An exploration of final year physiotherapy students’ experiences of early mobilisation and rehabilitation for critically ill patients during practice education

Introduction

In 2016/17 there were 9,280 admissions to Intensive Care Units (ICUs) across Wales. Mortality rates following critical illness are continually improving, with 84% of these admissions surviving to the point of discharge (Welsh Government 2017). Historically, bed rest was prescribed for critically ill patients due to the severity of illness, this combined with the administration of sedative drugs led to the assumption that higher levels of physical activity would be impractical or non-feasible (Brower 2009). However, research has begun to recognise the catastrophic physical and psychological consequences prolonged immobility may pose to patients (King and Gratrix 2009; McWilliams et al. 2018). Thus, the term survivorship has emerged as a major issue within intensive care medicine (Connolly et al. 2014; Fan et al. 2014). This emphasises the importance of patients’ longer-term quality of life (QoL) following critical illness with rehabilitation goals that now extend past just survival (Iwashyna et al. 2012; Engel et al. 2013). Therefore, the topic of early rehabilitation is one that has received significant attention within health literature (Adler and Malone 2012; GPICS 2015). With emerging evidence supporting early physical rehabilitation as both a safe and feasible means of improving long-term QoL for patients post ICU-discharge (McWilliams et al. 2018). The potential clinical and economical gains of early physical rehabilitation have been profiled in evidence-based guidelines recommending rehabilitation starts as early as clinically possible (NICE 2009).

The concept of early physical rehabilitation is however still within its relative infancy. To date, there has been limited research conducted to underpin current NICE (2009) guidelines. Furthermore, little guidance is available detailing exact interventions to aid clinicians with their decision making (Twose and Jones 2015). This lack of research has therefore challenged widespread implementation of early physical rehabilitation (Connolly 2014). Thus, the subjectivity of individual physiotherapists’ competence or attitudes is currently all too influential in determining rehabilitation practice within individual ICU sites (McWilliams et al. 2017).

Research involving physiotherapy students’ experiences within the ICU is comparably sparse. Undergraduate physiotherapy students at Cardiff University (CU) are in the unique position to be guaranteed a clinical placement within each of the core specialities including cardiorespiratory. Here presents a unique opportunity to explore, using a qualitative methodology, the experiences of students nearing qualification during clinical placement within the ICU. Additionally, these data can be used to explore current rehabilitation practice across Welsh ICU sites and to inform the ongoing development of the undergraduate respiratory curriculum, supporting practice-based education. Furthermore, it may ensure the appropriate support is provided for students as they transition to newly qualified physiotherapists. The study research question asks:

What are final year physiotherapy students’ experiences of early mobilisation and rehabilitation for critically ill patients during practice education?

Methodology

A qualitative, interpretive methodology was chosen to collect data via two focus groups with CU undergraduate physiotherapy students. The interaction elicited between participants during a focus group was seen as advantageous for exploring why participants held particular views, hence they were chosen over other qualitative methods (Barbour 2008). A guide to facilitate this discussion was formulated from key themes identified through an initial literature search. A mixture of questioning styles was employed to enhance the credibility of data collection, including key, open-ended and probing questions (Krueger and Casey 2014).

Prior to conducting the study, the CU School of Healthcare Sciences Research Ethics Committee granted ethical approval for the research to commence in July 2017. Participants were recruited via a non-probability, purposive, volunteer sampling technique. This technique was deemed appropriate due to the narrow focus of inclusion criteria (Silverman 2004): selecting CU undergraduate physiotherapy students in their final year of study, who had completed a cardiorespiratory placement. The project was advertised via an online portal exclusive to CU physiotherapy students. The first seven respondents participated in the study, 3 were allocated to the pilot study and 4 to the main study. The sample size of 7 was determined sufficient to achieve theoretical data saturation (Saunders et al. 2018). To assist transferability of the results participants were allocated to each group to reflect diversity in both age, gender, and placement locations spanning across acute hospitals within West, North West and South Wales (Shenton 2004). The pilot focus group gave the researcher the opportunity to trial the research process and questions. The pilot study yielded unique and interesting themes, deemed relevant for publication. As the sampling and research methodology remained the same, this pilot data was analysed and presented as part of the main research results (Thabane et al. 2010). A second focus group was conducted a week later.

An information sheet was provided to participants prior at commencement of the study, detailing an overview of the study including the associated benefits and risks. Also, informing participants of their right to withdraw from the research or refuse to answer any question at any time. Adhering to ethical constraints and ensuring participants made a fully informed decision to participate. Privacy was respected, and confidentiality maintained at all times. Participants used pseudonyms to minimise the risk of being made identifiable (Holloway and Galvin 2017). These pseudonyms have been utilised throughout. Participants signed a confidentiality agreement to ensure they understood their responsibilities in maintaining confidentiality throughout the study.

Both focus groups were recorded using a dictaphone and then transcribed verbatim using Express Scribe (NCH, Pty Ltd, USA) transcription software. These data was then combined with comprehensive field notes produced by the assistant moderator creating a complete account for in-depth analysis. Braun and Clarke’s (2006) thematic analysis approach was used to interpret the data from the participants perspective. Thematic analysis consists of six phases; first familiarising with the data set in order to generate initial codes, which are then translated into and reviewed as themes and sub themes. Finally, these themes were presented and discussed in synthesis with existing literature. Triangulation between the researcher, supervisor and participants themselves corroborated the themes, ensuring the researcher had correctly interpreted participants words, enhancing overall confirmability (Birt et al. 2016).

Results and discussion

Four themes emerged from the analysis, as shown in (Figure 1) below.

Theme 1: Role of the physiotherapist in ICU

Narrates the understanding of the role of the physiotherapist in ICU, including treatment priorities. Detailing the differing emphasis placed upon early mobility across sites.

Theme 2: Teamwork

Explores the participant perspective upon where exactly the role of providing routine early physical rehabilitation for critically ill patients falls. Incorporating discussion around who’s responsible for the initial decision upon when a patient is deemed safe for mobilisation.

Theme 3: Barriers

Explores the potential difficulties that may be encountered when implementing routine early mobilisation for critically ill patients. Furthermore, discussion surrounding strategies of how to overcome these potential barriers.

Theme 4: Evidence-based practice

Discussion regarding the current-evidence base, and how this currently fits within the process of a clinicians clinical reasoning and how this may facilitate patient-centred care avoiding a generalised ‘one size fits all’ approach to rehabilitation.

Role of the physiotherapist in ICU

Lack of emphasis on early mobility

A wealth of literature exists detailing the detrimental effects of prolonged bed rest or immobility (King and Gratrix 2009; Parry et al. 2015). Despite recognising mobility interventions to be the ‘gold standard for respiratory care’ [Zoe]. Participants reported the main role of the physiotherapist in ICU is to focus treatment around clearing airways, to maintain and improve the respiratory system. However, early mobility was not consistently cited as a possible treatment option. Mobility or rehabilitation interventions were consistently cited as less of a priority, with bed rest or immobility occurring as an inevitability of patients’ degree of illness, echoing what has previously been found by researchers such as Connolly et al. (2017).

‘I think on intensive care, ¾ of it was probably focused towards chest physiotherapy’ [Kate].

‘I found it was more directed towards their chests, so maintaining and optimising lung function and making sure their sats didn’t drop’ [Chloe].

The student safety blanket

Williams and Flynn (2013) highlighted the importance of having clinical experience when developing into an autonomous cardiorespiratory practitioner within the ICU environment: ‘utilising clinical judgement and experience to determine stability for initiation and progression of treatment’ (Williams and Flynn 2013, pp. 96). Clinical-educators acted as powerful role models for these students. At their stage of training, with comparatively little clinical experience, participants resorted to relying upon the support and decisions made by their clinical-educators.

‘I felt like a rabbit in headlights if I’m honest’ [Megan].

‘We don’t have the judgement of how ill someone is, when you can mobilise them [pause] because we don’t have that experience. Whereas the physios there, it’s just down to their experience. They know really well, they can look at someone and work out when it’s ok to mobilise them. Whereas for us, it can be difficult’ [Kate].

‘I feel like it depends on where you are and what your clinical educator does’ [Ben].

‘I think your clinical-educator builds you up to have like a safety blanket around you’ [Chloe].

Teamwork

Role-overlap and consultant led decisions

Participants described the overwhelming time pressures they experienced whilst working within the ICU environment. For effective implementation of early physical rehabilitation, participants emphasised the need for effective teamwork, involving engagement of all members of the Multidisciplinary Team (MDT) and delegation of roles and responsibilities throughout.

‘I think as an assessment tool, finding out what the patient can do, that’s a physiotherapy area. Once that’s established, I think it does kind of fall underneath the nurses too. I think it kind of falls under a bit of teamwork really’ [Sophie].

‘I think it was very much down to when consultants had cleared them, it was very much we had to make sure that it was safe to do so from their point of view. But it depended on the consultant, like some of the consultants were known for liking early mobilisation. Like the same day or day after, but some were wanting to wait a little longer’ [Kate].

Corroborating what has previously been documented within both the physiotherapy and nursing literature (Williams and Flynn 2013; Phelan et al. 2018), MDT collaboration and delegation of responsibilities is cited to be key in overcoming barriers and within effective implementation of early physical rehabilitation. Furthermore, this recommendation is strengthened by GPICS (2015), suggesting MDT ward rounds should include regular physiotherapy input.

Barriers to mobilisation

Patient-related barriers

Research has begun to identify various barriers that may challenge the routine implementation of early physical rehabilitation for critically ill patients. Common barri ers included a patient’s degree of physiological instability or level of consciousness, pain, fatigue or attitude towards mobilisation (Dubb et al. 2015; Knott et al. 2015). All of these factors were found to impact upon patients’ adherence to treatment (Williams and Flynn 2013). Participants also described facing such barriers during their time working in ICU.

‘I think because they are acutely unwell. A lot of the time in critical care, they will be, um, medications that they are having will mean they are sedated, or drowsy and it won’t be safe or appropriate to mobilise them’ [Kate].

‘Because they’re not medically stable [interruption from Megan: they’re too unwell] to do anything else at this stage, the primary aim is to get their respiratory stable’ [Henry].

‘I think pain as well, because I saw a couple of people, one patient in particular had lots of fractured ribs and although she wanted to get up and stuff, she physically couldn’t. Because every time she tried, she was just in so much pain. So, she just had to remain in bed’ [Rebecca].

Williams and Flynn (2013) reported strategies to overcoming potential barriers to be focused around building relationships with patients. Participants emphasised this, highlighting the importance of communication and engaging the patient within their rehabilitation journey.

‘I spent a lot of time educating patients on the importance of sitting out, I think that was a big thing’ [Zoe].

ICU cultural related barriers

Participants also cited the various equipment and attachments found within ICU as a frequent barrier to mobilising critically ill patients. Suggesting both the logistical and time constraints associated with such equipment to be challenging. For some, certain equipment presented as an absolute contraindication to mobilisation, whilst for others it only further complicated what already appeared a complex task. Following on from Knott et al. (2015) who demonstrated multiple attachments, and specifically the presence of endotracheal tubes to be a frequently reported barrier.

‘I have never attempted to mobilise someone who’s intubated’ [Beth].

‘They had chest drains, so if you’re trying to get them out of bed, you can’t lift the drains high if they’re not clamped. So, you have to get the nurses in and it makes everything so difficult and you have all these added things to worry about’ [Sophie].

‘There were a couple of patients where, to try and get them into a chair the attachments would be really taut. So that was quite difficult at times. On the odd patient you did get up and mobilise, that would take such a long time, because of all the attachments’ [Rebecca].

Contrastingly, one participant continued to describe their experiences routinely mobilising intubated patients in ICU. Echoing the results of Appleton et al. (2011) who previously found the routine mobilisation of patients with endotracheal tubes to vary significantly across sites.

‘On my placement, we did mobilise quite a lot of patients that were still ventilated. We had lots of long-term trachy patients, who we would switch to manual hyperinflation, and as they were walking we would hyperinflate them’ [Kate].

Evidence-based practice

Guidelines

Participants displayed a lack of awareness and knowledge surrounding the available NICE (2009) guidelines, for which only one of the participants reported having read. This finding echoes Appleton et al. (2011) who also found a lack of awareness among qualified physiotherapists, subsequently, finding implementation of these guidelines at the time to be comparatively low. Participants further voiced concerns regarding a potential loss of individualised, patient-centred care with the implementation of standardised guidelines or protocols.

‘I think it’s really hard to have a pathway when everyone is individualised. What’s the point in having a strict structure to follow because everyone is so different. So many people just don’t fit the pattern’ [Zoe].

‘Every patient is completely different, it’s so unpredictable in that setting. So, you can’t have a set pathway’ [Henry].

However, quality improvement programmes previously undertaken such as Connolly et al. (2017) have utilised individually tailored programmes set for each patient. Thus, suggesting implementation of early mobility, in line with NICE (2009) guidelines, can indeed be individualised and patient-centred.

Limitations of study

A non-probability, purposive, volunteer sampling technique was used to recruit participants. With this method of sampling, there is associated likelihood of response bias, which may impact upon the credibility of the results. However, the appraisal of sampling techniques differs within qualitative research. It is common for qualitative research to employ non-probability sampling as this type of research is concerned with theoretical generalisation, further drawing conclusions deemed valuable for the development of universal theories.

As an insider, the researcher may have posed an unintentional bias upon participants’ responses, further impacting the credibility of results. Triangulation between the researcher, assistant moderator and participants was employed to mitigate any influence of bias.

Despite clinical placement locations mapping across Wales, recruitment of participants from one university ultimately limits transferability of findings. Thus, recommendations drawn are particularly pertinent to the University in which the study took place. Although they may be of use to other institutions with similar teaching curriculums, additional research from other institutions may be required to strengthen findings and recommendations.

Conclusion

Currently, there is a growing but limited literature base supporting early mobilisation and rehabilitation within ICU. As such this novel qualitative research fills a gap in the literature by sharing final year physiotherapy undergraduate experiences of working within ICU.

The findings make a valuable contribution to the topic area in three ways.

Firstly, it was identified that these students felt overwhelmed during their ICU placements, reporting a great sense of reliance on their clinical-educators. They also demonstrated a lack of knowledge around available evidence and guidelines for practice in this area. Thus, echoing results of previous research conducted with qualified physiotherapists, suggesting a lack of knowledge and utilisation of available guidance. The findings also highlight significant variation in the provision of early mobilisation and rehabilitation across individual ICU sites in Wales.

Secondly, there is a need for future research to follow on from Connolly et al. (2017) and McWilliams et al. (2018) to inform the assembly of specific, evidence-based guidelines or recommendations to guide early mobilisation for the critically ill patient in ICU. Detailing exact safety considerations and contraindications, ultimately aiming to aid clinicians to make standardised, evidence-based clinical decisions for the rehabilitation of this patient group, whilst remaining patient-centred, intending to standardise the rehabilitation provided throughout Welsh ICU sites.

Finally, the findings also suggest higher education institutions may have a greater role to play in helping students understand the importance of evidence-based practice to inform their clinical decisions during practice-based education in ICU. It is important that students recognise the need for this during practice education in order to take forward post-qualification. Such an approach will ensure that newly qualified physiotherapists are equipped with the necessary knowledge and skills to successfully transition into fully competent cardiorespiratory practitioners.

Adler, J and Malone, D. (2012). Early mobilisation in the intensive care unit: A systematic review. Cardiopulmonary Physical Therapy Journal 23(1), 5–13. 

Appleton, R., MacKinnon, M., Booth, M., Wells, J., Quasim, T. (2011). Rehabilitation within Scottish intensive care units: A national survey. Journal of Intensive Care Society 12(3), 221–227. 

Barbour, R. (2008). Introducing qualitative research: A student guide to the craft of doing qualitative research (1st ed.). SAGE Publications.

Birt, L., Scott, S., Cavers, D., Campbell, C., Walter, F. (2016). Member checking: A tool to enhance trustworthiness or merely a nod to validation? Qualitative Health Research 26(13), 1802–1811. 

Braun, V., and Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology 3(2), 77–101. 

Brower, R. (2009). Consequences of bed rest. Critical Care Medicine 37(10), 422–428. 

Connolly, B., Douiri, A., Steier, J., Moxham, J., Denehy, L., Hart, N. (2014). A UK survey of rehabilitation following critical illness: Implementation of NICE Clinical Guidance 83 (CG83) following hospital discharge. BMJ Open 4(5). 

Connolly, B., Mortimore, J., Douiri, A., Rose, J., Hart, N., Berney, S. (2017). Low levels of physical activity during critical illness and weaning: The evidence-reality gap. Journal of Intensive Care Medicine 34(10). 

Dubb, R., Nydahl, P., Hermes, C., Schwabbauer, N., Toonstra, A., Parker, A., Kaltwasser, A., Needham, D. (2015). Barriers and strategies for early mobilisation of patients in intensive care units. Annals of the American Thoracic Society 13(5), 724–730. 

Engel, H., Tatebe, S., Alonzo, P., Mustille, R., Rivera, M. (2013). Physical therapist-estab- lished intensive care unit early mobilization program: Quality improvement project for critical care at the University of California San Francisco Medical Center. Physical Therapy 93(7), 975–985. 

Fan, E., Dowdy, D., Colantuoni, E., Mendez-Tellez, P., Sevransky, J., Shanholtz, C., Denni- son Himmelfarb, C., Desai, S., Ciesla, N., Herridge, H., Pronovost, P., Needham, D. (2014). Physical complications in acute lung injury survivors: A two-year longitudinal prospective study. Critical Care Medicine 42(4), 849–859. h

Guidelines for the Provision of Intensive Care Services (GPICS). (2015). Guidelines for the pro- vision of Intensive care Services. 

Holloway, I. and Galvin, K. (2017). Qualitative Research in Nursing and Healthcare (4th ed.). Wiley & Sons.

Iwashyna, T. (2012). Trajectories of recovery and dysfunction after acute illness, with implications for clinical trial design. American Journal of Respiratory and Critical Care Medicine 186(4), 302–304. 

King, J., and Gratrix, A. (2009). Delirium in intensive care. Continuing Education in Anaesthesia Critical Care & Pain 9(5), 144–147. 

Knott, A., Stevenson, M., and Harlow, S. (2015). Benchmarking rehabilitation practice in the intensive care unit. Journal of the Intensive Care Society 16(1), 24–30. 

Krueger, R. and Casey, M. (2014). Focus groups: A practical guide for applied research (5th edn.). SAGE Publications.

McWilliams, D., Atkins, G., Hodson, J., Snelson, C. (2017). The Sara Combilizer® as an early mobilisation aid for critically ill patients: A prospective before and after study. Australian Critical Care 30(4), 189–195. 

McWilliams, D., Jones, C., Atkins, G., Hodson, J., Whitehouse, T., Veenith, T., Reeves, E., Cooper, L., Snelson, C. (2018). Earlier and enhanced rehabilitation of mechanically venti- lated patients in critical care: A feasibility randomised controlled trial. Journal of Critical Care 44(April 2018), 407–412.

National Institute of Clinical Excellence (NICE). (2009). Rehabilitation after critical illness in adults. Clinical guideline [CG83]. https://www.nice.org.uk/guidance/cg83.

Parry, S., El-Ansary, D., Cartwright, M., Sarwal, A., Berney, S., Koopman, R., Annoni, R., Puthucheary, Z., Gordon, I., Morris, P., Denehy, L. (2015). Ultrasonography in the intensive care setting can be used to detect changes in the quality and quantity of muscle and is related to muscle strength and function. Journal of Critical Care 30(5). 

Phelan, S., Lin, F., Mitchell, M., Chaboyer, W. (2018). Implementing early mobilisation in the intensive care unit: An integrative review. International Journal of Nursing Studies 77, 91–105. 

Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, W., Bartlam, B., Burroughs, H. and Jinks, C. (2018). Saturation in qualitative research: Exploring its conceptualization and operationalization. Quality and Quantity 52(4), 1893–1907. 

Shenton, A. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information 22(2), 63–75.

Silverman, D. (2014). Interpreting Qualitative Data (5th ed.). SAGE Publications.

Thabane, L., Ma, J., Chu, R., Cheng, J., Ismaila, A., Rios, L., Robson, R., Thabane, M., Giangre- gorio, L. and Goldsmith, C. (2010). A tutorial on pilot studies: The what, why and how. BMC Medical Research Methodology 6(10). 

Twose, P. and Jones, C. (2015). A service evaluation exploring limitations to rehabilitation within critical care. Journal of Association of Chartered Physiotherapists in Respiratory Care 47, 14–26. 

Welsh Government. (2017). Annual statement of the progress 2017 for the critically ill. Available at: http:// www.wcctn.wales.nhs.uk/sitesplus/documents/1210/Annual%20Report%20for%20 the%20Delivery%20Plan%202017_WG.pdf

Williams, N. and Flynn, M. (2013). An exploratory study of physiotherapists’ views of early rehabilitation in critically ill patients. Physiotherapy Practice and Research 34(2), 93–102.