes Yes

Yes Yes Yes Yes

No

Yes

Yes

Yes

No

No

Yes No No Yes

Yes Yes Yes Yes

Yes Yes Yes Yes

Table 3 Themes related to facilitators to mobilisation identified by each focus group. Major themes Organisational change Standard care Mobility team Liaising with medical teams Multi-disciplinary team planning Follow-up failures Involving patient family Leadership Mobility champion Senior level support Adequate resources Higher staffing levels More equipment More training

Medical

Physiotherapy

Nursing

Yes Yes No Yes Yes No

No Yes Yes Yes No Yes

Yes Yes No Yes No No

Yes Yes

No Yes

No Yes

Yes No Yes

Yes Yes Yes

Yes Yes Yes

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I think it’s culture. The culture of the way we use sedation. Years ago we used to use intermittent diazepam and morphine. And there was also a culture at that time where we did get patients out of bed and sitting up. . ..But now we have continuous infusions of propofol and whatever else and we don’t seem to be able to do it. (N) There’s too much opioids, they’re too drowsy and you know their gait is going to be affected so it’s not as likely we’ll try. (N) The presence of unnecessary lines and location choice of lines limiting mobility was raised by two of the groups (N and P): We could take lines out of patients much earlier than we traditionally have. (N) The position of certain lines is frustrating, for example when the vascaths have been inserted femorally and you are ready to start them sitting, it’s just basic planning. (P) Two of the groups (N and P) reported that mobility was low on their list of priorities in the ICU: I think the tone of this prioritisation suggests that we are all bubbling away under there thinking that we should be mobilising these patients more. But we have prioritised it lower than perhaps other things. (N) 3.1.2. Theme 2: communication All groups reported that they found difficulties in communication amongst staff hindered patients’ mobility. This was associated with being able to both identify and contact the appropriate people necessary to allow mobility: I would say that often just chasing up orders and restrictions and finding the right people and getting hold of them in order to safely mobilise a patient. (P) One group (M) felt that a lack of communication and accountability meant that mobility orders were not carried through: I know I have asked to have a patient ambulating and I know others have as well and it doesn’t actually happen. You can write it on the chart and say let’s do it but it doesn’t actually happen. (M) 3.1.3. Theme 3: lack of resources All groups identified that mobilising critically ill patients was resource intensive and limited the ability to perform it. In particular a lack of staffing, particularly skilled staffing, was identified as a barrier: In the end sometimes they’re just left in bed because I can’t get a second pair of hands. (P) We have 30 something patients to mobilise, and only 3 physios then logistically it’s not ever going to work. (M) A lack of, or inappropriate, equipment was identified by both the nurses and physiotherapists: Is the patient actually appropriate, do I have the right resources, do I even have the right bed available? I recently had a patient who was ready to start sit to stand practice but the bed was way too high. It took two days to get them transferred onto a different bed. (P) Limited staff training for safety parameters, manual handling, equipment use and patient specific precautions and limitations were identified by the nursing and physiotherapy clinicians: I think for me it’s very overwhelming going into ICU in the first place . . .I knew that I wasn’t allowed to move the patient if this line was in, but I had no idea what it looked like so training was really important for that. (P)

Please cite this article in press as: Barber EA, et al. Barriers and facilitators to early mobilisation in Intensive Care: A qualitative study. Aust Crit Care (2014), http://dx.doi.org/10.1016/j.aucc.2014.11.001

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We just sort of wing it. Our back smart training is only about how to move someone in the bed or use the hoist, it’s not about how to get someone up or sit on edge of bed. (N) All groups felt that the increased effort and burden of work associated with moving patients was a barrier to mobility: We need to recognise that there is a degree of additional work that is associated with sitting patients out. (M) 3.2. Major themes associated with facilitators to mobility

So if you ask for it and it doesn’t happen you need to escalate it and made sure you follow it though. (M) Involving patient families in the early phases of rehabilitation was identified as being rewarding and encouraging and had the propensity to increase mobilisation levels: It’s very encouraging to the family to see that sort of a normal activity starting to be re-established. Everything else can be quite overwhelming and terrifying to them, so to see their loved one starting to sit, starting to stand, walk that’s very encouraging. (P)

All groups identified factors that enabled and encouraged mobilisation of critically ill patients. When answering the question “If you could change one thing to improve mobilisation rates in your ICU, what would you do?” all groups stated that increasing staff resources dedicated to mobilisation would increase the rate of patient mobilisation in ICU. They also provided suggestions of how to further improve levels of mobility in the ICU.

3.2.2. Theme 2: leadership Strong leadership and prioritisation of mobility from all staff, in particular senior staff, was identified as necessary by all groups. The need for a ‘champion’ of mobility was particularly identified by one group (M):

3.2.1. Theme 1: organisational change Two groups (M and N) identified that making daily mobility the standard of care, with exceptions only for patients with true contraindications, would raise levels of mobility:

The importance of senior level support was identified by all groups, with an emphasis on promotion of mobility from the top down:

It should be the assumption that everyone should be just automatically sitting out of bed awake and ambulating, and then you have to default out of that. So unless you opt out, then you would be expected to be awake and alert, SOOB and standing up. . .. If you make it the default that you do that, and then you have to have a reason for not doing it. (M) With the longer term patients the physio makes a daily routine and sets goals. If it’s in the daily routine that the patient needs to walk 20 m every 2 hours or whatever then it would be done. (N) The suggestion of a ‘mobility team’ or dedicated time and resources to carry out the treatment was raised by all groups: Even if you had like a walking round, where people spent 2 hours in the morning cruising around like we do with turns then we could just ambulate 10 m each way with each patient. You’d have 2 extras coming in plus yourself if would be so easy. And then you could just do it there is no fuss then. (N) Mobility leadership team combined with clinical education. (M) Good liaising with multiple medical parent teams (e.g. trauma, orthopaedics, plastics) was identified by one group (P): I think that’s a really important role of what we do down there. That we do coordinate all those people together and often you are that go-between person but I think that’s a really important role. (P) Multi-disciplinary team planning was identified by all groups as being important to develop daily goals and combine functional activities: We need to set up a process where we can identify who needs to mobilise early. (M) I think it’s functional, and so therefore perfect, how about I get in there and I can help you with that transfer but also at the same time they’re doing something it’s very important for their nursing care but very good for the patient’s psychological state. So I think combining our exercise therapy with something functional is often the best way. (P) One group (M) identified that when mobility orders are not carried out, further communication and follow-up with the team is required:

You need a champion of the mobilisation. Which is best a physiotherapist actually. (M)

With this proposed culture change would need to come acceptance of a degree of risk with doing this, such as extubation and that we as a group realise that it does take a degree of work and effort. It needs to be shared. (M) It requires demonstrating to the whole group, nurses, doctors and physios that there might be an associated risk but we don’t think its high and it should still be done. (M) 3.2.3. Theme 3: resources Adequate resources and training were identified by all groups as being necessary to increase mobility levels. Higher staffing numbers were raised by all groups: If you have enough people you can have someone following with a wheelchair and just plonk them down if there is an issue. I don’t think the equipment is such a big problem it’s just the physically getting everyone in one place and one time. (P) Having adequate equipment to aid mobility was identified by two groups (P and N): Even having a permanent monitor down in the window bay there. You could walk along with a little “pleth” then plug them into a big monitor when you get there. . . . It’s just little things like that I think would make life a bit easier. (N) The importance of training was raised by all groups: I think if you taught people how to do it they would be more inclined to do it as opposed to just having to think it through yourself. (N) 4. Discussion This unique study examined multi-disciplinary clinical staff perceptions of barriers and facilitators to mobility in the ICU setting using qualitative research methods. All groups supported the use of early mobility in the ICU where contraindications were not present. Three key themes emerged regarding barriers to mobilisation: culture, communication and lack of resources. Three key themes identified as mobility facilitators were: organisation change, leadership and improved resources. Group discussions generated numerous suggestions to overcome perceived barriers and how to support the further use of mobility in treating patients with ICU acquired weakness. A clear relationship emerged between the barriers and facilitators to mobilisation during the study. The

Please cite this article in press as: Barber EA, et al. Barriers and facilitators to early mobilisation in Intensive Care: A qualitative study. Aust Crit Care (2014), http://dx.doi.org/10.1016/j.aucc.2014.11.001

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three key themes which emerged as facilitators specifically address each of the barriers identified by the groups. The themes which emerged from the study were apparent in each of the focus groups. There was some discrepancy in the subcategories raised by each discipline; this was expected due to the differing role of each discipline in regards to mobility.15 The main differences apparent in the subcategories raised by each group in this study appeared to be task related i.e. the nurses and physiotherapists, who commonly deliver early mobility, reported barriers which related to the practicalities of early mobility, whilst the doctors reported barriers which included leadership and accountability. This provides a multi-disciplinary perspective of the barriers and facilitators to mobility in the ICU setting. These results differ from a recent observational study that reported data from mobility interactions with patients and found that nurses reported barriers specifically relating to haemodynamic instability and renal replacement therapy whereas physiotherapists reported barriers including neurological impairment as a main barrier.14 This study was unique in its use of qualitative research principles to explore the issue of mobility in the ICU. Many quantitative studies have explored the benefits,1,16,17 safety18–20 and barriers to mobilisation,15,21 however few studies have explored clinicians’ perceptions and experiences related to mobility in ICU. Therefore the results of this study provide a unique insight into early mobility to complement the current literature. The culture of an ICU, specifically the management practices, emerged in this study as being a potential barrier to patient mobility. This was particularly related to practices such as ETT management, sedation, line placement and removal, and prioritisation that may be negatively impacting on patient mobility levels. This occurred despite previous studies showing that mobilising patients with an ETT is safe, resulting in less than a 1% chance of an adverse event occurring.1,6,12 In addition, less sedation and more sedation breaks combined with mobility have been shown to improve patients’ functional ability and may reduce their length of mechanical ventilation.1 It also improved the psychological outcomes of patients with a shorter duration of delirium.1 A recent point prevalence study of mobility in ICU completed across Australia and New Zealand showed that out of 498 mobility episodes only 25% of patients stood and 18% mobilised. No patient on mechanical ventilation sat out of bed or walked.7 This proves that despite evidence on safety of early mobilisation low mobility rates exists in ICUs across Australia and New Zealand, and therefore it is possible that the cultural problems identified in this ICU are consistent with other ICUs across Australia and New Zealand. Cultural change is inherently difficult to achieve, however studies have suggested that reorganising management practices that interfere with mobility, developing strategies to improve teamwork and linking interventions with patient-centred outcomes facilitate mobility in the ICU.5,17 Critical to this is team members identifying and agreeing upon a need to change clinical practice and collective ownership over the ideas developed.15 This has been demonstrated with structured quality improvement frameworks showing success in achieving cultural change in ICUs.5,17 This involves envisioning the problem within the larger healthcare system and engaging collaborative multi-disciplinary teams. The ‘4E’s approach’ is also utilised: engage, educate, execute and evaluate and has demonstrated reductions in central line associated blood stream infections within the ICU setting.22 More recently these structured quality improvement approaches designed to change unit culture have been successfully translated into reducing deep sedation and its associated delirium, improving rehabilitation and patient mobility.23 Multi-disciplinary team planning and organisation combined with strong leadership were seen by all groups as vital to increase mobility levels. This is consistent with previous studies which have

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indicated that a multi-disciplinary approach is critical to ensuring best patient outcomes.21,24 The importance of physiotherapy leadership within this team is integral in improving rates of mobility and generating higher levels of function by patients.15 However physiotherapists are often treating assigned patients and then leaving the ICU to treat in other areas of the hospital. This can result in a fragmented delivery of service.3 Increasing physiotherapy staffing levels within ICUs has been shown to improve patient mobility and reduce length of stay.19,25 Uniquely, we identified that within the ICU, there is inadequate staff to safely perform mobilisation out of bed, even with physiotherapists in the ICU. The implementation of a new staff member dedicated to ICU mobilisation, such as an allied health assistant, may improve the rates and amount of mobilisation. The allied health assistant is a cost-effective employee who would be able to prepare the environment and equipment, and be specifically trained to assist the physiotherapist and bedside nurse with ICU mobilisation. A novel suggestion was the inclusion of family support and encouragement towards facilitating mobilisation levels in the critically ill. The integration of family into a caregiving role in the ICU has been previously described and supported.26 It seems plausible that by families performing and encouraging supervised exercises the patient will have more opportunities to participate in mobility practice. Making mobility routine through the use of early mobility protocols has been shown to reduce critical illness morbidity. In this system, daily assessments by the nursing and multi-disciplinary team determine protocol administration. Studies suggest that the development of patient population specific inclusion and exclusion criteria increases adherence to the protocol.19 Such a protocol addresses the concerns of low prioritisation and poor communication by ensuring daily review. This is consistent with the suggestion of an ‘opt out’ system of mobility by the medical clinicians in our study. The presence of a dedicated mobility team within the ICU has been shown previously to be the strongest predictor of ambulation in the ICU.19 Team decision making has been demonstrated to contribute to cultural change in other ICU quality improvements.27 All groups identified adequate training as essential to overcome the difficulties of mobilising patients who are critically ill. Small group training sessions have been shown to be effective to integrate new mobility practices in the ICU and are supported by research previously conducted in translating evidence into practice.28 The overarching suggestion by all three groups to facilitate mobility in the ICU was the implementation of a dedicated ICU mobility team, lead by an experienced physiotherapist, with input from the nursing team and medical teams and using an allied health assistant. The implementation of such a team would address numerous barriers relating to resources, accountability, prioritisation of mobilisation, training, communication and senior support. It would ensure that staff with specific experience and skills related to mobility were dedicating time and resources to mobilising patients in the ICU. This would aim to address the low mobility rates in the ICU identified by Berney et al.,7 and provide patients with the benefits of early mobility. A key strength of this study was the inclusion of medical, nursing and physiotherapy disciplines to gain a thorough understanding of current practice within our unit. This allowed for big picture ideas and organisational planning, as well as the day to day patient management details to be discussed. A limitation of this study was its single-centre design which reduces the external validity, as these findings may not reflect the culture of other ICU settings. Early mobilisation was considered to be an important aspect of the care of critically ill patients in the ICU by all members of the multi-disciplinary team. There were several major barriers to mobilisation identified, which included unit culture, lack of resources, prioritisation and leadership. This study also identified

Please cite this article in press as: Barber EA, et al. Barriers and facilitators to early mobilisation in Intensive Care: A qualitative study. Aust Crit Care (2014), http://dx.doi.org/10.1016/j.aucc.2014.11.001

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several changes that could be made to facilitate early mobilisation in ICU, including strong leadership, family involvement, dedicated staff time and resources to conduct mobilisation activities, improved communication between medical units involved in the care of the ICU patient and follow-up within the ICU when mobilisation activities are planned but not executed. A dedicated physiotherapy lead mobility team in the ICU setting could be a viable option to address the identified barriers related to mobility. Authors’ contributions EB, TE and CH conceived of the study, collected data, analysed the data, interpreted the data and wrote the manuscript. AH, CT and SB advised on data analysis and critical input into the manuscript writing and completion. All authors approved the final version of the paper and are entitled to authorship as listed authors. Appendix 1.

7.

8. 9. 10. 11.

12. 13. 14. 15.

16.

Questions 17.

1. Describe the current practice of mobilisation in your ICU. 2. Is it a priority? 3. Other than the direct effect on the patient, what else can be affected by mobilisation? 4. Do you think there are any other benefits or negatives? 5. What kind of factors influence your decision whether or not to mobilise a patient? 6. Have you experienced any difficulties or conflicts with regard to mobilising patients in ICU? 7. How important do you feel is it to receive education and training with regard to mobilisation in ICU? 8. Who would normally organise your training? 9. In your opinion, what is the main barrier to mobilisation in ICU? 10. If you could change one thing to improve mobilisation rates in your ICU, what would you do?

18.

19.

20.

21.

22.

23.

References 1. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373(9678):1874–82, http://dx.doi.org/10.1016/s0140-6736(09)60658-9. 2. Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest 2013;144:825–47. 3. Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA 2008;300:1685–90. 4. Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med 2013;41:1543–54. 5. Engel HJ, Needham DM, Morris PE, Gropper MA. ICU early mobilization: from recommendation to implementation at three medical centers. Crit Care Med 2013;41:S69–80. 6. Combes A, Costa MA, Trouillet JL, Baudot J, Mokhtari M, Gibert C, et al. Morbidity, mortality, and quality-of-life outcomes of patients requiring

24.

25.

26. 27.

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Please cite this article in press as: Barber EA, et al. Barriers and facilitators to early mobilisation in Intensive Care: A qualitative study. Aust Crit Care (2014), http://dx.doi.org/10.1016/j.aucc.2014.11.001