Early m o b iliza tio n o f m e c h a n ic a lly v e n tila te d

p a tie n ts : N u rs in g p ractice in Q u e b e c in te n s iv e
care u n its
By C harles Bilodeau, MScN, RN, Frances Gallagher, P h D, RN, and Andreanne Tanguay, P h D, RN

A b s tra c t
Background: Early mobilization (EM) of mechanically venti­ Results: More than 70% o f the nurses reported that they
lated patients in intensive care units (ICUs) is recommended to routinely assess the mobilization capacities of mechanically ven­
prevent complications associated with long-term physical, psy­ tilated patients and had performed EM interventions with such
chological, cognitive and functional disabilities, such as delirium patients in the past month. The most common interventions left
and intensive care unit-acquired weakness (ICUAW). However, the patient in bed, primarily repositioning, and few interven­
nursing practices vary significantly with regard to EM, and are tions were carried out more than once per shift. Just 26% said an
poorly documented in Quebec. EM protocol was available in their ICU, while 33% had received
training in EM.
Goal: Describe current nursing practice around EM of mechani­
cally ventilated patients in Quebec ICUs and potential influencing Conclusion: The findings of this study provide specific indicators
factors. on current EM practices with mechanically ventilated patients in
Quebec ICUs, along with potential influencing factors. Strategies
Method: A cross-sectional electronic survey of nurses working
to improve the provision of EM in Quebec ICUs would include
in Quebec ICUs was conducted using a convenience sample. A
ensuring that more ICUs introduce EM protocols and offer staff
questionnaire based on the current body of evidence regarding
training.
EM in the ICU was designed specificallyfor the study and showed
excellent content validity. Survey administration followed the
Key words: early mobilization, nurses, intensive care units,
guidelines ofDillman, Smyth and Christian (2014). Descriptive
practices, mechanical ventilation
analyses were done using SPSS.

Bilodeau, C., Gallagher, F., & Tanguay, A. (2018). Early mobilization of mechanically ventilated patients: Nursing practice in Quebec intensive care units.
Canadian Journal of Critical Care Nursing, 29(4), 21-28.

B a c k g ro u n d 2016; Berney et al., 2014; Hodgson et al., 2015; Nydahl et al.,

bout 33% of patients hospitalized in intensive care 2014b), and nursing practices, though not well documented,

A units (ICUs) receive mechanical ventilation (MV) as

part of their treatment (Canadian Institute for Health
Information, 2016). Drugs used during MV result in prolonged
immobility (Schweickert & Kress, 2011), which is associ­
appear to vary widely (Amidei, 2012). To our knowledge, until
our study, no empirical research had been done on nursing
practices with regard to EM of mechanically ventilated patients
in Quebec ICUs, and factors associated with EM practices have
ated with a higher risk of delirium (Zaal & Slooter, 2012) and yet to be confirmed in this setting.
intensive care unit-acquired weakness (ICUAW) (Walsh, Batt,
Herridge, & Dos Santos, 2014), leading to long-term physical, P u rp o s e
psychological, cognitive and functional disabilities (Brummel We set out to describe the current practices of Quebec ICU
et al., 2015; Desai, Law, & Needham, 2011; Fan et al., 2014). nurses regarding EM of mechanically ventilated patients and of
Early mobilization (EM) is recommended to minimize these potential influencing factors.
complications (Barr et al., 2013; Bein et al., 2015; Berry et al.,
2014). Many studies highlight the feasibility and safety of EM M e th o d
for mechanically ventilated patients (Nydahl, Ewers, & Brodda, Design. A prospective cross-sectional study design was
2014a), and its potential for shortening the duration of delir­ chosen to gather data using an online survey created with
ium, MV and the length of hospital stays (Adler & Malone, the LimeSurvey platform (LimeSurvey GmbH, Hamburg,
2012; Kayambu, Boots, & Paratz, 2013; Needham et al., 2010; Germany).
Schweickert et al, 2009).
Sampling and eligibility criteria. The target population
The constant presence of nurses at the patient’s bedside, along (n=2,937) consisted of nurses working in adult ICUs in Quebec
with their knowledge, skills and scope of practice, enables them public hospitals. Convenience sampling was done using a list
to play a key role in the initiation and performance of EM inter­ of active members of the Ordre des infirmieres et infirmiers du
ventions, thereby enhancing patient safety and the quality of Quebec (OIIQ) (Quebec order of nurses) who had consented
care. However, the provision of EM in the ICU is still not wide­ to be contacted for research purposes. To be eligible for the
spread (Bakhru, McWilliams, Wiebe, Spuhler, & Schweickert, survey, nurses had to be practising in an adult ICU, caring for

Volume 29, N umber 4, Winter 2018 • www.caccn .ca 21

mechanically ventilated patients, be registered members of the Table 1: Sociodemographic and Organizational
OIIQ for 2015-2016, and have a mastery of written French. Characteristics (n=237)

Survey. A questionnaire was designed based on the current Variable Results n %

body of evidence regarding EM in the ICU. The preparation
and administration stages were guided by the process set out by Gender Female 198 83.5
Dillman, Smyth and Christian (2014). The questions cover the Age 34 years and under 122 51.5
EM practice setting, relevant nursing activities (mobilization
assessments and EM interventions), the knowledge and beliefs Employment status Full time 161 67.9
of the respondents, and perceived barriers to EM. For purposes
Work shift Day 66 27.8
of comparison, some of the questions were inspired by another
study, concerning EM by physiotherapists and physicians in Evening 66 27.8
Canada (Koo et al., 2016). The questionnaire was reviewed for
Night 58 24.5
clarity and relevance by experts in the field, comprising three
clinical nurses in a university hospital, a physiotherapist with Rotation 47 19.8
expertise in EM, and a university professor in nursing sciences.
Content validity indices (CVIs) ranging from 0.92 to 0.94, val­ Nursing experience 5 and under 67 28.3
ues considered excellent by both Fleiss (1981) and Cicchetti (years)
6 to 10 57 24.1
and Sparrow (1981), were calculated using the method pro­
posed by Polit and Beck (2016). Finally, pretesting was done 11 to 15 37 15.6
by a subgroup of the target population (n=8) to verify that the
16 and over 76 32.1
questionnaire was feasible and comprehendible.
Intensive care 5 and under 106 44.7
Data collection. Each potential participant received a per­
experience (years)
sonalized email invitation with the URL of the online survey. 6 to 10 53 22.4
Reminder emails were sent to non-respondents on day 6,13,21
and 27. Data collection took place over the month of April 2016. 11 to 15 28 11.8
Respondents were informed that returning a completed ques­ 16 and over 50 21.1
tionnaire would signify their consent, and were assured that
their participation would remain anonymous. Ethics approval Hospital size (n 150 and under 28 11.8
was granted by the Research Ethics Committee of the CIUSSS beds)
151 to 300 45 19.0
de I’Estrie - Centre hospitalier universitaire de Sherbrooke.
301 to 450 43 18.1
Data analysis. Data coding was done using LimeSurvey and
verified by the authors. Data analysis was done using SPSS 451 and over 56 23.6
(Version 23, IBM Corp, 2014). The results are reported using
Doesn’t know 65 27.4
descriptive statistics (frequencies, percentages).
ICU size (n beds) 7 and under 26 11.0
Results
Participant characteristics. Predicting a low response rate, 8 to 15 93 39.2
the invitation email was sent to all 820 nurses from the target 16 and over 118 49.8
population who had consented to be contacted for research
purposes. A total of 237 questionnaires were completed, for a Average nurse to One nurse for one 23 9.7
response rate of 29%. Table 1 presents sociodemographic data patient ratio patient or less
and the organizational features of the workplaces concerned.
One nurse for two 183 77.2
Most of the respondents were female, 34 or younger (52%), and
patients
worked in surgical and medical ICUs. Some also worked in cor­
onary (25%), trauma (19%), neurological (19%) and burn units One nurse for three 31 13.1
(6%). Half worked in an ICU with more than 15 beds, and most patients or more
reported an average nurse to patient ratio of 1:2 (77%). Only 22
respondents (9%) said they had a critical care certification from
the Canadian Nurses Association.
be involved in EM. Few (26%) reported having access to an EM
Practice setting. Table 2 presents aspects of the practice set­ protocol in their ICU, or said they had received training in EM
ting that are most likely to have an impact on EM practices. (33%). Only 28% could identify an EM champion (i.e. some­
According to the nurses in our survey, the following persons one who encourages the practice of EM and works to improve
take part in providing EM for mechanically ventilated patients: its quality). However, 76% said that EM was discussed in daily
nurses (97%), volunteer attendants (88%), physio and occu­ rounds and that physiotherapists were available to help assess
pational therapists (75%), and respiratory therapists (43%). mechanically ventilated patients in the ICU.
Additionally, 48% considered that family members should also

22 T he C anadian Journal of C ritica l C are N ursing • C anadian A ssociation of C ritical C are N urses
 Table 2: Aspects of Practice Setting (n=237) Nursing activities related to EM. Our study considered two
types of nursing activities related to EM for mechanically ven­
Aspects n %
tilated patients. The first consisted of assessing the patient’s
Who Nursing staff 229 96.6 m obilization capacity: 174 respondents (73%) reported
participates in doing so, but just 28% of that number (n=49) said they used
Nurses aides (orderly) 209 88.2
EM practices an instrument to guide their assessment. The second type of
in your ICU? Physiotherapists, 177 74.7 activity consisted of performing an EM intervention. Besides
occupational therapists repositioning patients in bed (84%), 71% said they had taken
part in at least one other EM intervention. The main interven­
Respiratory therapists 102 43.0
tion reported was having the patient sit up in bed or on the
Physicians 48 20.3 side of the bed (78%), followed by bed-to-chair transfer using a
technical aid (47%), range-of-motion (ROM) exercises (43%),
Family members 39 16.5
standing bed-to-chair transfer (29%), and walking (18%).
Who should Nursing staff 226 95.3 Figure 1 presents the average frequency of these interventions.
participate in The most common frequency was once per shift or less (16%
Nurses aides (orderly) 211 89.0
EM practices to 54% of respondents depending on the intervention). Fewer
in your ICU? Physiotherapists, 220 92.8 than 15% reported performing an EM intervention twice per
occupational therapists shift, while the figure dropped to 3% for three or more times
per shift.
Respiratory therapists 144 60.8

Physicians 96 Knowledge and beliefs about EM practices. Most of the

40.5
nurses in our study (71%) indicated that they were not familiar
Family members 113 47.7 with the scientific literature on EM for mechanically ventilated
EM protocol available (Yes) 62 26.2 patients in ICUs. Nonetheless, 81% correctly identified the per­
centage of mechanically ventilated patients at risk of developing
Previous training about EM (Yes) 78 32.9 ICUAW. Four statements were used to assess their knowledge
EM discussed during daily round (Yes) 181 76.3 about: 1) the safety of EM interventions, 2) the effectiveness
of ROM exercises in maintaining muscular strength, 3) the
Physiotherapist available 181 76.3 effect of EM on MV duration, and 4) the effect of EM on the
Consultation request required (by MD 146 61.6 incidence of delirium. Correct responses were given by the
or nurse) following numbers of participants: 216 (91%), 188 (79%), 221
Presence of an EM champion 66 27.8 (93%) and 216 (91%) respectively.

Champion Nurse 47 (/66) 71.2 When asked about the optimal time to begin EM interventions,
occupation 67% said that first the cardiorespiratory system must be stabi­
Physiotherapist 27 {166) 40.9 lized, while 56% said that EM should begin within 72 hours
Physician 10 {166) 15.2 after admission to the ICU. Few respondents (11%) thought that
the risks outweigh the benefits of EM. However, a significant

80

Repositioning in bed Range-of-motion Sitting up in bed or on Bed to chair transfer Standing bed to chair Walking
(ROM) exercises the side o f the bed w ith aid transfer

EM interventions

Figure 1: Reported Frequency of EM Intervention

Volume 29, N umber 4, W inter 2018 . www.caccn .ca 23

proportion had concerns about hurting themselves (26%), the in other studies. Second, the EM activities provided for the
patient falling (29%), compromising the patient’s hemody­ relevant patients feature a high rate of mobilization assess­
namic stability (43%), and accidental extubation (51%). Some ment and a predominance of low-intensity EM interventions.
of the respondents (44%) believed that is unsafe to perform EM Third, although most participants seemed to have adequate
with mechanically ventilated patients who are on vasoactive knowledge about EM, they had many concerns about potential
drugs, while 66% considered repositioning in bed as the only negative effects of providing EM for such patients, and per­
permissible intervention. Also, a higher fraction of inspired ceived many barriers to performing it.
oxygen (Fi02> 0.5 vs FiO, < 0.5) led more nurses to believe EM
interventions should be restricted to bed. Irrespective of the F102 < 0 .5 v ia tra c h e o s to m y R 0 2 2 0 . 5 v ia tra c h e o s to m y

0-9 5.1
patients oxygen needs, 44% believed that bed-to-chair transfer
should only be done if ventilation is provided via tracheostomy,
while 34% considered that it is also safe when the patient has an
endotracheal tube. Perceived permissible level of mobilization
for different MV characteristics (FiO, and airway access) are
shown in Figure 2.

Perceived barriers to EM. From a list of 19 potential barriers

to EM documented in the literature, our respondents identi­ F i0 2 < 0 .5 v ia e n d o tra c h e a l tu b e R 0 2 2 0.5 v ia e n d o tra c h e a l tu b e

3.8 2.1
fied an average of 16 barriers in their ICU that they consider
to be of low, medium or high importance. Figure 3 shows
the percentages for three categories of high-importance bar­
riers: institutional, practitioner-related, and patient-related. 18.4

Hemodynamic instability (75%), shortage of staff (56%), lack 10.7

of training (46%), medical order for bed rest (46%), and inade­
quate analgesia (46%) were the principal barriers identified by
the nurses in our study. The presence of an endotracheal tube 29.5 35.5

was least frequently identified as a high-importance barrier,

although 60% saw it as an impediment to EM. ■ T otal bed rest ■ R epositioning in bed

■ R ange-of-m otion (ROM) exercises ■ S ittin g u p in bed o r o n th e side o f th e b ed

Bed t o c h a ir tra n sfe r w ith aid ■ S tanding bed t o c h a ir tra n sfe r

D is c u s s io n ■ W alking

Three main observations emerge from the results of our study.

Figure 2: Perceived Permissible Level of Mobilization for
First, the practice settings surrounding EM in which our
Different MV Characteristics
respondents work have many similarities with those described

80

70
O rganizational barriers Barriers related to practitioners
60

50 a? so.o

II I I I
40 S 40.0

30

I I
1 20
9
Q.
10

b e d re s t o r d e r la c k o f la c k o f m e d ic a l E M p r o to c o l u n c le a r m e d ic a l
la c k o f s ta ff la c k o f t r a in in g la c k o f c o n c e rn s f o r c o n c e rn s fo r
s p e c ia lU e d o rd e r fo r EM u n a v a ila b le o rd e r fo r EM
in te r d is c ip lin a r y p a tie n t s ta ff
e q u ip m e n t
c o lla b o r a tio n h e a lth /s a fe ty h e a lth /s a fe ty

80

70
Barriers related to patients
60

g 50

II
£ 40
S. 30
u
1£ 20

h e m o d y n a m ic
in s ta b ility
In a d e q u a te a n a lg e s ia s e d a tio n
I I
fe m o r a l v a s c u la r a ccess p a tie n t / f a m ily r e fu s a l d e lir iu m p h y s ic a l r e s tr a in ts e n d o tr a c h e a l
in tu b a tio n

Figure 3: Perceived High Importance Barriers to EM

24 The C anadian Journal of C ritical Care N ursing • Canadian Association of C ritical C are N urses
Similar practice setting. The practice setting described by our W hen asked if they had perform ed any EM intervention
respondents is similar to that reported in other studies on EM. with MV patients in the last month, 37 participants (16%)
First, the nurses in our study overwhelmingly identified nurs­ responded in the negative. Here we must note that our defini­
ing staff as the professionals who provide EM interventions in tion of EM included repositioning in bed, long considered the
their ICU. A study by Koo el al. (2016) of 117 physiotherapists minimal practice (Krishnagopalan, Johnson, Low, & Kaufman,
and 194 physicians working in ICUs across Canada showed 2002). But many studies do not include it in their definition of
that 99% of the respondents identified nurses as the main EM (Jolley et al., 2015; Koo et al., 2016). A respondent who had
participants in EM practices. Since nurses spend a consider­ not read the questionnaire carefully might have thought that
able amount of time at the bedside of mechanically ventilated EM only referred to out-of-bed activities. It is also possible that
patients, they are in an ideal position to perform EM inter­ in the period concerned (the month before completing ques­
ventions (Kneafsey & Haigh, 2009). Furthermore, Atkins and tionnaire), those who responded in the negative only worked
Kautz (2014) suggest that a nurse should always be present for with patients who were not mechanically ventilated, or who
EM interventions to ensure the patients hemodynamic stabil­ had already been under MV for several days (so that any mobi­
ity and the integrity of equipment, therefore, referring to the lization provided would not have been considered early).
nurses’ knowledge and skills as a safeguard for patients safety.
For the most part, the EM practices reported were low-intensity
Around three-quarters of the nurses in our study reported that interventions restricted to bed. The most common interventions
a physiotherapist was available to assess mechanically ventilated were repositioning in bed, sitting up in bed, and sitting on the side
patients in their ICU. Physiotherapists make an undeniable con­ of the bed. The least common was walking. The same situation
tribution to the interdisciplinary team, since they have extensive has been observed in other countries, as described in point-prev­
expertise in assessing neuromuscular functions and recom­ alence studies (Berney et al., 2014; Nydahl et al., 2014b) and in
mending appropriate interventions (Perme & Chandrashekar, prospective and retrospective cohort studies (Hodgson et al,
2009). Physiotherapists achieve higher mobilization rates than 2015; Pires-Neto, Lima, Cardim, Park, & Denehy, 2015). All of
nurses, and their interventions are of higher intensity such as the foregoing highlight the low rate of out-of-bed EM interven­
standing and walking (Garzon-Serrano et al., 2011). tions. Organizational culture maybe a determining factor in this.
Historically, the organizational culture of the ICU has focused
Internationally, it is still uncommon for an EM protocol to be
exclusively on short-term recovery (Kress, 2013). Fully exploit­
available in the ICU, and in our study just 26% of respondents
ing the possibilities of EM intervention would require a shift
reported having access to such a protocol. A survey of 951 ICUs
toward a long-term perspective of care and rehabilitation, with
in the United States, United Kingdom, France and Germany
movement and physical activity treated as key components of the
showed that only 21% had an EM protocol (Bakhru et al.,
recovery process (Bailey, Miller, & Clemmer, 2009). Our findings
2016). In Canada, a survey of 215 ICUs indicated that 38% had
indicate that in Quebec at least, this shift has yet to be achieved.
EM protocols available (Rose et al„ 2015). The importance of
this factor has been demonstrated by Jolley, Dale and Hough Adequate knowledge, negative perceptions, significant bar­
(2015) who found an association between the availability of an riers. The nurses in our study generally displayed an adequate
EM protocol and the use of higher-intensity EM interventions understanding of the benefits of EM, despite the fact that rela­
(OR 5.26; Cl 95% 1.23-22.55; p=0.03). The design and imple­ tively few (13%) said they had received training on the subject.
mentation of such protocols have been explored in numerous Although most (71%) said they were not familiar with the sci­
studies supporting their valuable clinical impact (Hickmann et entific literature on EM for MV patients, thus reflecting the
al., 2016; Sigler et al., 2016). limited generalizability of currently published EM clinical trials,
they recognized that EM interventions are safe, as evidenced
In addition, the role of family members deserves special atten­
by many studies (Adler & Malone, 2012; Cameron et al., 2015;
tion, since nearly half of our respondents said that family
Nydahl et al. 2014a). Interestingly, 81% of our respondents
members should be involved in providing EM. Rukstele and
correctly identified the proportion of mechanically ventilated
Gagnon (2013) explain that when family members are involved
patients who are at risk of developing ICUAW. This contrasts
they enrich the meaning of EM interventions beyond the scien­
with the study by Koo et al. (2016), in which 69% of the respon­
tific rationale of professionals, encouraging the patient’s active
participation. dents (311 physicians and physiotherapists) underestimated
that proportion. The difference could be due to the special
High assessment rate, low-intensity mobilization interven­ attention paid by hospital accreditation programs to the risk of
tions. A high proportion of the nurses in our study (73%) physical deconditioning during hospitalization. Our respon­
reported that they do a mobilization assessment of mechani­ dents also displayed a better understanding of the impact of
cally ventilated patients. This is unsurprising, since assessment EM in reducing the incidence of delirium and the duration of
is widely recognized as an important nursing activity. However, MV than previous studies of physicians and physiotherapists
few respondents (28%) reported using a tool to guide this (Koo et al., 2016) and even other ICU nurses (Jolley, Regan-
activity. Our literature search turned up just two partially vali­ Baggs, Dickson, & Hough, 2014) have found.
dated tools for assessing mobilization in the ICU (Hodgson et
Most of our respondents (89%) believed that the benefits of EM
al. 2014a; Perme, Nawa, Winkelman, & Masud, 2014). To our
outweigh the risks for MV patients, except when the patient is
knowledge, neither has been translated into French.
receiving vasoactive agents intravenously; when that is the case,

Volume 29, N umber 4, W inter 2018 • www.caccn .ca 25

only 56% consider it a safe practice. This concern is shared by answered more positively. Also, the wording of certain ques­
many experts from academic and clinical settings, who have tions could have caused a measurement bias, and interactions
yet to reach a consensus on the dosing and combination of between questions could have caused a response bias.
vasopressors that would allow safe EM with mechanically ven­
Implications for nursing practice and research. For clinical
tilated patients (Hodgson et al„ 2014b). Given the widespread
practice, this study was a unique opportunity to raise the aware­
use of vasopressors in ICUs, there is a need for further research
ness of nurses about EM practices. The participation of our
to provide guidelines for clinicians, to avoid keeping patients
respondents might have stimulated their interest in EM and bol­
immobilized unnecessarily.
stered their future involvement in quality improvement projects.
A common constraint on performing EM is the fear of acci­ We identified two strategies that could enhance the use of EM
dental extubation. This fear was shared by over half of our in Quebec ICUs: increasing the offer of appropriate training and
respondents (60%) although, apparently, it is unfounded. In providing EM protocols in more ICUs. As for research, this study
2014, a systematic literature review of 3,613 EM interventions contributes to knowledge about EM in the ICU by providing
with 453 patients turned up only one accidental extuba­ specific indicators of practices in Quebec. Based on preliminary
tion, and in that case re-intubation was deemed unnecessary. tests, the questionnaire created for the study has acceptable con­
Nevertheless, as noted in other studies (Barber et al., 2014; tent validity. Psychometric research is needed into its reliability,
Harrold, Salisbury, Webb, & Allison, 2015; Hodgson et al., to better define its psychometric properties and enable its use in
2015), the presence of an endotracheal tube continues to be other French-language settings. Future research should focus on
seen as an impediment to EM. documenting EM interventions in the ICU, using field observa­
tions or retrospective chart reviews, for a more detailed portrait
The nurses in our study identified an average of 16 elements
of when, how and by whom EM interventions are carried out.
as impediments to EM in their ICU. This large number of per­
We hope that our study will encourage research on the design
ceived barriers could explain the prevalence of low-intensity
and implementation of EM interventions, collaborative and
interventions. Many of what our respondents saw as high-im-
interdisciplinary approaches to providing them, and the evalua­
portance barriers are often mentioned in other studies (Atkins
tion of patient outcomes. Finally, with regard to nursing training
& Kautz, 2014; Barber et al., 2014; Dubb et al., 2016; Koo et
programs, we believe that EM should be included in the critical
al., 2016). Hemodynamic instability was the most frequently
care curriculum, with an emphasis on collaboration with reha­
reported as high-importance barrier, chiefly because few ICUs
bilitation and medical programs.
(26%) have adopted an EM protocol to identify patients that
could safely receive EM. Also, as stated earlier, there is no con­
Conclusion
sensus on the safety of EM for patients receiving vasoactive
This study provides specific indicators of the EM practices of
agents (Hodgson et al., 2014b).
nurses caring for mechanically ventilated patients in Quebec
Another frequently reported important barrier was the shortage ICUs, and on potential influencing factors. The most common
of personnel, since EM interventions on mechanically ventilated EM interventions are of low intensity. Many Quebec ICUs lack
patients require the involvement of multiple persons. Besides the tools for the assessment of mobilization capacities, and proto­
nurse who oversees the process, such interventions require the cols to guide EM practices. Although Quebec nurses seem to be
expertise of a physician to confirm the absence of contraindica­ knowledgeable about EM interventions, they have many lim­
tions, a physiotherapist to assess neuromuscular functions, and iting beliefs and report numerous barriers to performing such
a respiratory therapist to secure airways (Balas et al., 2012). It interventions. Clinicians and stakeholders should give careful
is also common for one or more nursing staff (e.g., orderlies or consideration to these barriers when designing and implement­
aides) to contribute by holding lines and tubes or by using man­ ing EM practices for their ICUs. It is crucial that mechanisms
ual lift techniques. Unfortunately, relentless budget cuts have led be developed for monitoring the practice change process, and
to chronic understaffing, so the lack of personnel is a daily real­ that strategies be described for surmounting EM barriers.
ity for many clinicians. Lack of education on this topic is also
a major barrier, since 67% of our respondents said they had Implications for nurses
received no training in EM. This study was a unique opportunity to raise the awareness of
nurses about their EM practices and the performance of their
Strengths and limitations. This is the first study to exam­
ICU in this regard.
ine nursing practices in Quebec ICUs with regard to EM for
• Two strategies could enhance the use of EM in Quebec ICUs:
mechanically ventilated patients. We followed approved guide­
increasing the offer of appropriate training and providing
lines for the design and administration of our survey (Dillman
EM protocols in more ICUs.
et al., 2014), and our 29% response rate is considered accept­
• Future research should focus on documenting EM interven­
able for this kind of study (Burns & Grove, 2012). Our sample
tions in the ICU, using field observations or retrospective
was diverse in terms of sociodemographic characteristics and
chart reviews, for a more detailed portrait of when, how and
practice settings. However, representativeness was limited
by whom EM interventions are carried out.
by the small proportion of ICU nurses (28%) who had con­
• With regard to nursing training programs, EM should be
sented to be contacted for research purposes. Our study could
included in the critical care curriculum, with an emphasis on
be subject to volunteer bias, since respondents who wanted to
collaboration with rehabilitation and medical programs. *
promote EM could have overestimated their interventions or

26 The C anadian Journal of C ritical C are N ursing • C anadian Association of C ritical C are N urses
About the authors Address fo r correspondence: Charles Bilodeau, MScN, RN, Ecole
des sciences infirmieres, Faculte de medecine et des sciences
Charles Bilodeau, MScN, RN, Lecturer, Ecole des sciences
de la sante, Universite de Sherbrooke, 3 001,12‘ avenue Nord,
infirmieres, Faculte de medecine et des sciences de la sante,
Sherbrooke, QC J1H5N4
Universite de Sherbrooke, Sherbrooke, QC
Tel: 1-819-578-9005
Frances Gallagher, PhD, RN, Associate Professor, Ecole des
Email: [email protected]
sciences infirmieres, Faculte de medecine et des sciences de la
sante, Universite de Sherbrooke, Sherbrooke, QC
Acknowledgement
Andreanne Tanguay, PhD, RN, Associate Professor, Ecole des We thank the Faculte de medecine et des sciences de la sante de
sciences infirmieres, Faculte de medecine et des sciences de la I’Universite de Sherbrooke fo r funding, along with the Ministere
sante, Universite de Sherbrooke, Sherbrooke, QC de I’Education, de I'Enseignement superieur et de la Recherche
du Quebec.

REFERENCES
Adler, J., & M alone, D. (2012). Early m o ­ bilization in prophylaxis or therapy of D illm an, D.A., Smyth, J.D., 8c C hristian,
bilization in the intensive care unit: A p u lm o n ary disorders: Revision 2015: L.M. (2014). Internet, phone, mail, and
system atic review. Cardiopulmonary S2e guideline o f th e G erm an Society mixed-mode surveys: The tailored design
Physical Therapy Journal, 23(1), 5-13. of Anaesthesiology and Intensive Care method (4th ed.). H oboken, N.J: Wiley
A m idei, C. (2012). M obilisation in c riti­ Medicine (DGAI). Der Anaesthesist, 64 8c Sons.
cal care: A concept analysis. Intensive & Suppl 1, 1-26. D u b b , R ., N y d a h l, P., H e rm e s , C .,
Critical Care Nursing: The Official Journal Berney, S.C., H arro ld , M., W ebb, S.A., Schwabbauer, N., Toonstra, A., Parker,
of The British Association of Critical Care Seppelt, I., Patm an, S., Thomas, P.J., 8c A .M ., ... N e e d h a m , D .M . (2 0 1 6 ).
Nurses, 28, 73-81. Denehy, L. (2014). Intensive care unit B arriers and strategies for early m o ­
A tkins, J.R., & Kautz, D.D. (2014). Move m o b ility p ra c tic e s in A u stralia an d bilization o f patients in intensive care
to improve. Dimensions of Critical Care New Zealand: A point prevalence study. units. Annals o f The American Thoracic
Nursing, 33, 275-277. Critical Care and Resuscitation: Journal Society, 13, 724-730.
Bailey, P.P., M iller, R., 8c C lem m er, T.P. of The Australasian Academy o f Critical Fan, E., D ow dy, D.W., C o la n tu o n i, E.,
(2009). Culture of early mobility in m e­ Care Medicine, 15, 260-265. M endez-Tellez, P.A., Sevransky, J.E.,
chanically ventilated patients. Critical Berry, A., Beattie, K., B ennet, J., Cross, S h a n h o ltz , C ., ... N e e d h a m , D .M .
Care Medicine, 37(10 Suppl), S429- Y„ Cushway. S., H assan, A., ... Elliot, (2014) . Physical complications in acute
S435. D. (2014). Physical activity and move­ lung injury survivors: A two-year longi­
B akhru, R.N., M cW illiam s, D.J., W iebe, ment: A guideline for critically ill adults. tudinal prospective study. Critical Care
D.J., Spuhler, V.J., 8c Schweickert, W.D. Agency for Clinical Innovation, NSW Medicine, 42, 849-859.
(2016). Intensive care u n it stru c tu re Government. Fleiss, J. (1981). Statistical methods for rates
variation and implications for early m o­ Brummel, N.E., Balas, M.C., M orandi, A., and proportions (2nd ed.). New York,
bilization practices: An in tern atio n al Ferrante, L.E., Gill, T.M., 8c Ely, E.W. NY: John Wiley.
survey. Annals of The American Thoracic (2015) . U n d erstan d in g and reducing G arzo n -S erran o , J., Ryan, C., W aak, K.,
Society, 13, 1527-1537. disability in older adults following crit­ H irschberg, R„ Tully, S„ Bittner, E.A.,
Balas, M.C., Vasilevskis, E.E., Burke, W.J., ical illness. Critical Care Medicine, 43, ... Eikerm ann, M. (2011). Early m obi­
Boehm, L., P un, B.T., Olsen, K.M., ... 1265-1275. lization in critically ill patients: Patients’
Ely, E.W. (2012). C ritical care nurses’ Burns, N., 8c Grove, S.K. (2012). The practice m obilization level depends on health
role in im p le m e n tin g th e “A BCD E of nursing research: Appraisal, synthesis, care p ro v id e r’s profession. PM & R:
B undle” in to practice. Critical Care and generation of evidence (7th ed.). Saint The Journal o f Injury, Function, and
Nurse, 32, 35-48. Louis, MO: Saunders Elsevier. Rehabilitation, 3, 307-313.
Barber, E.A., Everard, T., H olland, A.E., C a m e ro n , S., B all, I., C e p in sk a s , G., Harrold, M.E., Salisbury, L.G., Webb, S.A.,
Tipping, C., Bradley, S.J., 8c H odgson, C hoong, K., D oherty, T.J., Ellis, C.G., Allison, G.T. (2015). Early mobilisation
C.L. (2014). B a rrie rs a n d fa c ilita ­ ... Fraser, D.D. (2015). Early mobiliza­ in intensive care units in Australia and
tors to early m obilisation in intensive tion in the critical care unit: A review of Scotland: A prospective, observational
care: A qualitativ e study. Australian adult and pediatric literature. Journal of cohort study examining mobilisation prac­
Critical Care: Official Journal o f The Critical Care, 30, 664-672. tises and barriers. Critical Care, 19,336.
Confederation o f Australian Critical Canadian Institute for Health Information. H ickm ann, C.E., Castanares-Zapatero, D.,
Care Nurses, 2 8 , 177-182. (2016) . Care in Canadian ICUs. Ottawa, Bialais, E., D ugernier, J., Tordeur, A.,
Barr, J., Fraser, G.L., Puntillo, K., Ely, E.W., Canada: Author. C olm ant, L., ... L aterre, P.-F. (2016).
Gelinas, C., D asta, J.F.,... Jaeschke, R. C ic c h e tti, D.V., 8c Sparrow , S. (1981). Team w ork enables high level o f early
(2013). C linical p ra c tic e g u id elin es D eveloping c rite ria for estab lish in g m obilization in critically ill patients.
for th e m a n ag e m e n t o f p ain , a g ita ­ in terra ter reliability of specific items: Annals o f Intensive Care, 6, 80.
tion, and delirium in adult patients in Application to assessment of adaptative Hodgson, C., Bellomo, R„ Berney, S., Bailey,
the intensive care un it. Critical Care behavior. Amerian Journal o f Mental M „ Buhr, H., Denehy, L., ... Webb, S.
Medicine, 41, 263-306. Deficiency, 86, 127-137. (2015) . Early m obilization and recov­
B ein , T., B ischoff, M ., B ru c k n e r, U., Desai, S., Law, T., 8c N eedham , D. (2011). ery in mechanically ventilated patients
G eb h ard t, K., H enzler, D., H erm es, L o n g -term co m p licatio n s o f critical in the ICU: A bi-national, multi-centre,
C ., ... W rig g e , H . ( 2 0 1 5 ) . S2e care. Critical Care Medicine, 39, 37 1 - prospective cohort study. Critical Care,
guideline: Positioning and early m o ­ 379. 19, 81-81.

Volume 29, N umber 4, Winter 2018 • www.caccn .ca 27

Hodgson, C., Needham, D., Haines, K., Bailey, Kress, J.P. (2013). Sedation and mobility: P o lit, D., 8c B eck, C. (2 016). N ursing
M., Ward, A., Harrold, M .,... Berney, S. C hanging the paradigm . Critical Care research: Generating and assessing evi­
(2014a). Feasibility and inter-rater reli­ Clinics, 2 9 ,67-75. dence fo r nursing practice. Philadelphia,
ability of the ICU Mobility Scale. Heart & K rishnagopalan, S., Johnson, E.W., Low, PA: W olters Kluwer H ealth/Lippincott
Lung, 4 3 ,19-24. L.L., 8c K aufm an, L.J. (2002). Body Williams 8c Wilkins.
Hodgson, C.L., Stiller, K., Needham, D.M., positioning of intensive care patients: Rose, L., Fowler, R.A., Fan, E., Fraser,
T ipping, C.J., H arro ld , M ., Baldw in, C lin ic a l p ra c tic e v ersu s sta n d a rd s. I., L e a s a , D ., M a w d sle y , C ., ...
C.E., ... W ebb, S.A. (2014b). E xpert Critical Care Medicine, 30, 2588-2592. CANuVENT Group. (2015). Prolonged
consensus and reco m m en d atio n s on Needham, D.M., Korupolu, R., Zanni, J.M., mechanical ventilation in Canadian in­
safety criteria for active m obilization Pradhan, R, Colantuoni, E., Palmer, J.B., tensive care units: A national survey.
of mechanically ventilated critically ill ... Fan, E. (2010). Early physical m edi­ Journal o f Critical Care, 3 0 ,25-31.
adults. Critical Care (London, England), cine and rehabilitation for patients with Rukstele, C.D., 8c G agnon, M.M. (2013).
18, 658. acute respiratory failure: A quality im ­ M aking strid e s in p re v e n tin g ICU -
Jolley, S.E., D ale, C.R., & H o u g h , C.L. provement project. Archives o f Physical acquired weakness: Involving family in
(2015). H ospital-level factors associ­ Medicine & Rehabilitation, 91, 536-542. early progressive mobility. Critical Care
ated w ith re p o rt o f physical activity Nydahl, P., Ewers, A., 8c Brodda, D. (2014a). Nursing Quarterly, 3 6 ,141-147.
in patients on m echanical ventilation Complications related to early mobiliza­ Schw eickert, W.D., 8c Kress, J.P. (2011).
across W ashington State. Annals o f The tion of mechanically ventilated patients Im plem enting early m obilization in ­
American Thoracic Society, 1 2 ,209-215. o n in te n siv e care u n its. N u rsin g in terventions in m echanically ventilated
Jolley, S.E., Regan-Baggs, J., Dickson, R.R, Critical Care, 21, 323-333. patients in the ICU. Chest, 140, 1612—
8c H ough, C.L. (2014). M edical in ten ­ N y d ah l, P., R uhl, A.P., B arto szek , G., 1617.
sive care u n it clinician attitu d es and D u b b , R., F ilip o v ic , S., F lo h r, H .- Schweickert, W.D., Pohlman, M.C., Pohlman,
perceived barriers tow ards early m o ­ J., ... N e e d h a m , D .M . (2 0 1 4 b ) . A.S., Nigos, C., Pawlik, A.J., Esbrook,
bilization o f critically ill p atients: A E arly m o b iliz a tio n o f m ech a n ically C .L.,... Kress, J.P. (2009). Early physical
c ro s s-se c tio n a l su rv ey study. BM C ventilated patients: A 1-day point-prev­ and occupational therapy in m echani­
Anesthesiology, 1 4 ,1-9. alence study in Germany. Critical Care cally ventilated, critically ill patients: A
Kayambu, G„ Boots, R., & Paratz, J. (2013). Medicine, 4 2 ,1178-1186. randomised controlled trial. Lancet, 373,
Physical therapy for the critically ill in Perme, C„ 8c Chandrashekar, R.K. (2009). 1874-1882.
the ICU: A systematic review and m e­ Early mobility and walking program for Sigler, M., Nugent, K., Alalawi, R., Selvan,
ta-analysis. Critical Care Medicine, 41, patients in intensive care units: Creating K., Tseng, J., Edriss, H., ... Krause, D.
1543-1554. a standard o f care. American Journal o f (2016). M aking o f a successful early
Kneafsey, R., 8c Haigh, C. (2009). Moving Critical Care, 18,212. m o b ilizatio n p ro g ram for a m edical
and handling rehabilitation patients: A Perme, C., Nawa, R.K., W inkelm an, C., 8c intensive care unit. Southern Medical
survey of nurses’ views...including com ­ Masud, F. (2014). A tool to assess m o ­ Journal, 109, 342-345.
mentaries by Menzel, N.V. and Mitchell, bility statu s in critically ill p atients: Walsh, C.J., Batt, J., Herridge, M.S., 8c Dos
E.A. International Journal o f Therapy & T h e P e rm e I n te n s iv e C a re U n it Santos, C.C. (2014). M uscle w asting
Rehabilitation, 16, 431-441. M o b ility Score. M eth o d ist D ebakey and early mobilization in acute respira­
K oo, K.Y., C h o o n g , K ., C o o k , D.J., Cardiovascular Journal, 10, 41-49. tory distress syndrome. Clinics in Chest
H erridge, M., N ew m an, A., Lo, V., ... Pires-Neto, R.C., Lima, N.P., Cardim, G.M., Medicine, 3 5 ,811-826.
M eade, M.O. (2016). Early m obiliza­ Park, M., 8c Denehy, L. (2015). Early mo­ Zaal, I.J., 8c Slooter, A.J.C. (2012). Delirium
tion of critically ill adults: A survey of bilization practice in a single Brazilian in critically ill patients: Epidemiology,
knowledge, perceptions and practices of intensive care unit. Journal o f Critical pathophysiology, diagnosis and m an ­
C anadian physicians and physiothera­ Care, 30 ,896-900. agement. Drugs, 72, 1457-1471.
pists. C anadian M edical Association
Journal Open, 4(3), E448-E454.

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