Decision making

Prior to mobilising a patient for the first time all the respondents stated that the patient would have to be “medically stable”. Staff defined medical stability as blood pressure, heart rate and oxygen saturation levels being within the normal ranges. A need for cardiovascular stability has been regarded by HCPs in other studies as a key consideration when mobilising patients for the first time.^{178 179}

“… and I think, um, general not wellness has always been a factor as well, so, um, physiologically, we’re told always that if saturations are low or if they’re tachycardic, or blood pressure’s too high or low, then they don’t get mobilised.”

(ID 22, Doctor)

Other terms such as “medically unfit” and “medically unwell” were also used. It is unclear if these terms were used in addition to “medically stable” and had different meanings or used interchangeably. Other factors such as level of consciousness, headaches and temperature were also included in the definition of “medically unfit”. It may be that “medically stable” relates to cardiovascular stability while “medically fit” relates to the patient’s general health status.

“Other reasons for not getting people up? Pain, not that common with strokes I suppose, headaches and things you get with it. Headaches and drowsiness but, I suppose, that’s a medically unfit patient with a headache or drowsiness. They probably need to just take things more slowly.”

(ID 10, Doctor)

Signs of medical instability were monitored during the first mobilisation using either physiological monitoring equipment or subjective assessment. The need for medical stability appeared to be a communally approved criterion evolved from clinical opinions; “we’re told always” rather than evidence-based. This prerequisite for medical stability was only challenged by doctors.

“ Well, I don’t, I don’t, um, it’s not that I don’t believe it, nobody can give me any evidence [voices overlap] to say that it’s a harmful thing to-to mobilise somebody with those issues. Um, and I suppose at the moment, nobody can give me a lot of evidence that only mobilisation…definitely, definitely, definitely is the right thing to do either.”

(ID 22, Doctor)

Doctors viewed the patient’s ability to achieve sitting balance as an important factor in the decision making process in mobilisation a patient for the first time.

This agrees with the existing theory that concerns are related to the area of non-expertise i.e. doctors towards the physical aspect of mobilisation.¹⁷⁸

“I guess the key thing would be that the physio would decide if the patient had enough sitting balance to get up to a chair would be the first step and if they didn’t they couldn’t and if they did you know they would be got up”.

(ID 9, Doctor)

In contrast when posed to nurses and therapists in later interviews sitting balance was not considered as a determinant to mobilising patients.

I: “Sure, if they've got enough sitting balance?

R: Well, he hasn’t got any, but he's safe enough in...we've got an appropriate chair for him.”

(ID 30, Nurse, non-VEM)

Unlike therapists, the level of weakness the patient had seemed to be more of a deciding factor in whether a nurse would mobilise the patient for the first time.

This depended on “what nurse was on [shift]” with some nurses going ahead and mobilising patients regardless the degree of weakness: “especially if they look like they have got a dense weakness there, we would normally just hoist them anyway regardless”. Nurses believed they take the lead from physiotherapists with regards to mobilisation, especially of patients with more complex needs, but it could be that nurses underestimated the extent of their role in the mobilisation of patients. One strength of the focus group data is that the participants can choose whether to agree or disagree with the other

participants’ impressions or opinions. In the conversation below, the nurse explains that she usually relies on physiotherapists however the physiotherapist present in the same focus group quickly interjects the nurse to correct her colleagues perceived role in mobilisation.

ID 014: “It's taking the lead really from you.

ID 012: Well, it's not always the case, because yous are often...

ID 014: Aye, no, at the weekend, at the weekend, uh huh.

ID 012: You'll always get people up.

ID 014: Aye, we still do. Unless they're going to be a huge mobility risk and then we would say, do you know, it's not really advisable for us, we need to wait for physios or other therapists to come in and assess them.”

Focus group 3 (012 – Physiotherapist, VEM; 014 – Nurse, VEM)

Other factors including the patient’s risk of complications, level of consciousness or fatigue played a role in influencing the HCP’s decision to mobilise a patient for the first time.

“I mean, he was medically kind of stable enough, though, to kind of get him up, but he had gurgle chest, so getting him up to sit in the chair is much better than, than being in the bed anyway”

(ID 30, Nurse, non-VEM)

Low levels of consciousness did not discourage the mobilisation of a patient;

therapists reiterated the need for a “dynamic risk assessment” to detect any changes in the patient’s medical status in response to being upright. The

following extract from a physiotherapist provides a step-by-step commentary of the typical decision making process when mobilising a patient for the first time.

“…then actually if they are medically stable regardless of their GCS [Glasgow Coma Scale] we would probably get them up but not necessarily out of bed but we would assess them sitting over the edge of the bed to see what their arousal state is like and see if they are actually waking up to any stimulation and then from there check monitor their cardiac, blood pressure stability and if we feel that it is appropriate we will get them out of bed with the appropriate means…but of you feel it is still a wee bit too early then we would get them back to bed and go back the next day…GCS 3…mmmm…maybe just put them back to bed depending if there are 98 [years of age] or whatever but yeah if they’re starting to come round we would probably push them.”

(ID 4, Physiotherapist, VEM)

There was some agreement between nurses and physiotherapists that nurses were more tentative than physiotherapists when deciding to mobilise a patient for the first time. Furthermore, some nurses were critical of nursing colleagues for their overly zealous approach to mobilisation while it was physiotherapists that considered themselves to be the pro-active group in having a more

“aggressive” approach to mobilising patients than nurses. This was not always the case with one nurse posing the following question;

“And sometimes we take a risk even when they are not medically stable don’t we?”

(ID 3, Nurse, VEM)

The majority of nurses and therapists regarded fatigue as a direct consequence of stroke which may have resulted in a more cautious or protective approach to mobilising patients had it been related to some other cause such as disturbed sleep patterns or associations with a result of low mood.

“I’m a bit of a stickler for people sitting out [of bed] and I, I sometimes get this chat about they’ve not been sat out cos they were too sleepy. But I mean it’s all relative, and yeah, some people occasionally are too

drowsy…even to sit out, and certainly people can be too drowsy to have physiotherapy, but, yeah, I’d just…occasionally I’ve thought perhaps just needed to be slightly more…”

(ID 11, Doctor)

Relatives/carers placed value in knowing their relative had been up sitting in a chair, often asking if “they been up to sit today?” when they phoned in the morning. The meaning of mobilisation to relatives did require special

consideration. Although not usually reported as a reason for not getting someone up early after stroke, mobilisation may provide relatives/carers with false hope which was particularly relevant for patients with poor rehabilitation potential or prognosis where patients may appear to look a lot better when sitting upright.

“…maybe they are not for resus but they are still for active treatment then to sit someone out that may give their relatives the wrong impression so we have to take that into consideration as well so again kind of

weighing up the individual and thinking well is it appropriate that they sit out”

(ID 3, Nurse, VEM)