Implementation strategies to overcome barriers to early mobilisation practices in Zimbabwean and South African public sector ICUs: A Delphi study
Main Article Content
Abstract
Background. Barriers to early mobilisation in healthcare settings encompass various factors, including practical challenges, accountability and the crucial role of leadership.
Objective. To gain consensus from multidisciplinary team members in South African (SA) and Zimbabwean public sector hospitals to formulate implementation strategies addressing identified barriers for early mobilisation.
Methods. An online two-round modified Delphi study including 23 experts from SA and Zimbabwe was undertaken. The implementation strategies were aligned with the Consolidated Framework for Implementation Research that outlines five areas impacting implementation.
Results. The expert panel included intensive care unit (ICU) clinicians, academics and managers, who participated in both Delphi rounds. The median years of ICU experience was 8.5 (range 5 - 17) years, with 16 (80.0%) having a general ICU background. The panel reached consensus on several strategies to standardise early mobilisation practices in ICUs, including defining specific early mobilisation activities, appointing champion leaders, ensuring timely management of fractures, promoting patient admission to specialised units, creating dedicated physiotherapy positions, and providing skills training for staff responsible for implementing early mobilisation activities in ICUs.
Conclusion. The strategies developed represent an important step toward implementation of early mobilisation in routine ICU patient care.
Article Details

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The SAJCC is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited.
Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository.
How to Cite
References
1. Hodgson CL, Berney S, Harrold M, Saxena M, Bellomo R. Clinical review: Early patient mobilisation in the ICU. Critical Care 2013;17(1):1-7. https://doi.org/10.1186/cc11820
2. Parry SM, Remedios L, Denehy L, et al. What factors affect implementation of early rehabilitation into intensive care unit practice? A qualitative study with clinicians. J Crit Care 2017;38:137-143. https://doi.org/10.1016/j.jcrc.2016.11.005
3. Phelan S, Lin F, Mitchell M, Chaboyer W. Implementing early mobilisation in the intensive care unit: An integrative review. Int J Nurs Stud 2018;77:91-105. https://doi.org/10.1016/j. ijnurstu.2017.09.019
4. Parry SM, Knight LD, Connolly B, et al. Factors influencing physical activity and rehabilitation in survivors of critical illness: A systematic review of quantitative and qualitative studies. Intensive Care Med 2017;43(4):531-542. https://doi.org/10.1007/s00134-017-4685-4
5. Eakin MN, Ugbah L, Arnautovic T, Parker AM, Needham DM. Implementing and sustaining an early rehabilitation program in a medical intensive care unit: A qualitative analysis. J Crit Care 2015;30(4):698-704. https://doi.org/10.1016/j.jcrc.2015.03.019
6. Sibilla A, Nydahl P, Greco N, et al. Mobilisation of mechanically ventilated patients in Switzerland. J Intensive Care Med 2020;35(1):55-62. https://doi.org/10.1177/0885066617728486
7. Hariohm K, Jeyanthi S, Kumar JS, Prakash V. Description of interventions is under-reported in physical therapy clinical trials. Brazil J Physical Ther 2017;21(4):281-286. https://doi. org/10.1016/j.bjpt.2017.05.006
8. De Queiroz RS, Saquetto MB, Martinez BP, Andrade EA, da Silva PAMP, Gomes-Neto M. Evaluation of the description of active mobilisation protocols for mechanically ventilated patients in the intensive care unit: A systematic review of randomised controlled trials. Heart Lung 2018;47(3):253-260.
9. Cameron S, Ball I, Cepinskas G, et al. Early mobilisation in the critical care unit: A review of adult and pediatric literature. J Critical Care 2015;30(4):664-672. https://doi.org/10.1016/j. jcrc.2015.03.032
10. Lean MEJ, Mann JI, Hoek JA, Elliot RM, Schofield G. Translational research. BMJ 2008;337:a863.
https://doi.org/10.1136/bmj.a863
11. Tadyanemhandu C, Aswegen HV, Ntsiea V. Early mobilisation practices of patients in intensive care units in Zimbabwean government hospitals - a cross-sectional study. South Afr J Crit Care 2018;34(1):16-21. https://pmc.ncbi.nlm.nih.gov/articles/PMC9256537/
12. Tadyanemhandu C, van Aswegen H, Ntsiea V. Organisational structures and early mobilisation practices in South African public sector intensive care units—a cross-sectional study. J Eval Clin Pract 2021;27(1):42-52. https://doi.org/10.1111/jep.13378
13. Tadyanemhandu C, van Aswegen H, Ntsiea V. Barriers and facilitators to implementation of early mobilisation of critically ill patients in Zimbabwean and South African public sector hospitals: A qualitative study. Disabil Rehab 2021;44(22):6699-6709. https://doi.org/10.1080/09638288.20 21.1970827
14. Costa DK, White MR, Ginier E, et al. Identifying barriers to delivering the awakening and breathing coordination, delirium, and early exercise/mobility bundle to minimise adverse outcomes for mechanically ventilated patients: A systematic review. Chest 2017;152(2):304-311. https://doi.org/10.1016/j.chest.2017.03.054
15. Barrett D, Heale R. What are Delphi studies? Evidence Based Nursing 2020;23(3):68-69.
16. Nasa P, Jain R, Juneja D. Delphi methodology in healthcare research: How to decide its
appropriateness. World J Method 2021;11(4):116-129. https://doi.org/10.5662/wjm.v11.i4.116
17. Hsu C-C, Sandford BA. The Delphi technique: Making sense of consensus. Pract Assess Res Eval 2007;12(10). https://doi.org/10.7275
18. Van der Lee L, Hill AM, Patman S. Expert consensus for respiratory physiotherapy management of mechanically ventilated adults with community-acquired pneumonia: A Delphi study. J Eval Clin Pract 2019;25(2):230-243. https://doi.org/10.1111/jep.13077
19. Shahiri S, Gélinas C. The validity of vital signs for pain assessment in critically ill adults: A narrative review. Pain Manage Nurs 2023;24(3):318-328. https://doi.org/10.1016/j.pmn.2023.01.004
20. Boitor M, Richard-Lalonde M, Bérubé M, Émilie G, Gélinas C. Vital signs fluctuations and their relationship with pain in the brain-injured adult critically ill – A repeated-measures descriptive- correlational study. Intensive Crit Care Nurs 2019;55:102743. https://doi.org/10.1016/j. iccn.2019.07.002
21. Brissie MA, Zomorodi M, Soares-Sardinha S, Jordan JD. Development of a neuro early mobilisation protocol for use in a neuroscience intensive care unit. Intensive Crit Care Nurs 2017;42:30-35. https://doi.org/10.1016/j.iccn.2017.03.007
22. Barber EA, Everard T, Holland AE, Tipping C, Bradley SJ, Hodgson CL. Barriers and facilitators to early mobilisation in intensive care: A qualitative study. Austral Crit Care 2015;28(4):177-182. 23. Hanekom SD, Louw Q, Coetzee A. The way in which a physiotherapy service is structured can improve patient outcome from a surgical intensive care: a controlled clinical trial. Crit Care
2012;16(6):1-11. https://doi.org/10.1186/cc11894
24. Harrold ME, Salisbury LG, Webb SA, Allison GT. Early mobilisation in intensive care units
in Australia and Scotland: A prospective, observational cohort study examining mobilisation
practises and barriers. Crit Care 2015;19(1):1-9. https://doi.org/10.1186/s13054-015-1033-3
25. Hodgson CL, Schaller SJ, Nydahl P, Timenetsky KT, Needham DM. Ten strategies to optimise
early mobilisation and rehabilitation in intensive care. Crit Care 2021;25(1-4).
26. Zhang L, Hu W, Cai Z, et al. Early mobilisation of critically ill patients in the intensive care unit: A systematic review and meta-analysis.PLoS 2019;14(10):e0223185. https://doi.org/10.1371/
journal.pone.0223185
27. Nydahl P, Jeitziner M-M, Vater V, et al. Early mobilisation for prevention and treatment of delirium in critically ill patients: Systematic review and meta-analysis. Intensive Crit Care Nurse 2023;74:103334. https://doi.org/10.1016/j.iccn.2022.103334
28. Hodgson CL, Capell E, Tipping CJ. Early mobilisation of patients in intensive care: Organisation, communication and safety factors that influence translation into clinical practice. Crit Care 2018;22(1-7). https://doi.org/10.1186/s13054-018-1998-9
29. Toccolini BF, Osaku EF, de Macedo Costa CRL, et al. Passive orthostatism (tilt table) in critical patients: Clinicophysiologic evaluation. J Crit Care 2015;30(3):655.e1-e6. https://doi. org/10.1016/j.jcrc.2014.12.018
30. Van Willigen Z, Collings N, Richardson D, Cusack R. Quality improvement: The delivery of true early mobilisation in an intensive care unit. BMJ Quality Improvement Reports 2016;5(1):u211734.w4726. https://doi.org/10.1136/bmjquality.u211734.w4726
31. Zayed Y, Kheiri B, Barbarawi M, et al. Effects of neuromuscular electrical stimulation in critically ill patients: A systematic review and meta-analysis of randomised controlled trials. Aust Crit Care 2020;33(2):203-210. https://doi.org/10.1097/ccm.0000000000005941
32. Takaoka A, Utgikar R, Rochwerg B, Cook DJ, Kho ME. The efficacy and safety of in-intensive care unit leg-cycle ergometry in critically ill adults. A systematic review and meta-analysis. Ann Am Thorac Soc 2020;17(10):1289-1307. https://doi.org/10.1513/annalsats.202001-059oc
33. Wyatt GE, Thames A, Simbayi L, Stein DJ, Burns J, Maselesele M. Trauma and mental health in South Africa: Overview. Psychological Trauma: Theory, Research, Practice, and Policy 2017;9(3):249-251. https://doi.org/10.1037/tra0000144
34. Engel HJ, Tatebe S, Alonzo PB, Mustille RL, Rivera MJ. Physical therapist–established intensive care unit early mobilisation program: Quality improvement project for critical care at the University of California San Francisco Medical Center. Phys Ther 2013;93(7):975-985. https:// doi.org/10.2522/ptj.20110420
35. McWilliams D, Jones C, Atkins G, et al. Earlier and enhanced rehabilitation of mechanically ventilated patients in critical care: A feasibility randomised controlled trial. J Crit Care 2018;44:407-412. https://doi.org/10.1016/j.jcrc.2018.01.001