الفهرس 
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Abstract
SUMMARY
The intensive care unit (ICU) is a medical facility for treating patients with serious illness, postoperative, and multiple organ dysfunction using advanced devices, treatments, and a variety of nursing interventions (Chen et al., 2022). Technological advancement and progression in critical care patient management have improved intensive care delivery (Kerlin et al., 2021).
Critical illness is usually associated with catabolic stress, increased infectious morbidity, prolonged hospitalization, and mortality rate (Cattani et al., 2022). Critically ill patients that stay in Intensive Care Units (ICUs) for long periods suffer from Post-Intensive Care Syndrome or ICU Acquired Weakness, whose effects could decrease patients’ quality of life for years. To prevent such complications and aiming at shortening intensive care treatments period, Early Mobilization (EM) had been proposed as an encouraging technique (Ferre et al., 2021).
Early mobilization, defined as the application of physical activity as early as the second to the fifth day after the onset of critical illness or injury to reduce the incidence of ICUAW at the point of ICU or hospital discharge, improve patients’ unassisted walking distance, and to decrease the overall length of stay at ICU, as well hospital and rehabilitation facilities (Lad et al., 2020; Semsar et al., 2020).
Assessment of nurses’ knowledge, practice, attitude and perception towards applying early mobilization among critically ill patients and its barriers had faced much interest from researchers in last few years. Current evidence appears that 38%-67% of critically ill patients worldwide experienced dysfunctions and impairments, and 62% of the survivors developed persistent complications for up to ten years after discharge from the intensive care unit (Liu et al., 2019).
Aim of the study:
This study aimed to assess nurses’ perception regarding barriers of early mobilization among critically ill patients through the following:
1- Assess nurses’ knowledge, practice and attitude regarding early mobilization among critically ill patients.
2- Assess nurses’ perception regarding barriers of early mobilization among critically ill patients.
Research Question:
What is the level of nurses’ knowledge, practices and attitude regarding early mobilization among critically ill patients?
What is the nurses’ perception regarding barriers of early mobilization among critically ill patients?
The present study was carried out through the following four design:
I. Technical Design.
II. Operational Design.
III. Administrative Design.
IV. Statistical Design.
I. Technical Design:
The technical design includes (research design, setting, subjects, and tools for data collection).
Research design:
A descriptive exploratory design was utilized to achieve the aim of this study.
Setting:
The Medical Intensive Care Unit at El-Demerdash Hospital and the Cardiac Intensive Care Unit, both of which are affiliated to Ain Shams University Hospitals in Egypt, served as the sites for this study. These ICUs are well-equipped with cutting-edge machinery, tools, and number of staff needed to care for patients. The ground-floor medical intensive care unit, which has 15 beds overall and two isolated rooms with two beds each connected to a monitor and a mechanical ventilator. The first-floor cardiac intensive care unit is divided into three rooms, room (A) include six beds, each connected to a monitor, and two mechanical ventilators. Room (B) include three beds, each connected to a monitor, and Room (C) include two beds only, each connected to a monitor too.
Subjects:
The study included a convenience sample of all the nurses (60) working in the selected ICUs who were directly involved in patient care and who agreed to participate in the study.
Tools of data collection:
Four tools were used to achieve the aim of this study included:
Tool I: Nurses’ interviewing questionnaire:
It used to assess nurses’ knowledge regarding barriers of early mobilization among critically ill patients and it was developed by the researcher based on reviewing of the recent related literature (Soni & Sharma, 2021) & (Mohamed et al., 2020) and include two parts:
Part I: It was concerned with the demographic characteristics of the nurses under study, included seven closed-ended questions about age, gender, marital status educational attainment, years of ICU work experience, protocol for early mobilization and training programs attended for EM of CIPs.
Part II: It was concerned with nurses’ knowledge regarding barriers of early mobilization among critically ill patients. This section consisted of six major divisions. It had 39 questions, including 19 multiple-choice and 20 true/false inquiries, about the meaning of mobility (1 question), the significance of EM (12 questions), the different kinds of exercises (4 questions), the negative effects of immobility (7 questions), obstacles to EM (8 questions), and the safety issues relating to EM (7 questions).
Scoring system: The scoring system for this part was as following: one grade was given for the correct answer and zero for the incorrect answer, with total mark= 39
The total level of nurses’ knowledge was categorized as following:
• ≥80% was considered satisfactory level, it equal 31.2 grade based on statistical analysis.
• <80% was considered unsatisfactory level.
Tool II: Nurses’ Practice Observational Checklist:
It was used to assess nurses’ practice regarding barriers of early mobilization among critically ill patients, this part was adopted from (Audrey, 2022; Patricia, 2020 & Rowden et al., 2019), and had five main sections:
Part I- Early Mobilization of conscious Patient:
- This section contains the following related questions, active range-of-motion exercises (30 items), transferring a patient from the bed to a chair (21 items), assisting the patient with ambulation (19 items), assisting the patient with ambulation using a walker (21 items) and deep breathing and coughing exercises (14 items).
Scoring system:
• ≥80% was considered satisfactory level.
• <80% was considered unsatisfactory level.
Part II- Early Mobilization of Unconscious Patient:
- This section contains questions related to turning and positioning the patient in bed (15 items), as well as passive range-of-motion exercises (19 items).
Scoring system:
• ≥80% was considered satisfactory level.
• <80% was considered unsatisfactory level.
Part III- Early Mobilization of Post-Operative Patient:
- This section consists of questions related to exercises for deep breathing (16 items) and coughing, 13 items to help the patient use an incentive spirometer, 12 items to help the patient with foot and leg exercises, and 19 items to help the patient walk.
Scoring system:
• ≥80% was considered satisfactory level.
• <80% was considered unsatisfactory level.
Part IV- Early Mobilization for Patient with Connective Devices:
- This section consists of questions related to assisting a patient with an intravenous (IV) infusion (13 items), assisting a patient with a urinary drainage bag (15 items), assisting a patient with a drainage tube (13 items) and assisting a patient with a closed chest tube drainage system (18 items).
Scoring system:
• ≥80% was considered satisfactory level.
• <80% was considered unsatisfactory level.
Part V- Early Mobilization for Patient with fractured leg:
- This section consists of questions related to assisting the patient with ambulation using crutches this checklist involved (19 items).
Scoring system:
• ≥80% was considered satisfactory level.
• <80% was considered unsatisfactory level.
The total score of practice was 300 marks, the response to each item in the procedure was categorized into (done correctly & not done). One grade was given for each correct step and zero for each incorrect or not done.
Total score categorized as the following:
• ≥80% was considered satisfactory, it equal 240 grade based on statistical analysis.
• <80% was considered unsatisfactory level.
Tool III: Nurses’ attitude regarding early mobilization among critically ill patients:
This tool was used to assess nurses’ attitude regarding early mobilization among critically ill patients. It involved 14 statements, it was adopted from (Golaszewski, 2019).
Scoring system:
This part consists of 14 statements with total score 42 marks. Ranging from one to three. One was given for disagree, two was given for partially agree and three was given for agree. Calculate the mean score for each participant by summing up the scores for all items and dividing by the number of items.
The total score was categorized into:
• Positive attitude <80%
• Negative attitude >80%
Tool IV: Nurses’ perception regarding barriers of early mobilization among critically ill patients.
It was developed by the investigator based on reviewing of recent literature (Soni & Sharma, 2021) & (Mohamed et al., 2020) and were include 23 statements divided into: Patient related barriers (11 items), Nurses related barriers (9 items) and ICU related barriers (3 items).
Scoring system:
This part consisted of 23 statements with total score 69 marks. The response for each statement ranged from one to three. One was given for disagree, two was given for partially agree and three was given for agree. Higher mean scores indicate a positive perception of barriers to early mobilization among critically ill patients, while lower mean scores indicate a negative perception of barriers. Calculate the mean score for each participant by summing up the scores for all items and dividing by the number of items.
The total score was categorized into:
• Positive perception <80%
• Negative perception >80%
Operational Design:
Preparatory phase:
It included reviewing of the related literature, and theoretical knowledge of various aspects of the study using books, articles, internet periodicals, and magazines to develop tools for data collection.
Testing validity and Reliability (Appendix V):
Validity:
Testing validity of the proposed tools by using content validity. Validity was tested through a jury of five experts from critical care nursing department, Ain-Shams university (two Professors and one Assistant professor). The experts reviewed the tools for relevancy, comprehensiveness, minor modification was done.
Reliability:
The Cronbach Alpha Test was used to evaluate the proposed tools’ dependability (Tool I: 0.867, Tool II: 0.704, Tool III: 0.822, and Tool IV: 0.786).
Administrative Design:
To carry out the study, the approval letter was obtained from the dean of the faculty of nursing, Ain shams university and the director of the hospital were the study conducted after taking a letter from the faculty ethical committee explaining the aim of the study to obtain the permission for data collection.
Ethical consideration:
The research approval obtained from the ethical committee before starting the study. The investigator obtained the objectives & aim of the study to nurses included in the study. The investigator assured maintaining anonymity & confidentiality of subjects’ data. Nurses were informed that they allowed choosing to participate or withdraw from the study at any time.
Pilot study:
A pilot study was conducted on 10% of the study subjects in order to test applicability of the study tools, clarity of the included questions as well as estimations of the average time needed to complete all questions to fill in the study tools. Results obtained were studied and analyzed. Accordingly, modifications were done for the final development of the study tools. Nurses selected for the pilot study were included in the study.
Field work:
- Prior to any written data collection, included interviews with (60) nurses who were caring to critically ill patients who were immobilized in the previously described setting. These interviews were conducted in order to explain the study’s objectives, assess how they would affect their performance and the quality of care provided to the patients, and obtain their consent to participate in the study.
- Data collection took about 4 months start from the beginning of January 2023 until the end of April 2023.The data were collected by the investigator through 3 days/week (Sunday, Tuesday & Wednesday) during the morning and afternoon shifts, each nurse was interviewed individually by the investigator.
- Assessing nurses’ knowledge, practice, attitude and perception regarding barriers of early mobilization among critically ill patients in intensive care units by using the study tools as follow:
1- The observational checklist was used by the investigator to assess nurses’ skills during applying care for patients. It takes about 40-45minutes for every nurse to fulfill by the investigator at morning and afternoon shifts.
2- The interviewing questionnaire tool was filled by the nurses. It takes about 20-25 minutes for every nurse fulfilled.
3-The 3rd and 4th tools were filled by the nurses. It takes about 10-15 minutes for each tool to be fulfilled by each nurse.
Statistical Design:
- After the data collection process was complete, the statistical package for social sciences, version 22.0 (SPSS Inc., Chicago, Illinois, USA) was used to analyze the recorded data. The mean and standard deviation (SD) were used to express quantitative data. Frequency and percentage were used to express qualitative data.
The following tests were done:
- To compare proportions between qualitative parameters, the Chi-square (x2) test of significance was applied.
- The strength of the correlation between two sets of variables was evaluated using Pearson’s correlation coefficient (r) test.
- The accepted margin of error was set at 5%, and the confidence interval was set at 95%.
Results:
The important findings that were obtained from the study can be summarized as follow:
- Regarding demographic data, 83.3% of the studied nurses were less than 30 years old while 13.3% aged from 30 to 35 years old. 63.3% of the studied nurses were male while, 36.7% were female and 71.7% of the studied nurses were single.
- Regarding educational level, 70.0% of the studied nurses were Technical Nursing Institute while, 26.7% were BSc Nursing. Moreover, 75.0% of the studied nurses less than 10 years of ICU working experience. 100% of the studied nurses were Not attend training programs or workshops about early mobilization of critically ill patients and there is not a protocol for early mobilization of the patient in the intensive care unit in the selected ICUs.
- Regarding level of knowledge, 63.3% of the studied nurses had unsatisfactory total level of knowledge regarding barriers of early mobilization among critically ill patients. While, 36.7% had satisfactory total level of knowledge.
- Regarding nurses’ perception of barriers of early mobilization among critically ill patients, 91.7% of the studied nurses agreed with ICU related barriers. 83.3% of the studied nurses agreed with nurses related barriers. Moreover, 60% of the studied nurses agreed with patient related barriers.
-Regarding nurses’ attitude about barriers of early mobilization among critically ill patients, 95% of the studied nurses agreed with the physical therapist should be the primary care provider to mobilize the patients. 80% of the studied nurses agreed with not sure when it is safe to mobilize my patients. 78.3% of the studied nurses agreed with that increasing the application of early mobilization of patients is considered a job that is not of their specialty. Moreover, 73.3% of the studied nurses agreed with don’t feel confident in their ability to mobilize the patients. 53.3% of the studied nurses agreed with it is safe for the patient to have early mobilization in the intensive care unit.
-58.3% of the studied nurses had a negative level of total attitude regarding barriers of early mobilization among critically ill patients.
- Regarding nurses’ practice about early mobilization among critically ill patients, 65% of the studied nurses had unsatisfactory level of practice.
-Regarding Correlation between total level score of nurses’ knowledge, opinion about barriers, attitude & practice of early mobilization among critically ill patients, there were statistical significance positive correlation between total knowledge and practice at (p-value<0.001) & r (0.230 & 0.342 respectively). While, there is statistical significance negative correlation between total level of knowledge and nurses’ opinion at (r =0.656). Also, results reveals that there is a highly statistical significance negative correlation between nurses’ opinion about barriers and their knowledge, attitude & practice respectively at (p-value=0.00) & (r= -0.656, -0419, & -0.638 respectively). Moreover, results reveals that there is a statistical significance positive correlation between nurses’ practice and their knowledge & attitude at (p-value<0.001) & (r= 0.342 & 0.392 respectively). While there is a negative correlation between nurses’ practice and their opinion about barriers at (p-value<0.001) & (r= -0.638).
Conclusion:
Based on the results of the present study and research question the study concluded that:
Less than two thirds of the studied nurses had unsatisfactory total level of knowledge regarding early mobilization among critically ill patients. And less than two thirds of the studied nurses had unsatisfactory total level of practices regarding early mobilization among critically Ill patients. Also more than half of the studied nurses had a negative attitude regarding early mobilization among critically Ill patients. Additionally, most of the studied nurses agree with ICU related barriers of early mobilization among critically ill patients. While, minority of studied nurses disagree with these barriers.
Recommendations:
In the light of the finding of this study, the following points are recommended:
1- Critical care nurses should periodically attend training programs and workshops about EM training to maintain their knowledge and competency.
2- Develop and apply a protocol for early mobilization of the patients in the medical intensive care unit that affiliated to Ain Shams University.
3- The need for future studies to apply educational program for nurses about early mobilization among critically ill patients and investigate its effect on the patient’s status.