5.3 Findings
5.3.18 Summary of barriers and facilitators
Barriers to mobilising patients within 24 hours included lack of staff stroke experience, delays in diagnosis and patient presentation to hospital, break-downs in the referral process, lack of bed availability in the ASU, patient
“medically unstable”, perceived risks of mobilisation, time of admission to stroke unit, individual patient requirements, staff lack of
confidence/experience, staff clinical decision making and the belief by staff that ‘we already mobilise early’. Barriers to increasing the frequency of mobilisation patient had been mobilised for the first time, included a lack of resources, unpredictability of stroke care, lack of evidence-base, patient fatigue, lack of and competing demands on time and the physical layout of ward.
Facilitators to mobilising patients within 24 hours included the provision of stroke specific training for hospital admission staff, a protocol for early
mobilisation, support from hospital managers and the education of non-specialist staff working in general medical units in the principles of VEM. A structured therapy referral system, perceived benefits of mobilisation, early team
communication, earlier admission to the stroke unit, planning the patient day, daily team communication, therapy cover at weekends and an increase in resources, were the facilitators identified to mobilising a patient more
frequently within the ASU. These barriers and facilitators are summarised for each stage of the stroke pathway in Figure 5-1.
Figure 5-1 Barriers and facilitators by stage of the stroke pathway BARRIERS
Patient medically unstable
Percieved risks of mobilisation Lack of resources
Time of admission to stroke unit Unpredictability of stroke care Individual patient requirements Lack of evidence base
Lack of staff stroke experience Staff lack of confidence/experience Patient fatigue
Delay in diagnosis Break-down in referral process Staff clinical decision-making Lack of and effective use of time Delay in patient presentation Bed availability in ASU Belief ‘we already mobilse early' Physical layout of ward
Stroke diagnosis Admission to ASU First Mobilisation Mobilisation
FACILITATORS
Ongoing training for admission staff Protocol for early mobilisation Structured therapy referral system Planning patient day Support of hospital managers Perceived benefits of mobilisation Daily team communication Educate non-specialist staff in VEM Early team communication Therapy cover at weekends
Earlier admission to stroke unit Beliefs against bed rest
Increase in resources
Patient pathway Patient pathway
Patient pathway Patient pathway
5.4 Discussion
This study has provided rich narratives about HCPs’ experiences of working within an ASU. Barriers and facilitators to implementing VEM have been
identified and a set of beliefs that HCPs hold towards VEM has been formulated.
Summary of key findings: barriers and facilitators identified
As previously explained, information about barriers and facilitators is
particularly salient for a complex intervention such as VEM. Factors that may promote or inhibit the embedding of VEM in routine practice were identified for each stage of the stroke pathway. Accessing the patient during the acute stage, with the patient being off ward for tests was viewed as problematic by staff.
Interestingly, the observational data estimated that the time spent off the ward by patients was only 3.7% which illustrates that potentially, there is
incongruence between perceived barriers and real-life (Appendix 14). The need for more staff was an automatic and recurring response when the participants were asked what would be required to facilitate VEM in routine clinical practice.
Few participants were able to provide details of the form that this required additional resource may take and fewer (two participants at the same hospital) challenged that the focus should be more on how best to use current staffing resources.
At a site level, the same barriers and facilitators to VEM were raised regardless whether they had experience of the trial or not. Staff currently involved in AVERT phase III were more forthcoming in identifying requirements for the
delivery of a rapid mobilisation service to patients such as an outreach service to wards outside the ASU. Making comparisons between sites is important to
identify the factors that may predict implementation. For example, staff from all but one of the sites believed that communication between nurses and therapists was cohesive, fluid and responsive. At the other site, also a non-AVERT site, there were signs of tension between staff which impacted on the opportunity for mobility practice. Comparing sites is useful to identify the absence of key processes or components of care. This example highlights that communication is pivotal to patient mobilisation and that targeted strategies are
required to prepare such sites prior to implementation of VEM.
Barriers and facilitators are often classified into environmental or organisational, however this requires knowledge about the cause of the barriers and facilitators.
For example, lack of resources may be an individual’s perception of the
organisation rather than the organisation not providing enough staff to organise the system. Bed availability may be due to the break-down in operating the system, not the actual system put in place by the organisation.
Summary of key findings: healthcare professionals’ beliefs
The main beliefs about VEM were centred around the perceived impact on the patient’s outcome and the HCPs routine practices. More specifically, it was believed that VEM:
• is already being conducted
• relies on the time of symptom onset being available
• is beneficial to patients but may have some risks
• is associated with an increased workload
• is a shared task between therapists and nurses
• requires tailoring to meet individual patient requirements
• is appropriate only for patients who are medically stable
Each of these beliefs will be discussed briefly in turn. All of the participants were aware of the current Scottish Intercollegiate Guideline Network which states that “stroke patients should be mobilised as early as possible after stroke”.2 Therefore, HCPs may have been eager to portray themselves as adhering to the current guideline about early mobilisation. This may explain their immediate response that they are already practising VEM when first asked.
When the definition of VEM was reiterated and participants were asked to compare the VEM principles with their current practice and processes, it emerged that staff were actually mobilising patients for the first time as early
after stroke as they believed was possible. Indeed, the observational data (Chapter 3) did indicate that the time of first mobilisation was either more than 24 hours or unknown, conflicting with HCPs beliefs of what happens (Appendix 15). Integrating the qualitative and quantitative data in this way (triangulation) raises an interesting question about how behaviour can be perceived to be different to that which actually occurs. The more general question that is raised here is - how best to define VEM so that it is distinguishable from current
practice? This is a common issue associated with complex interventions. Current mobilisation practice appeared to be highly variable (patient and context
dependent), implicit (‘just something that we do’) and largely undefined as a specific intervention in acute stroke care. As the time from symptom onset to hospital arrival is the factor determining eligibility for many acute stroke interventions this does pose challenges in being able to ascertain this information and subsequently deliver the intervention within an acute
timeframe.193 The belief that VEM is beneficial was based on the understanding that bed-rest can result in immobility-related complications.
The association of VEM with an increase in workload was a prevalent topic discussed amongst all therapists and nurses, particularly therapists.
Interestingly, for HCPs working at non-AVERT sites and with no experience of VEM this perception had been shaped through conversations with other local HCPs who were working at AVERT phase III sites and delivering the intervention.
Some HCPs did believe that perceptions of increased workload could be
alleviated once experience of delivering the intervention was gained. This raises once again the issue of contamination of complex interventions, initially
presented in Chapter 1. The AVERT phase III intervention protocol prohibits communication between trial and non-trial staff. Contamination in the form of current behaviour inadvertently being changed due to attempts to adopt the intervention under study, does not appear to be the issue here. More
disconcerting are the negative preconceptions around VEM as a result of communication between trial and non-trial staff.
Staff regularly stated that their current workload was busy enough. Although, there was a sense (when comparing findings in Chapter 3) that staff tended to over-estimate and make assumptions about the length of time a patient was
inaccessible during the day. Perceptions about the patient’s accessibility and readiness for therapy/mobilisation resulting in missed opportunities. It may be that staff need to realise that they may not be using time as efficiently as they believe. The Productive Ward: Releasing time to careTM programme by the NHS Institute for Innovation and Improvement provides an example of how this
realisation could be provoked in real-life. This initiative aims “to empower ward teams to identify areas for improvement by giving staff the information, skills and time they need to improve the way they work and the care they provide”.194 Staff are video-recorded during routine practice (referred to as an ‘activity
follow’) and then these recordings are fed back directly to the staff included.
Exposing staff to their own actual data separated their beliefs about goings on and reasons for things occurring with reality. The video recordings from these
‘activity follows’ provided a sense of revived individual responsibility amongst HCPs and reactive engagement to collectively identify problem areas and provide simple solutions.
The majority of participants viewed the first mobilisation as a shared task whilst in a previous study the majority of nurses and therapists believed that each professional group had independent responsibility.178 Staff worked together to deliver mobilisation to patients and were cognisant that the success of this depended not only on their individual skill-set but also understanding and having confidence in the skills of their colleagues. At the sites where this was not the case (evidence at two sites) there was an obvious and historical divide between the nurses and therapists where roles appeared to be based on traditional models. There were occasions where the physiotherapists believed that the nurses had made the incorrect judgement. At one AVERT phase III site the physiotherapists were unclear as to who actually delivered the first mobilisation for intervention trial patients. This illustrates that there is some evidence that the division of labour may not always be explicit and this can differ markedly between sites depending on the skills and experience of staff.
There were a number of patient level factors that contributed to the decision whether to mobilise a patient for the first time. Many patients have
comorbidities which may determine the level of physical activity that they are able to engage in. The factors were not only multiple, varied by individual
patient but were also considered simultaneously making it challenging to
identify the key factor(s) driving decision making. For example, HCPs commonly used trade-offs when deciding to mobilise a patient up-to-sit in a chair for the first time:
• increasing fatigue levels versus creating a more stimulating environment
• reduced consciousness level versus reducing risk of chest complication This decision making was an intuitive process for most staff when mobilising a patient for the first time and it was believed that the same principles would apply to VEM. Reliance on subjective evaluations of patient progress based on intuition or clinical experience is recognised elsewhere.195 Medical stability was the most pressing issue for professionals, which is in line with a previous study whereby along with the level of consciousness, medical stability was considered one of the most important factor in deciding whether or not to mobilise a
patient.178 There is a need for the term “medical stability” to be clearly defined and for more evidence around the mobilisation of patients considered to be
“medically unstable”. The patient’s level of consciousness was a key factor in deciding whether or not to mobilise a patient both for the first time and when continuing mobilisation practice. Defining consciousness was difficult due to the number of terms used and an acceptable level of consciousness was not agreed;
it was clear that if patients were almost asleep staff questioned the worth of getting them sitting up in a chair.
Strengths and limitations
The findings are based on a relevant sample of HCPs and provides multiple and diverse perspectives. One limitation in the study was that no nursing assistants participated. Nursing assistants are considered to be the group who deliver a large proportion of patient care and are involved in the day-to-day mobilisation of patients.
The findings from triangulation of data (using the observational data and the qualitative data) presented at points through this discussion have proved useful in highlighting discrepancies between what staff believe they do and what they