Iran Journal of Nursing

Introduction
The early mobility of a patient hospitalized in the intensive care unit (ICU) is a complicated issue that requires coordination between departments and between all ICU staff, including physicians, nurses, and physiotherapists. Early mobilization is safe and feasible and has positive results for the patient, medical staff, families, and health system. On the other hand, early immobility in the bed can lead to ICU-acquired weakness in the patient, which itself can lead to joint injuries, venous thromboembolism, insulin resistance, microvascular changes, bedsores, atelectasis, occurrence of pneumonia, increase in mortality, decrease in quality of life, muscle and skeletal disabilities. In this regard, the North American Nursing Diagnosis Association (NANDA) has considered physical mobility disorders related to pain, weakness, fatigue, the reducing effect of anesthetics, painkillers, narcotics, reduced joint mobility, decreased muscle strength, lack of treatment planning in nursing diagnoses. This study aims to determine the barriers to early mobility of patients admitted to the ICU of hospitals in Kohgiluyeh and Boyer-Ahmad Province, Iran.

Methods 
This is a descriptive cross-sectional study that was conducted in 2020-2022. The study population consists of ICU staff of hospitals in Kohgiluyeh and Boyer-Ahmad province including physicians, nurses and physiotherapists The entry criteria were willingness to participate in the study, at least six months of work experience in the ICU (for nurses), being the resident physician of the ICU or the attending physician (for physicians), at least one year of work experience in the ICU (for physiotherapists). Sampling was done by a census method after explaining the study objectives to the participants and obtaining their informed consent. 
A demographic form and a researcher-made questionnaire of early mobility barriers for ICU patients were provided to the participants. Since the sampling was done during the COVID-19 pandemic, the questionnaire was provided and completed online. It should be noted that the questionnaire was designed based on the literature. It had 48 items and four domains of patient-related barriers, cultural barriers, structural barriers, and process-related barriers. The items are rated on a 5-point Likert scale: Completely agree, to some extent agree, no idea, disagree, and completely disagree. This questionnaire was used after confirming its validity and reliability. After collecting data, they were analyzed in SPSS software, version 18. Kolmogorov-Smirnov test was used to check the normal distribution of the data. Kruskal-Wallis test was used to examine the differences. The significance level was set at 0.05.

Results 
In this study, participants were 174 nurses, physicians, and physiotherapists, where 57.8% were female and 59.8% were single. Among the barriers to early mobility, the patient-related barriers had the lowest mean (0.411±0.108) and cultural barriers had the highest mean (0.478±0.146).

Conclusion 
This study showed that, according to physicians, nurses and physiotherapists, cultural barriers were the most important factors in preventing the early mobility of patients followed by process-related and structural barriers. This may be due to the importance of religious beliefs in patients. One of the limitation of this study was the small number of physiotherapists. In this study, only two physiotherapists were included. The perspectives of physiotherapists could help more in understanding the barriers of early mobility in patients due to their important role in this field. The reason was their lack of time; they were too busy in performing their own tasks and did not have time to pay attention to the early mobility of patients. To facilitate the implementation of early mobility protocols in the ICUs, a sufficient number of physiotherapists should be recruited. In addition, the cooperation between physiotherapists, nurses and physicians should be taken into consideration. In-service trainings should be provided to the ICU staff to increase their knowledge of early mobility protocols.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Tehran University of Medical Sciences (Code: IR.TUMS.FNM.REC.1399.085). The study objectives were explained to the participants and they were assured of the confidentiality of their information. Then, written informed consent was obtained from the study participants.

Funding
This article was extracted from a master’s thesis of Javad Sajadifar, Critical Care Department, Tehran University of Medical Sciences. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

Authors' contributions
The authors contributed equally to preparing this article. 

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the nurses, physicians, and physiotherapists participated in the study for their cooperation.


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