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Abstract

Introduction

Prone positioning is an established therapeutic intervention for acute respiratory distress syndrome (ARDS) patients. However, its utilization in ARDS treatment remains low, despite recommendations and evidence of its benefits.

Objective

This study aims to explore the phenomenon of performing prone position for ARDS patients in the intensive care unit (ICU), especially from the nurses’ perspective of the facilitators and the barrier.

Methods

A qualitative phenomenological approach was employed. Fifteen ICU nurses from a referral hospital in Surabaya, Indonesia, who had performed at least 10 prone positions on intubated patients, were interviewed. Thematic analysis was conducted to identify emerging themes.

Results

The facilitator factors are the availability of specially designed tool, the knowledge about benefit for the patient, and the availability of plan to mitigate complication. The barrier factors are the heavy maneuver during the process, the needs of lots of manpower, and the agitating patient. The facilitators lead the nurse to following way, the availability of specialized design tools enhances nurse confidence and patient safety. Then, the knowledge related to prone positioning benefit reinforced prone position importance. Additionally, a planning and proactive measures are necessary since the prone positioning is posed risk. The barrier holds the nurse performance in the following way: the physical demand may lead to musculoskeletal problems, such as back pain; inadequate staffing results in procedure delays or cancellations. Patient agitation, especially in intubated and mechanically ventilated patients, posed additional challenges, including the risk of extubating and increased congestion.

Conclusion

ICU setting needs to be supportive to promote safe and effective prone positioning practices. This can be achieved through addressing the facilitator and the barrier of prone position. Additionally, prone positioning guideline development should involve the nurse.

Keywords

ARDS barrier facilitator ICU physical prone position staffing

Introduction

Prone positioning is an established therapeutic intervention for patients diagnosed with acute respiratory distress syndrome (ARDS) (Mathews et al., 2021; Setiawan et al., 2023; Usamah et al., 2023). However, despite its recommendation, the utilization of prone positioning in ARDS treatment remains low and is consistently mentioned (Giovanni et al., 2021; Hochberg et al., 2023). Nevertheless, research has shown that prone positioning is financially beneficial and cost-effective from both societal and hospital perspectives (Baston et al., 2019). Yet, the facilitators and barriers of this procedure remain unclear (Klaiman et al., 2021). Ongoing research continues to explore various factors, benefits, and barriers associated with the implementation of prone positioning in the management of ARDS (Binda et al., 2021; Chen et al., 2023; Hochberg et al., 2023).

Review of Literature

Numerous studies consistently demonstrate that prone positioning during ventilation significantly improves the oxygenation index, blood oxygen saturation, mortality rates, and shorter hospitalization duration (up to 4.8 days) in a majority of ARDS patients (Chen et al., 2023; Chui & Craen, 2016; Moghadam et al., 2020). The effect of performing prone position to the change of blood oxygen level in the non-COVID-19 population found a change of 85%–95% (Chui & Craen, 2016), in the COVID-19 population without mechanical ventilation found 85.6%–95.9% (Moghadam et al., 2020), and in COVID-19 with mechanical ventilation was 70%–80% (Chen et al., 2023). The therapeutic effects of prone positioning in ARDS are believed to occur through two main mechanisms: increased arterial oxygen saturation and enhanced lung expansion (Chui & Craen, 2016). Additionally, the intervention promoted recruitment of lung dependent regions, optimized chest wall mechanics, and enhanced drainage of tracheobronchial secretions (Moghadam et al., 2020).

However, it is important to note that, while prone positioning may have a beneficial effect on mortality, there is also an increased incidence of adverse events for these patients (Cao et al., 2020; Guérin et al., 2013). Although these adverse events are inconsistent through the research, it is worth to note since this could be related to the low usage of the intervention (Moghadam et al., 2020). A study found that there are no significant differences between prone and supine position ventilation regarding the duration of mechanical ventilation (Cao et al., 2020). In a separate study involving patients on extracorporeal membrane oxygenation, it was found that the majority of patients developed pressure ulcers, particularly in the face and chin areas, when placed in the prone position (Binda et al., 2023). Additionally, there are other complications associated with prone positioning, including nerve compression, crush injuries, venous stasis (e.g., facial edema), pressure ulcers, retinal damage, vomiting, and cardiac arrhythmias (Binda et al., 2021; Chen et al., 2023).

Prone positioning has not been proven to have a survival benefit when used as a late rescue therapy for refractory hypoxemia (Petrone et al., 2021), leading to ongoing debates on its implementation (American Thoracic Society, 2020; Hochberg et al., 2023). During the COVID-19 pandemic, the utilization of prone positioning for mechanically ventilated patients with COVID-19-related ARDS has increased (Hochberg et al., 2023). However, previous studies have shown low utilization rates of prone positioning for severe ARDS patients, including those with COVID-19, due to various factors such as isolation precautions and shortages of personal protective equipment (Petrone et al., 2021). Knowledge as to the procedure and outcome is also suspected to be the cause (American Thoracic Society, 2020). Furthermore, another study mentioned that, during the COVID-19 pandemic, increased prone positioning to patients and enhanced clinician comfort with the procedure have led to its perceived low-risk, high-benefit nature. Adequate staffing, improved team consensus on prone positioning, and the availability of specific equipment (e.g., pressure injury prevention measures) have facilitated greater utilization of prone positioning in intensive care units (ICUs) (Hochberg et al., 2023).

Following the shift from the COVID-19 pandemic to an endemic phase and the varying evidence available, the decision to implement prone positioning interventions for ARDS patients remains uncertain. This study aims to explore the phenomenon of performing prone position for ARDS patients in the ICU, especially from the nurses’ perspective of the facilitators and the barrier.

Methods

Design

This was a qualitative phenomenology research. The philosophical aim of the method was to understand the nurse perspective and lived experience on performing prone position to the ARDS patient in the ICU. The method was chosen to explain the nurse lived experience while performing prone positioning. The researchers were aware of the possibility of preconceived ideas that might disrupt the research finding. The interviewer question was bracketed by minimizing any hint that might lead the answer to the direction that the interviewer aimed (Jang et al., 2022; McConnell-Henry et al., 2009). The interviewer focused on extracting the phenomenon by directing the point of view on how the nurse feel during the interview. The directed point of view was intentional to reveal the meaning and essences of the nurse feeling about the prone positioning (Jeffery et al., 2017).

This inductive study followed the Collaizzi method and the Standards for Reporting Qualitative Research (O’Brien et al., 2014). The study started by immersing to the nurse experience, identifying the pattern during the observation, and then explaining the essence of the experiences into a live experience driven insight (Jang et al., 2022).

Researcher Reflexivity

The interviews were conducted by the first and second author (both male), who are a registered nurse and a lecturer. The first author has doctoral degree and the second author has master degree, both of them are experienced in qualitative research and critical care. Both of them had no clinical or supervisory relationship with any participant and was not affiliated with the ICU where the study was conducted. To minimize bias, the interviewer applied bracketing by being aware of personal assumptions and avoiding leading questions during the interview.

Research Question

The research question was “What is the nurse perspective about the facilitator and the barrier to perform prone positioning for ARDS patient in the ICU?”

Sample

The study was conducted with ICU nurses from a referral hospital in Surabaya, Indonesia. The hospital was chosen for its high patient volume during the COVID-19 pandemic, which made the prone position a routine activity in the ICU.

Inclusion/Exclusion Criteria

All participants met the inclusion criteria, which was: have performed at least 10 prone positions on intubated patients and having experienced at least one complaint related to the prone position. No participant had the exclusion criteria, which was: administrative staff related to prone position.

Data Collection

The study used in-depth interview to collect the empirical data, between November and December 2022. Participants were approached via telephone or in person after initial coordination with the ICU nurse unit manager. Of the 50 eligible ICU nurses listed, none refused participation or dropped out during the study. All interviews were conducted in a private setting, either in the hospital meeting room or via encrypted video call, with only the participant and interviewer present. No repeat interviews were conducted. In addition to audio recordings, the interviewer took field notes to document nonverbal cues and contextual observations during and immediately after each session. As many as 15 participants were selected to ensure data saturation was achieved. To avoid bias associated with work hierarchies, a simple random sampling technique was used to select qualified participants who were then personally recruited. The participant explained the study purpose and they provided informed consent (Jang et al., 2022; Jeffery et al., 2017).

The interview was conducted by online and offline, depending on the participants’ preferences. Both methods were delivered in a comfortable communication atmosphere by delivering daily conversation to start the interview and never judging any answer found during the interview. The interviews lasted approximately 60 min. Every interview was recorded with the consent of participant.

Questionnaire

The interview guide used in this study was developed based on a review of relevant literature and qualitative research methodology standards. While the guide was not a previously validated instrument, its content was reviewed by two qualitative research experts for face and content validity prior to use (O’Brien et al., 2014). This ensured alignment with phenomenological inquiry and enhanced the relevance and clarity of each item.

The research instrument consisted of structured questions aimed at gathering information about the participants’ experiences with prone positioning (Appendix A). Each participant was asked about his/her experience, the perspective of facilitator and the barrier to performing the prone position. Follow-up questions were asked if new information emerged during the interview.

Can you describe your experience performing prone positioning in the ICU?

What factors support you in conducting the procedure?

What are the barriers or challenges you encounter?

Can you give an example of a situation where prone positioning was especially difficult or successful?

Data Analysis

Data were analyzed manually without the use of software. A codebook was developed based on Colaizzi's method, and a basic coding tree was created to categorize themes. No deviant cases were observed in the data (Wirihana et al., 2018). First, two researchers immersed themselves in all the nurses’ prone position experience by reading the transcription couple of times. Second, the researcher extracted any information that reflected positive or negative expression about the prone positioning experiences. Third, the collected expressions were defined and tracked to uncover the latent meaning. Fourth, these meanings were structured into clustered themes. Fifth, the phenomenon was described by considering the clustered themes. Sixth, the fundamental category of the theme was defined. Seventh, the findings were delivered to two participants for validation.

Rigor

Trustworthiness was achieved by extracting rich information during the interview which still maintains the participant comfort feeling. Verbatim transcripts were not returned to all participants. However, two participants were invited to validate the emergent themes to ensure representational accuracy. Applicability was achieved by make sure the participant met the eligibility criteria to assure the experience was not misleading. Consistency was achieved by strictly following the Colaizzi method, positioned as neutral, excluding bias, and minimizing the researcher personal opinion. The other researchers reviewed the result and confirmed whether there were any data deviations (Jang et al., 2022; Jeffery et al., 2017; Wirihana et al., 2018).

Ethical Consideration

The research followed the International Ethical Guidelines for Health-related Research Involving Humans (Council for International Organizations of Medical Sciences & World Health Organization, 2016). All the participants were agreed to join the research, signed the informed consent, and understood that they have the right to withdraw from the study anytime. All the data is stored secretly only known by the research team. The ethical clearance was granted in Indonesia. The recorded number was UA-02-22135.

Results

Sample Characteristics

All 15 participants in this study, who were ICU nurses, responded, resulting in a response rate of 100% (Table 1). The participants were equally distributed between male and female nurse. The average age of the participants was 28.8 years. The majority held diplomas in nursing, and registered nurse were equally represented, with one participant holding a master's degree in nursing. The average number of years of ICU work experience was 4.3 years, with most participants having less than five years of experience, except for one nurse who had 15 years of experience. All participants had experience in prone positioning for intubated patients and high-flow nasal cannula, and 63.6% had additional experience with spontaneous breathing, while 18.2% had experience with non-invasive ventilation. The majority of participants did not report any complications from prone positioning (54.4%), although a few reported pressure ulcers (27.3%) and facial edema (18.2%), with one report each of accidental extubating (9.1%), cardiac arrest (9.1%), and desaturation (9.1%). Nearly all nurses believed that prone positioning is beneficial for patients (90.9%). Only a small number of nurses indicated that they would definitely perform the maneuver on non-COVID-19 ARDS patients (27.3%), while the majority were uncertain about whether to perform the maneuver (54.5%).

Table 1.

Participants Characteristics.

Participants characteristics (n = 15)		Frequency	Mean	%
Gender	Male	8		53.33%
Gender	Female	7		46.67%
Age	21–30	10	28,8 years	66.67%
Age	31–40	5	28,8 years	33.33%
Education	Diploma	7		46.67%
	Registered Nurse	7		46.67%
	Master	1		6.67%
Work in ICU period (years)	< 5 years	9	4,3 years	60.00%
	5–10 years	5		33.33%
	> 10 years	1		6.67%
Experience to patient breathing with	Spontaneous	10		23.26%
	NIV (non-invasive ventilation)	3		6.98%
	HFNC (high flow nasal canula)	15		34.88%
	ETT (endo tracheal tube)	15		34.88%
Belief on the benefit of prone position	No	0		0.00%
	Maybe	1		6.67%
	Yes	14		93.33%
Willingness to perform for ARDS non-COVID-19 patients	No	1		7.14%
	Maybe	9		64.29%
	Yes	4		28.57%

n = sample size; % = percentage.

Research Question Results

The emerged themes explained below, the list of the themes and the respective participants that bring up the theme are available in Table 2.

Table 2.

List of Emerged Themes.

No.	Theme	Participant
	Facilitators
1	Special design tool	P1, P2, P3, P5, P6, P8, P9, P10, P12, P13, and P14
2	Benefit for patient	P4, P8, P12, P15
3	Complication mitigation	P1, P6, P7, P8, P10, and P11
	Barrier
1	Heavy maneuver	P1, P5, P6, P7, P9, and P12
2	Loads of manpower	P1, P3, P4, P6, P8, P9, P10, P11, P12, and P13
3	Patient agitation	P3, P9, P12, P11, and P14

Facilitator

(1)

Special design tool

The nurse expressed that the availability of specialized design tools was identified as a benefit for nurses while in a prone position.

P2: If we were provided with a tool to help with prone maneuvers, it would really help us.

P3: … we feel safer if we turn the patient over using a tool, so as not to injured the patient.

(2)

Benefit for patient

The nurse mentioned that the knowledge of benefit of prone position to the patient increased their willingness.

P8: The journal I read explains the benefits, … the team in my shift considers this action especially when the anesthesiologist is on duty.

P12: I discussed with the anesthesiologist the benefits of the prone procedure before carrying out the procedure.

(3)

Complication mitigation

The nurse was aware that complication might occur, so that, before the procedure, the team prepared a care plan to mitigate the worse complication.

P6: We have found mild pressure ulcers on the patient's face several times, we apply lotion to the prone parts and keep the moisture from getting worse.

P1: Some patients are displaced and some are even extubated because the patient is restless, that's why it's important to have an anesthesiologist.

Barrier

The common barrier that nurse perceived is heavy maneuver, loads of manpower, risk of complication, and other. The nurse expressed that lifting a patient is heavy especially when the patient is intubated so more caution is exercised during the process. (1)

Heavy maneuver

The ICU nurse performing the prone position manually requires a lot of energy, especially in patients who are overweight.

P12: …the condition of the patient who is oversized in weight above 100 kg, usually complaints appear.

P7: …especially for obese patients, because it is difficult, usually back pain.

Nurse is prone to injury during the shifting and lifting process, so coordination between teams is necessary, because injuries often occur when the process is not well-coordinated.

P9: … when lifting or moving because it doesn't fit or isn't ready it's usually the back that has problems, so to do prone again sometimes I think about it.

(2)

Loads of manpower

Prepared full team staff ready all the time is not always possible, especially when there are many activities during the shift. Since the waiting is too long, the prone position is skipped and changed.

P11: … we need a lot of nurses, sometimes waiting for a complete and long team, so the action is postponed.

P8: ETT can't be done alone, you have to be with a team, there is a team of consultants or PPDS, anesthesiologist, and a team of nurses.

The need of more staff to perform the prone positioning makes them prefer the supine position.

P6: Sometimes if we don't have an anesthetic resident, we don't have the courage either because to minimize unwanted events.

(3)

Patient agitation

Nurse perceived that prone for agitated patient raises the risk of some complications, especially in the intubated patient. Mechanically ventilated patient attached with endotracheal tube poses higher risk of extubated, and according to the regulation the staff that could reintubate is the anesthesiologist. If the required staff is not ready to perform reintubation, then there will be trouble for the patient.

P3: Patients who are sedated but agitated tend to rebel, so they are prone to making the patient more congested.

P12: … if the patient is agitated it is more difficult, if the patient agitation reoccurs, the patient comes short of breath and becomes restless.

Discussion

The study's findings highlight numerous elements that influence nurse desire and barriers to performing the prone position for patients. The availability of unique design tools, awareness of the benefits for the patient, and the execution of techniques to limit potential difficulties all influenced nurse willingness to execute prone posture. The physical demands of the maneuver, the requirement for appropriate manpower, and the risk of complications, particularly in agitated patients, were all impediments to executing prone posture (Fischer et al., 2023; Klaiman et al., 2021; Laili et al., 2019).

The availability of specialized design tools was identified as a benefit for nurse while in a prone position. Nurse said having a specific instrument to help with the maneuver would boost their confidence and safety when turning the patient. This finding shows that investing in specialized equipment or tools created expressly for prone positioning may increase nurse willingness to undertake the treatment (Budarick et al., 2020; Klaiman et al., 2021; Wiggermann et al., 2020).

Another aspect that influenced nurse is their understanding of the advantages of prone positioning for patients. Nurse who was aware of the benefits of prone positioning indicated a higher willingness to execute the technique. The nurse needs to be provided with current information on the benefits of prone positioning via educational programs, journal publications, and talks with other healthcare professionals. Understanding the possible benefits may drive nurse to participate in the practice (Elmer et al., 2023; Klaiman et al., 2021; Moghadam et al., 2020).

Complication avoidance methods were discovered as a significant factor influencing nurse willingness to execute prone positioning. Nurse acknowledged that difficulties could occur during the treatment and reported putting care plans in place to reduce potential negative occurrences. Nurse, for example, take steps to prevent pressure ulcers by administering lotion and keeping prone body regions moist. This conclusion emphasizes the importance of complete care planning and proactive approaches in resolving potential difficulties and, as a result, boosting nurse readiness to execute prone posture (Binda et al., 2021; Dewi et al., 2019; Elmer et al., 2023).

The physical demands of the maneuver appeared as a prominent worry among nurse when it came to the hurdles to conducting prone positioning. Manually performing the prone position, particularly for overweight or obese patients, required significant energy and frequently resulted in musculoskeletal problems such as back pain, according to nurse. This research emphasizes the significance of ergonomic factors and proper staffing in reducing physical strain on nurse. Using supportive devices or procedures for lifting and moving patients could reduce the stress on nurse and increase their willingness to engage in prone positions (Budarick et al., 2020; Morata et al., 2023; Ovayolu et al., 2014; Wiggermann et al., 2020).

Inadequate staffing was recognized as a hindrance to prone positioning. Nurse reported difficulties in organizing a complete team, which resulted in procedure delays or cancellation. The requirement for a multidisciplinary team, including consultants, anesthesiologists, and nurse, made it difficult to secure the simultaneous availability of all required staff. This impediment emphasizes the need of workforce management and resource allocation in ensuring enough worker numbers for prone positioning. Allocating enough staff and improving communication and coordination among team members could assist in overcoming this obstacle and increasing nurse willingness to execute the treatment (Callihan & Kaylor, 2021; Fan et al., 2017; Klaiman et al., 2021; Munshi et al., 2017; Tasaka et al., 2022).

Patient agitation, particularly in intubated and mechanically ventilated patients, has been highlighted as additional barrier to prone placement. Concerns were raised by nurse concerning consequences such as extubation risk and increased patient congestion in agitated patients. The requirement for anesthesiologists or other specialized personnel to manage reintubation complicated matters even more. This observation emphasizes the significance of sedative and agitation management before attempting prone positioning. It is critical to ensure the availability of skilled personnel to address potential complications, such as extubating, in order to reduce risks and increase nurse willingness to undertake the surgery (Binda et al., 2021; Elmer et al., 2023; Moghadam et al., 2020; Munshi et al., 2017; Tisminetzky et al., 2022).

Strengths and Limitations

This study was strong in the part of addressing the nurse experience about facilitator and barrier of performing prone position. The research captured the phenomenon of nurse experiences during the COVID-19 pandemic, a period when prone positioning was frequently employed. The research was somewhat limited because the respondents were from only one hospital.

Implications for Practice

The findings suggested that addressing the identified barriers, such as providing specialized tools, enhancing knowledge of benefits, implementing complication mitigation strategies, addressing physical demands, ensuring adequate staffing, and managing patient agitation, could improve nurse willingness to engage in prone positioning. By recognizing these factors and implementing appropriate interventions, healthcare organizations can create a supportive environment that promotes safe and effective prone positioning practices.

Conclusion

In conclusion, ICU setting needs to be supportive to promote safe and effective prone positioning practices. This can be achieved through addressing the facilitator and the barrier of prone position. Additionally, prone positioning guideline development should involve the nurse.

Supplemental Material

sj-docx-1-son-10.1177_23779608251371102 - Supplemental material for Nurse Perspectives on Prone Positioning for ARDS Patient in the ICU: A Qualitative Phenomenological Study of Facilitator and Barrier

Supplemental material, sj-docx-1-son-10.1177_23779608251371102 for Nurse Perspectives on Prone Positioning for ARDS Patient in the ICU: A Qualitative Phenomenological Study of Facilitator and Barrier by Sriyono Sriyono, Hakim Zulkarnain, Erna Dwi Wahyuni, Jujuk Proboningsih, Wikan Purwihantoro and Maria-Pilar Mosteiro-Diaz in SAGE Open Nursing

Supplemental Material

sj-docx-2-son-10.1177_23779608251371102 - Supplemental material for Nurse Perspectives on Prone Positioning for ARDS Patient in the ICU: A Qualitative Phenomenological Study of Facilitator and Barrier

Supplemental material, sj-docx-2-son-10.1177_23779608251371102 for Nurse Perspectives on Prone Positioning for ARDS Patient in the ICU: A Qualitative Phenomenological Study of Facilitator and Barrier by Sriyono Sriyono, Hakim Zulkarnain, Erna Dwi Wahyuni, Jujuk Proboningsih, Wikan Purwihantoro and Maria-Pilar Mosteiro-Diaz in SAGE Open Nursing

Footnotes

Acknowledgment

The authors acknowledge the Universitas Airlangga as the research setting.

ORCID iDs

Sriyono Sriyono

Hakim Zulkarnain

Erna Dwi Wahyuni

Jujuk Proboningsih

Ethical Consideration

Ethical clearance for the study was obtained from the Universitas Airlangga Hospital, Indonesia, under the record UA-02-22135. This study pays attention to aspects of ethics, autonomy, and justice by means of the respondent recruitment process through simple random sampling and does not involve hospital management in the data collection process.

Author Contributions

First author led the conceptualization, methodology design, and investigation, and drafted the original manuscript. Second author contributed to the investigation, formal analysis, and drafting of the original manuscript. Third author was involved in the development of methodology, performed formal analysis, and contributed to writing and reviewing. Fourth author contributed to data analysis and critically reviewed and edited the manuscript. Fifth author supported the methodology and formal analysis. Sixth author contributed to the formal analysis, review and editing process and validated the final version. All authors reviewed and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Universitas Airlangga grant with contract number of 1716/UN3.1.13/PT/2021.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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