Healthcare professionals’ experiences of mobilising adult patients out of bed shortly after major abdominal surgery – a qualitative study

Abstract

Background

Early mobilisation is endorsed after abdominal surgery. Healthcare professionals are key figures in mobilisation. However, their experiences of barriers and enablers of mobilisation shortly after abdominal surgery is yet not fully explored. Therefore, the aim was to describe the healthcare professionals’ experiences of postoperative mobilisation shortly after abdominal surgery.

Methods

This study has a qualitative descriptive design. In November 2017, individual interviews were conducted with a convenience sampling of ten nurses, three nurse assistants and four physiotherapists who participated in an interventional trial mobilising adult patient within two hours after abdominal surgery. Data were analysed with inductive content analysis. Reporting of the study followed the COREQ checklist.

Findings

The study findings are presented in two categories: ‘a responsibility for the patient’ and ‘prerequisites and challenges’ with five subcategories. The healthcare professionals had initial concerns that mobilisation shortly after surgery would not be safe for the patient and would add extra burden on their workload. However, with time, their perceptions changed to believing that it enhanced the recovery and was feasible to conduct at the postoperative recovery unit.

Conclusion

Mobilisation shortly after abdominal surgery at the postoperative recovery unit, was found to be beneficial for the patients without reducing patient safety. However, it is important to assure that sufficient resources and adequate competence are available if such intervention should be implemented in clinical practice.

Keywords:

• Interview
• healthcare professionals´ perspective
• early mobilisation
• abdominal surgery
• qualitative research

Background

Bedrest after surgery is associated with increased risk of postoperative complications such as thromboses and pneumonia [1,2]. To prevent complications and to enhance recovery, international guidelines recommend that patients are mobilised out of bed for at least two hours on the day of surgery, postoperative day 0 (POD 0) [3]. However, major surgery is often extensive, and not completed until late afternoon or early evening when the staffing levels generally are lower, and in clinical practise mobilisation does not start until the day after surgery [4]. There is an ongoing debate about what is defined as early mobilisation. Most studies regard mobilisation as early if the patients are out of bed at postoperative day 1 [4,5]. However, despite recommendations of early mobilisation, previous studies have focused on aspects of mobilisation within the first week after surgery [4], the association between mobilisation and postoperative complications [6,7], or the benefits of structured mobilisation protocols [4,5]. Regardless, patients and healthcare professionals are key figures in mobilisation, and every step in the recovery pathway after surgery is important. Still, most research about experiences of mobilisation is focused on mobilisation at intensive care [8], or at the wards, days after surgery [4,9], not early mobilisation, at POD 0. There are studies though providing evidence for that mobilising patients, already at the postoperative recovery unit improves respiratory function [10,11], and facilitate patients’ autonomy, and alertness [12]. In a randomised controlled trial conducted in a postoperative recovery unit at Karolinska University Hospital in Stockholm, Sweden in 2017, mobilisation out of bed already two hours after major abdominal surgery were evaluated and the results indicated respiratory benefits for patients [10]. Yet, how healthcare professionals experienced mobilising adult patients shortly after major surgery remains unexplored. In order to refine the postoperative care of patients and to further evaluate the feasibility of mobilisation, earlier than common practise, there is a need to understand healthcare professionals´ perceptions of the procedure. Therefore, this study aimed to describe healthcare professionals´ experiences of postoperative mobilisation of adult patients, shortly after abdominal surgery.

Methods

Study design

A qualitative descriptive design was used to obtain a direct description of healthcare professionals’ experiences of mobilisation shortly (within two hours) of major abdominal surgery. Using qualitative descriptive methodology enabled the healthcare professionals to describe their perspective of the new procedure and assured that the researchers presented findings in line with the informants’ responses [13]. Data were collected through individual interviews using semi-structured questions.

Setting

Every year, approximately 4500 patients undergo elective abdominal surgery, mainly due to cancer, at the current hospital. The study was conducted at a postoperative recovery unit at Karolinska University Hospital in Stockholm, Sweden. The nurse: patient ratio at the postoperative recovery unit is 1:5 and the nurse assistant: patient ratio is 1:10. Outside the trial, a physiotherapist is present during office hours and an anaesthesiologist oversees the postoperative recovery unit around the clock.

The intervention

In 2017, a randomised controlled trial conducted at a postoperative recovery unit, evaluating the respiratory effect of mobilising adult patients out of bed, to sit in a chair, within two hours after major abdominal surgery. Prior to the trial, only patients with acute respiratory failure or those assigned mobilisation for urgent matters were mobilised within two hours of surgery. No patient received pre-habilitation or preoperative education regarding mobilisation. In brief, 214 adult patients (ages ranging from 22 to 93 years), who underwent elective open, or robot assisted laparoscopic gynaecological, urological or endocrinological abdominal surgery were randomised to either a) breathing exercises and mobilisation out of bed, or b) mobilisation out of bed, or c) to remain in bed with a maximum of 30 degrees elevation of the headrest. Nurses, nurse assistants, and physiotherapists assisted the patients in transferring from bed to chair. The healthcare professionals were instructed to mobilise patients in the intervention arms within two hours of surgery. The patient was instructed to sit for as long as he or she was able to. All healthcare professionals were introduced to the mobilisation procedure prior to study start. Moreover, chairs were available at the postoperative recovery unit and a physiotherapist was present between 8 AM and 10 PM [10].

Participants

All healthcare professionals who were involved in the trial, mobilising patients, were eligible for the study. A convenience sampling strategy was applied to obtain a heterogeneous sample regarding age, sex, profession and years of work experience [14]. The head nurse of the postoperative recovery unit informed those who met the inclusion criteria about the study and asked if they were interested to participate in the study. Thereafter, one researcher informed them about the reasons behind the study and the purpose of the study. Recruitment ceased when no new information from the interviews emerged, a consensus decision between the two interviewers [15].

Data collection

The interviews were conducted in November 2017, one month after completion of the trial. A semi-structured interview guide was used [Additional file 1]. The interview guide was developed by the researchers and was based on previous knowledge in the research field. Each interview started with questions regarding age and work experience (Table 1). The interview guide was tested in a pilot interview to confirm the relevance of the content [16]. Only small adjustments were made and therefore the pilot interview was included in the analysis. Some questions were intentionally left open, to enable reflections, and probing questions such as; ‘can you tell me more about this?’, ‘what happened then?’, and ‘can you elaborate on this?’ were posed to explore issues that appeared important [17]. The first interviews indicated that the wording was clear, and no adjustments to the interview guide were necessary. All interviews were conducted individually, in a private room close to the postoperative recovery unit, by one of the two researchers (MFO and MNB). They conducted eight and nine interviews, respectively. The interviewers (MFO and MNB) were physiotherapists and not known by the healthcare professionals. The interviewees were not familiar with the results of the randomised controlled trial. The interviews were digitally recorded and lasted between 19 and 46 min (mean: 31 min). All interviews were transcribed verbatim by a professional transcriber. The researchers cross-checked the transcripts and removed statements that indirectly could reveal the identity of the informant.

Table 1. Characteristics of the healthcare professionals included in the study (n = 17).

Characteristics	Nurses	Nurse assistants	Physiotherapists
Total number (n = 17)	10	3	4
Sex (n)
Female (n = 16)	9	3	4
Male (n = 1)	1	0	0
Age mean, range	33 (26-53)	44 (20-59)	38 (27-54)
Years in occupation mean, range	9 (2-30)	24 (1-37)	10 (1-15)
Years in postoperative care mean, range	5 (1-15)	12 (0-28)	7 (1-12)

Ethics consideration

The study was approved by the Regional Ethical Review Board in Stockholm, Sweden and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. All participants gave written informed consent prior to study inclusion and consent for publication. Reporting followed the consolidated criteria for reporting qualitative research (COREQ) checklist [18].

Analysis

The qualitative analysis process followed the inductive content analysis described by Elo & Kyngäs [19]. The analysis was data driven and based on participants’ unique perspectives. The transcribed text was read several times to grasp a sense of the entirety. With the purpose of the study in mind, the text was then reread, and meaning units were identified [19]. Meaning units were condensed and coded, staying as manifest as possible to keep the core of the text intact. According to the content analysis process as described by Elo & Kyngäs, codes that were related to each other were grouped and organised into categories and subcategories [19]. Each subcategory was named using content-characteristic words. The process was iterative, going back and forth checking codes against the whole data material. The categories and subcategories were compared for differences and similarities with the aim of being as internally homogeneous and externally heterogeneous as possible. Demographic data was analysed with The Statistical Package for the Social Sciences Version 24 (SPSS; IBM Corp, Armonk, NY, USA) and presented with numbers, mean and range.

Rigour

The research team consisted of three physiotherapists (MFO, MNB and ASR) and one intensive care nurse (AS). The physiotherapists were specialised in intensive care/postoperative care (ASR), surgical care (MFO), and respiration (MNB). All researchers were familiar with qualitative methods. The multi-professionality of the research team allowed different perspectives on the topic. By following the process for content analysis and to increase the credibility and dependability, transparency was strived for in preparing, organising, analysing and reporting of the results [14,20,21]. The initial coding and data analysis was performed independently by two researchers (ASR and AS) to ensure credibility [20]. The classification of categories and subcategories were discussed between the researchers until consensus was reached. Investigator triangulation was used to examine the preliminary categories and subcategories from different perspectives. The results were then discussed again between the researchers and final adjustments were made [14,19,21,22]. The categories, subcategories and citations were translated from Swedish to English. Lastly, the synthesised findings were presented at a meeting for the healthcare professionals who worked at the recovery unit, in order to confirm the results of the analysis [23].

Findings

Ten nurses, three nurse assistants and four physiotherapists (aged 20–59 years) joined the study (out of 29 total invited). Sixteen were women and mean time of work experience in postoperative care was six years (Table 1). The study findings are presented in two categories with five subcategories, as displayed in Table 2.

Table 2. Overview of the main categories and the subcategories.

Main categories	Responsibility for the patient’s well-being	Prerequisites and challenges
Subcategories	Safety risks	Worries about an increased workload
	Observed beneficial effects	Access to sufficient resources to accomplish mobilisation
		Collaboration - a key to achieve mobilisation

Category: a responsibility for the patient´s well-being

In this category, the healthcare professionals emphasise that they were responsible for delivering safe care to each patient. They referred to the ‘do no harm’ principle and said that they had to weigh the risk of that mobilisation shortly after surgery would hurt the patients against its potential to improve that patients’ condition. They were worried that such early mobilisation would entail wound ruptures or induce other serious complications. On the other hand, they stated that they were also responsible for delivering prescribed care (in this case, mobilisation) and when they witnessed the positive effects of mobilisation, they were pleasantly surprised. One nurse stated that It is a kind of internal conflict in that I know that this (mobilisation) is important, but at the same time, I feel that it (mobilisation) is a bit too early… Participant 3.

Safety risks

Since this was a new routine, only evaluated in a research project, the healthcare professionals expressed safety concerns. They stated that they were responsible for patients’ well-being and safety at the recovery unit and said that they were worried that the patients would be too drowsy to mobilise safely this soon after surgery. They feared that the mobilisation would cause discomfort and entail negative consequences for the patients: I thought that this (mobilisation) would be too stressful for the patients, that they (the patients) would be too tired, too nauseous, or their blood pressure would be too low Participant 10.

Some of them stated that if the patients stayed in bed during the first hours after surgery, the safety risks would be reduced.

Observed beneficial effects

The healthcare professionals perceived that the patients became more lucid after mobilisation. They described that they noticed that patients who sat upright in a chair seemed to regain autonomy and independence, a transformation that the patients appeared to appreciate. One of the nurse assistants explained it as, the patient transforms from being a patient to becoming a human being…. Participant 14. As quoted by a nurse –Many patients expressed a relief to be out of bed, they felt more conscious and were satisfied that they actually could do it Participant 7.

The healthcare professionals described that very few incidents with circulatory or respiratory problems occurred during mobilisation. On the contrary, they said that they noticed that the patients’ vital signs improved, and the change of position helped the patient breathe, cough and to stabilise the blood pressure. They perceived that the mobilisation led to an ability to accelerate the extraction of the oxygen, and reduce drugs for preventing hypotension, as expressed by one of the nurses Looking back at the blood test results and the blood gases, I can see positive effects on gaseous exchange related to the mobilisation Participant 3.

In contrast to what some healthcare professionals feared, pain was not considered to be an obstacle to mobilisation. In fact, the healthcare professionals perceived that pain was reduced when the patients started to move. It was expressed that a lucid patient needed less attention and assistance, which reduced the healthcare professionals’ workload, and they could concentrate their work on those who were perceived to be in greater need of postoperative care. They believed that the mobilisation led to earlier discharge from the recovery unit, something that contributed to increased job satisfaction, as described by one of the nurses If the patient has been mobilised, with no circulatory instability or pain, it is a good criterion for discharge from the recovery unit…It is reassuring. It is a good safety marker Participant 14.

It was perceived by the healthcare professionals that the patients received a kick-start in their recovery, as exemplified by the following quote by a nurse they (the patient) have not just been sitting on the bedside, they have really been out of bed Participant 10.

The healthcare professionals described that they received positive feedback from the personnel on the surgical wards, who found that it was much easier to help patients mobilise a second time, because the patients were more confident and knew how to do it, as exemplified by one of the physiotherapists My colleagues at the general surgical ward, said that it was much easier to mobilise patients who already been out of bed at the recovery unit… Participant 9.

Category: prerequisites and challenges

In this category, the healthcare professionals described that they were worried that the requirement to attempt early mobilisation would increase their workload, especially during the afternoon and evening when the number of patients at the recovery unit was high. Yet, they were aware that the recovery unit was a resource-intense unit compared with the general wards and since they had adequate medical resources in close vicinity and better access to physicians and physiotherapists, they found the recovery unit to be a safe place for a first mobilisation. The importance of collaboration between professions was also highlighted as central for the success of mobilisation shortly after surgery.

Worries about an increased workload

To start with, the healthcare professionals were worried that mobilisation shortly after surgery would increase their work-burden and level of stress, as quoted by a nurse: Mobilisation feels like another work task that you have to deal with, despite a lack of time… Participant 3. They said that, in the afternoon, the recovery unit was almost filled with newly operated patients and that many of them arrived at the same time. They were worried that they would not be able to help patients to mobilise and simultaneously monitor patients’ vital signs. They said that monitoring patients, and alleviating pain and nausea was easier to do with the patient in bed rather than sitting in a chair.

Access to sufficient resources to accomplish the mobilisation

The healthcare professionals stated that, while mobilising patients at the recovery unit, they had access to monitors for surveillance, and if analgesics or anti-emetics were needed, nurses were close by and could provide the medications without delay. Furthermore, throughout the trial, they had access to experienced physiotherapists who could help and guide the procedure, even during the evening, and if questions were raised, anaesthesiologist and surgeons were on site or nearby, around the clock. The healthcare professionals concluded that they had the knowledge, access to safe surroundings, and were better staffed than the general surgical wards and therefore they found the recovery unit to be an appropriate place to safely conduct mobilisation shortly after surgery. This statement is illustrated by the quote: Since we have the ability to constantly monitor the patients and we have the support from nurses, doctors and physiotherapists, it is a safe environment for the patients’ first mobilisation… Participant 12.

Collaboration - a key to achieve mobilisation

Multidisciplinary teamwork was described as a cornerstone of successful mobilisation since each profession contributed with their unique competence and knowledge to help patients safely mobilise out of bed. It was found important that the team, together with the patient, collaborated towards a common goal, as quoted by one of the physiotherapists …it somehow feels like we have the same goal, …which makes the job a lot easier… Participant 2.

They stated that a well-informed and prepared patient, and team, who knew what to do, prevented possible negative events and promoted safe mobilisation. The different professions described that they took on separate roles, depending on professional knowledge and responsibility and everyone knew what to expect from each other, as expressed by one of the nurses the physiotherapist knows mobilisation, the nurse has competence of monitoring vital signs, and administering medication. The nurse assistants are close to the patients and can assist with many of these things too. So, in a way, we are all needed. Participant 10. The healthcare professionals described how the team guided the patient through the mobilisation. To have the whole team (nurses, nurse assistants and physiotherapists) present was found to be important to ensure that every patient, irrespective of time of arrival at the recovery unit, received high quality care. The collaboration across professions was described to increase the appreciation of the other’s competence and knowledge which further strengthened the teamwork, exemplified by one of the physiotherapists in the following quote, It is the teamwork that enables the mobilisation, that together we make the decisions and use each other’s competence. Participant 8.

Discussion

This is the first study investigating healthcare professionals´ experiences of postoperative mobilisation of adults, already at POD 0, within two hours after abdominal surgery. The current study indicated that the healthcare professionals had initial concerns about that mobilisation shortly after surgery would not be safe for the patient and add extra burden on their workload. But with time, their perceptions changed to believing that it enhanced the recovery and was feasible to conduct at the postoperative recovery unit.

Patients mobilised early after surgery or during intensive care emphasise that it is central to have healthcare professionals on board while performing early mobilisation, since they are responsible for initiating and ensuring a safe procedure [12,24,25]. However, healthcare professionals’ scepticism and reluctance towards new procedures are well-known, as for example described when implementing ERAS protocols [26,27]. Even though the current qualitative study was conducted adjacent to an interventional trial, the healthcare professionals were confronted with problems related to clinical practice. Since this was a new procedure, they expressed their doubts about the safety of the intervention. With a more thorough education and training of mobilising patients from bed to chair, prior to study start, the healthcare professionals’ safety worries might have been reduced. This finding is supported by some existing literature indicating that increased compliance may be obtained through expertise development and skill training to equip the healthcare professionals to undertake successful mobilisation [5,28,29]. Further, mobilisation protocols may also be of help to reduce such barriers [29–31].

In a Chinese study of early mobilisation at the ward, nurses’ lack of knowledge and ability to assist in mobilisation, inadequate pain management, indwelling catheters and uninformed patients were identified as factors that hindered early mobilisation. However, having a perioperative audit who addressed and managed these problems facilitated the adherence [31]. In the present study, the perceived obstacles of patient safety concerns and anticipated increased work burden were mitigated through collaborative work with the patient and across professions. The mobilisation team included nurses and nurse assistants, with physicians nearby to oversee the patients’ medical status, and was led by a physiotherapist, a multidisciplinary team set-up that has been recommended in other studies [5,32,33]. The value of collaborative work to enhance patients’ recovery has been emphasised by the World Health Organisation (WHO) [34] and enables meeting patients’ different needs [35]. Interestingly, the healthcare professionals were positively surprised that most patients who sat up in a chair required less help than those who remained in bed, contrary to what they had expected, possibly underestimating the value of mobilisation. Considering patients’ positive attitude towards early mobilisation [9,12], but healthcare professionals’ limited ability to assist implies a need for organisational support, to help them prioritise early mobilisation of postoperative patients [5,26]. Future research should be directed to investigating how organisational changes can support implementation of mobilisation shortly after surgery, but also on subjectively reported patient outcomes to evaluate the effect from a patient perspective.

Strengths of the present study include the use of qualitative methods to explore healthcare professionals’ experiences of mobilisation shortly after surgery, a method that allows the informants to, in own words, describe their experiences. Face-to face interviews with the three major professions who were involved in the mobilisation procedure (nurses, nurse assistants and physiotherapists) afforded a broad perspective of the experience. The study also has some limitations.

There are few studies focusing on healthcare professionals’ experiences of mobilisation shortly after abdominal surgery. Therefore, findings of this study were discussed mostly in relation to the intensive care context. It must be kept in mind that the setting and patient cohort are different, and generalisability of results may be done with caution.

Preparedness of early mobilisation may influence engagement in the intervention, which in turn may also affect healthcare professionals’ experiences and perception. However, neither pre-habilitation, nor preoperative education were provided at the Karolinska University Hospital in Sweden at the time of the study. This study covered perceptions of mobilising adults only, where comorbidities and/or age-related changes were an integral part of the experience. However, experiences of mobilising children or adolescents after surgery may be different.

There were no physicians included in the study, and therefore findings may not reflect the opinions of the whole team surrounding the patient. To speculate, the physicians did not actively participate in the bedside mobilisation and might not have considered themselves as a part of the team. Moreover, data were analysed on team level and not in relation to the profession, which may reduce the transferability of each professions’ experiences. The number of nurse assistants and physiotherapists was rather low and may not resemble the thinking of others throughout the recovery unit. However, sampling was continued until no new information emerged [15]. Some interviews were relatively short, but data were considered rich and offered a variation of the healthcare professionals’ narratives [15,36]. Most of the informants were women and all worked in an urban university hospital. The experiences of male healthcare professionals and those in rural settings may be different. Lastly, interpretations of the study findings should be done cautiously across different contexts and for other types of surgery.

Conclusion

The healthcare professionals at the postoperative recovery unit found that mobilisation out of bed, within two hours after abdominal surgery was beneficial for adult patients without reducing patient safety. However, it is important to assure that sufficient resources and adequate competence are available if such intervention should be implemented in clinical practice.

Relevance to clinical practice

Early mobilisation out of bed is one of the cornerstones in enhanced recovery programs and recommended within the same day as surgery. The current study contributes to the evidence supporting that mobilisation of adult patients shortly after abdominal surgery, at POD 0, already at the postoperative recovery unit, is feasible and beneficial for the patient from a healthcare professional perspective. However, the healthcare professionals need to be trained in how to perform ergonomic and safe mobilisation, and hospital management must ensure adequate and sufficient resources to conduct mobilisation at the postoperative recovery unit, not only during daytime but at all hours.

Author contribution

All authors were involved in the methodological design, data analysis, writing and reviewing the manuscript. MFO and MNB conducted the interviews and data collection. The data analysis was mainly performed by ASR and AS. ASR drafted the manuscript, and all authors approved the final version of the manuscript.

Ethics approval

The study was approved by the Regional Ethical Review Board in Stockholm, Sweden (Dnr: 2015/703-31/1, 2016/1831-32, and 2017/836-32). The research included was planned and conducted according to Good Clinical Practice and in line with the ethical principles of the Declaration of Helsinki and its later amendments.

Patient and public contribution

None in the conceptualisation or design of the study.

Acknowledgement

The authors would like to thank all participants and all healthcare professionals at the postoperative recovery unit, who made this study possible.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

The data that support the findings of this study are available upon request by the corresponding author. The data are not publicly available since allowances on public data sharing were not included in the informed consent procedures.

Additional information

Funding

The research team received grants from the Swedish Research Council (Grant nr: 2017-01452) and Åke Wiberg foundation (Grant nr: M17-0226). The sponsors of the study had no role in the study design, data collection, analysis, interpretation or writing of the report.