Comparison of perceptions and barriers to mobilization in critical care: A comparison of nursing staff and physiotherapists — A single-site service evaluation

Introduction: Mobilization is a key component in the recovery of those admitted to critical care. However, previous research has demonstrated challenges in the implementation of mobilization within critical care, including staff knowledge, attitudes, and behaviours. The aim of the current study was to explore the perceived barriers and limitations to mobilization from the perspective of nursing staff, and to compare these with physiotherapists. Methods: Single-site service evaluation utilizing the patient mobilizations attitudes and beliefs survey for ICU and locally developed barriers to rehabilitation questionnaire. Results: About 135 participants (126 nurses and 9 physiotherapists) were invited to anonymously complete the questionnaires (either paper or electronic), with a response rate of 73.0% (n = 92) for nursing staff and 100% for physiotherapists. Nursing staff reported significantly higher perceived barriers to rehabilitation on both questionnaires when compared with physiotherapy staff, which was not associated with years of experience within critical care. Behavioural barriers were most frequent in both professions which included items such as time availability and presence of perceived contra-indications to mobilization. Conclusion: Nursing staff reported greater perceived barriers to rehabilitation when compared with physiotherapists. Further quality improvement projects are now required to reduce these barriers and assist the implementation of mobilization as part of the rehabilitation process.

recovery, guidance is limited on the decision-making process on appropriateness for completing mobilisation within critical care.
Clearly, some barriers to mobilization may be patient related. Stiller  In addition to these patient-related barriers, the perceptions and attitudes of the staff caring for those patients will also influence the occurrence of mobilization, as will institutional/unit cultures. Dubb et al 10 identified 18 unique barriers to early mobility. While 50% of barriers were indeed patient related, the remaining 50% was formed of structural (18%), unit cultural (18%), and process-related barriers (14%). Notably research has also suggested that barriers be more or less present depending on the clinician's profession and may be affected by an individual's years of experience of working within critical care. [11][12][13] Utilizing a validated questionnaire, Goodson and colleagues 11 explored the barriers to mobility in a North American medical ICU. While overall relatively low perceived barriers to patient mobility were identified, behavioural factors such as capacity and concerns around injury (both to staff and patient) were reported most frequently, with nursing staff the most likely to report such barriers.
Within the United Kingdom, several studies have identified that routine involvement of physiotherapists in directing rehabilitation may promote mobilization of critically ill patients, 5,14 however, the reasons for this are not fully understood. Clearly implementing mobilization is key to ensuring return of physical performance. However, gaining knowledge about the barriers and facilitators is key to ensuring the implementation of the existing evidence base.
Within the researchers host organization, patient-related barriers to mobilization from the perspective of physiotherapy staff has previously been explored. 14 Similarly, unpublished service evaluations within the host organization have demonstrated that the vast majority (>96%) of mobilization sessions were completed by physiotherapy staff rather than nursing. However, a detailed exploration of non-patient related barriers has not previously been completed either locally or elsewhere within the United Kingdom from either the perspective of nursing or physiotherapy staff. Clearly other members of the multi-disciplinary team, for example, physicians and occupational therapists may influence the implementation of mobilization. However, previous local service evaluations did not consider these additional stakeholders to have significant impact on the occurrence of rehabilitation, nor should influence the differences between the occurrence of mobilization by either nursing staff or physiotherapy staff.
Based on the above, the aim of the current study was to explore the perceived barriers and limitations to mobilization from the perspective of nursing staff, and to compare these with physiotherapists.
These barriers may be patient related or because of staff knowledge, attitudes, or behaviours. By gaining an understanding of existing barriers, and difference between barriers in nursing and physiotherapy will aid the implementation of vital mobilization or will identify areas for further exploration to reduce/eliminate existing barriers and limitations.

| Design
This single-site project used paper questionnaires based on previous research. 11,14 The questionnaires consisted of quantitative-based questions using a Likert scale, with opportunity for free-text comments and suggestions.

| Participants, centres, and eligibility procedure
All participants were recruited from the Critical Care Unit within a tertiary critical care unit in South Wales. To be eligible for the study, participants must have been registered nursing staff (excluding agency staff) or phys-  The second questionnaire, "Cardiff and Vale UHB barriers to rehabilitation" (Table A2), was based on previous research 5, 14 and explored patient-specific barriers to rehabilitation, for example, physiological and clinical observational barriers. This was a nonvalidated questionnaire and was piloted prior to use. The questionnaire consisted of 26-items and was answered using the same 5-point Likert scale as the previous questionnaire, with the option for free text comments as required. All of the scores for each barrier were combined to provide an overall barrier score ranging from 0 to 100, with higher scores suggesting more perceived barriers. The pilot process involved physiotherapists and practice educator nurses within the host organization. Following the pilot, no modifications were required.
For the purposes of this study, mobilization referred to either sitting the patient on the edge of the bed or getting the patient out of bed with or without mechanical aids.

| Procedure
Following approval from the host critical care unit's service/quality improvement lead, participants were invited to complete the questionnaires electronically via posters within the host critical care unit, private social media accounts, and by word of mouth. Additionally, paper copies of the questionnaires were distributed to staff working within the host unit during a 2-week period in January 2020. An introductory paragraph outlined the project and provided all necessary participant information.
The questionnaires were made available in both electronic and paper format and took no longer than 10 minutes to complete. Paper questionnaires were returned via envelopes located within staff rooms and in a centralized location within the critical care units. As the questionnaires were anonymous it was not possible to send reminders for completion or to identify any staff yet to complete the questionnaire.

| ANALYSIS
Demographic data were collected for profession and years of experience within critical care, as well as response rates. For the PMAB-ICU overall barrier scores and subscales were calculated in accordance with previous literature. 11,12 The overall and subscale score distributions were assessed by discipline using medians (95% confidence intervals), and between profession differences were tested using the Independent-Samples Mann-Whitney U Test. For the nursing staff participants, overall barrier scores and years of experience were compared using Pearson's correlation. All P values are two-sided with values ≤.05 indicating statistical significance. The same process was utilized to analyse the findings of the "Cardiff and Vale UHB barriers to rehabilitation" survey. Data entry and analysis was performed using Microsoft Excel™ and SPSS v25 statistical software (SPSS, Chicago, Illinois).

| Ethics
This project met the definition of a service evaluation under the NHS Health research authority guidelines. As such ethical approval was not required. Consent for involvement was assumed by completion of the questionnaires.

| Demographics
Electronic versions of the questionnaires were completed by 24 nursing staff, with further 102 questionnaires distributed to nursing staff and 9 physiotherapists who were working within the 2-week completion period. Of the 102 paper questionnaires distributed to nursing staff, a total of 68 were returned (combined paper and electronic response rate of 73%) and all nine questionnaires provided for physiotherapists were returned (100% response rate). The average number of years of critical care nursing experience (n = 92, 90.2%) was 6.0 (SD 7.0) years compared with physiotherapists (n = 9, 8.8%) with 3.6 (3.2) years of experience.

| Patient mobilizations attitudes and beliefs survey for ICU
The median (confidence interval [CI]) overall barrier score for nursing staff was 31.5 (30.0-33.8), which was significantly higher than the 20.8 (15.4-26.2) reported by physiotherapists (P = .007) (see Table 1). Significant differences between nursing and physiotherapy staff were also recorded for each of the subscales of knowledge (P = .039), and behaviour (P = .045). Attitude scores were non-significantly different between the nursing and physiotherapy staff (0.088). Average scores for all barrier items are demonstrated in Table A1. For the nursing staff, the higher rated barriers included "increasing mobilisations of patients will result in more work for nursing staff" and "nurse to patient staffing is adequate to mobilise patient on my unit." Conversely, there was strong agreement that staff "believed that my patients who are mobilised at least one daily will have better outcomes" and that "leadership is very supportive of patient mobilisations." Physiotherapy staff reported lower perceived barriers but recognized that "patients often have contra-indications to mobilization." No comments were made by any participants and therefore no qualitative analysis was required.
For the nursing staff, no correlation was observed between perceived barriers and increasing experience of working within critical care (P = .663). Due to the small sample size, the correlation for physiotherapy staff and years of experience was not calculated.

| Cardiff and Vale UHB barriers to rehabilitation questionnaire
Overall barrier scores for nursing staff and physiotherapy staff were 53.1 and 45.4, respectively, suggesting an increase in perceived barriers by nursing staff (P = .024). Individual barrier scores for each profession are shown in Table A2. As with the previous questionnaire, nursing staff tending to score higher for each barrier, however, differences between the professions were less. Of the 26 items, nursing staff and physiotherapy scored the same on 11 occasions, with no average perceived barrier having a greater than 1-point median difference. Of note, weaning/sprinting was perceived as a low barrier as was the presence of an endotracheal tube (ETT), whereas advanced modes of ventilation (APRV and HFOV) were perceived as much greater barriers. As with the PMABs questionnaire, no comments were made by any participants and therefore no qualitative analysis was required (Table 2).
Within in the nursing cohort, there was no correlation between experience of working in critical care and perceived barriers (P = .607) suggesting no difference in perceived barriers with increasing experience.

| DISCUSSION
In this single-site evaluation, utilizing previously developed surveys, nursing staff reported significantly higher perceived barriers to rehabilitation when compared with physiotherapists. These barriers included knowledge, attitudes, behaviours, and patient-specific factors. Within the nursing staff cohort, there was no correlation between years of experience and perceived barriers. The two surveys were completed by 101 healthcare workers from either nursing or physiotherapy professions.

| Patient mobilizations attitudes and beliefs survey for ICU (PMABS-ICU): Survey
In the current service evaluation, the PMABS-ICU survey, demonstrated significant differences between the perceived barriers for nursing staff and physiotherapists. These differences were apparent in all three domains of knowledge, attitudes, and behaviour, as well as in the overall scoring. The greatest difference between the professional groups occurred for knowledge (four questions) which highlighted awareness for appropriate referrals to physiotherapy, occupational therapy, and knowledge of how to mobilize patient's safety. The difference was lowest for behaviours ( For the nursing staff cohort, the current study reported no effect of years of clinical experience on perceived barriers, whereas the previous work demonstrated lower barrier scores with each additional year of work experience during the first 10 years. 11 It could be hypothesized that with increased experience the perceived barriers may reduce but it could also be argued that those working in critical care for longer may be more impacted by historical perceptions of rehabilitation and institutional barriers.  Previous local service evaluations exploring barriers to rehabilitation suggested that sedation was the key barrier to active rehabilitation, followed by invasive neurological management (Intra-cranial pressure monitoring and external ventricular drains) and unstable spinal injuries. 13

| Overall
For both surveys, significant differences were observed between nursing staff and physiotherapist perceptions of barriers and limitations to rehabilitation. These findings are supported by the literature.
Jolley and colleagues 15 explored clinician attitudes and perceived barriers towards early mobilization of critically ill patients. In this crosssectional survey, the authors reported that most multi-disciplinary clinicians are knowledgeable regarding the potential benefits of early mobilisation, but significant barriers remain including concerns around risk to the patient and time considerations. As with the current study, nursing staff reported higher frequencies of perceived barriers including risk of self-injury (71% compared with 41% for physical therapists) and excess work stress (65% and 41% for nursing and physical therapy respectively). Additionally, and in similarity with the current survey, the authors reported no differences with increasing experience of the clinicians involved. This therefore suggests that pre-existing professional or unit culture barriers remain no matter the experience of the clinician.
Anekwe et al 16 also identified differences between different professional groups in terms of perceptions of when to start mobilizations. In their study "interprofessional survey of perceived barriers and facilitators to early mobilisation of critically ill patients in Montreal, Canada," the authors concluded that safety concerns by nursing was rated as a big barrier to early mobilization despite the evidence suggesting that early mobilization is safe and feasible in this patient group. Interestingly, the authors also suggested that this perception may lead to late initiation of mobilization as most other members of the multi-disciplinary team believe that the nurse should be the first to identify when a patient is ready. This likely contrasts with UK practice where therapy staff (eg, physiotherapists) working in conjunction with the rest of the team will make decisions on readiness to start mobilizations.

| Limitations
There were potential limitations to this survey. Firstly, is the use of

| CONCLUSION
Within this single-site study, nursing staff reported significant higher perceived barriers to rehabilitation when compared with physiotherapists.
However, these perceived barriers occurred less frequently than in previously reported research and the barriers did not appear to be influenced by years of experience. Further work is now required to explore improvement projects to reduce these potential barriers both at an individual and critical care unit level. These projects must be multi-disciplinary in nature, focused on increasing staff knowledge and confidence in the implementation of mobilization. This further work should in turn alter the unit wide culture towards mobilization, and enhance in the provision of rehabilitation.

DATA AVAILABILITY STATEMENT
Raw data available by direct request to the corresponding author.

ETHICS STATEMENT
This study constituted an improvement in the standard care delivery with no randomization and thus met the definition of a service evaluation under the NHS Health research authority guidelines. As such ethical approval was not required. Consent for involvement was assumed by completion of the questionnaires.