Nurses' perceptions of barriers to mobilizing intubated patients receiving mechanical ventilation

Concerns about safety, competing priorities and uncooperative patients were among the barriers identified by critical care nurses for not mobilizing intubated patients receiving mechanical ventilation, according to a study published in American Journal of Critical Care.

"Nurses' Perceptions of Barriers to Out-of-Bed Activities Among Patients Receiving Mechanical Ventilation" explores the mobility practices of critical care nurses in a 56-bed medical intensive care unit (MICU) at Yale New Haven Hospital in Connecticut. Without a designated mobility team for the unit, efforts to get patients out of bed are integrated into nurses' individual patient care responsibilities.

Participating nurses were interviewed at the end of their shifts about mobility practices for their intubated patients who met specific mobility criteria. Interviews were completed with 48 nurses, with corresponding data for 105 adult patients.

Although all 105 patients met early mobility criteria within eight to 173 hours after intubation, none were mobilized for out-of-bed activities. For the study, the definition of mobility was narrowed to nurse-initiated interventions that helped patients get out of bed to stand, sit in a chair or walk, excluding range-of-motion exercises or in-bed activities.

Patients were deemed ready to begin mobility activities within a mean of 41.5 hours after oral endotracheal intubation. The authors believe the study is the first to report how soon patients were in stable-enough condition after intubation to begin out-of-bed activities based on a defined set of early mobility parameters.

Creating a unit culture that embraces early mobility practices requires collaboration, education and a commitment that patients who can do out-of-bed activities are actually mobilized," she said. "Most nurses in our study reported that they never or rarely got intubated patients receiving mechanical ventilation out of bed, and clinicians infrequently entered mobility orders for these patients."

Dawn Cooper, MS, RN, CCRN, CCNS, Study Co-Author and Clinical Nurse Specialist in MICU at  York Street Campus, Yale New Haven Hospital

The most commonly identified barrier was some patients' uncooperative behavior, agitation or anxiety, even though the study excluded patients who were very agitated or combative. Other patient-related reasons for not mobilizing patients included active medical issues, such as undergoing procedures during the shift, being weaned from a ventilator or awaiting extubation, and having an unstable respiratory status.

The most common nurse-related barriers were competing demands from other patients or concerns about patient safety or potential adverse events.

The environment of care posed very few barriers; nurses rarely mentioned that lack of help from other nursing staff, physical therapists or respiratory therapists, or lack of a clinician's activity order impeded mobility.

Most nurses indicated they had received training on portable lift equipment, yet only 58% reported feeling comfortable using it. In addition, six rooms in the unit have a ceiling lift, but only 17% of the nurses reported being trained on its use and only 12% felt comfortable or very comfortable using it.

The authors recommend that units begin by reviewing their mobility criteria and protocols for patients with complicated medical conditions. Together, the team should take an inventory of the patient, nurse and environment-of-care factors unique to their setting that present barriers to early mobilization. Once this groundwork is laid, an interdisciplinary protocol-driven mobility program that is known to be safe and effective can be systematically applied to overcome them.