Early pulmonary rehabilitation recommended decision-making behavior experience among pediatric intensive care unit medical staff: a qualitative study

Background: To understand the reasons for hindering and promoting the recommended decision-making behaviors for early pulmonary rehabilitation of PICU medical staff, and to provide a basis for developing corresponding management plans.

Methods: Based on the Capability, Opportunity, Motivation-Behavior (COM-B) model and Theoretical Domains Framework (TDF), interview outlines were developed. A descriptive qualitative research method was used, and a purposive sampling method was employed to select medical staff from the intensive care unit of a tertiary children's hospital in Nanjing from September to December 2023 for semi-structured interviews. The interview data were coded using the COM-B and TDF frameworks, and analyzed, summarized, and refined using the Colaizzi 7-step method to extract themes.

Results: Four main themes and 13 sub-themes were extracted, including the need for pulmonary rehabilitation knowledge and skills, the experience of implementing pulmonary rehabilitation in critically ill children, communication and collaboration in the PICU rehabilitation platform, and external support for PICU pulmonary rehabilitation.

Conclusion: In the process of recommending early pulmonary rehabilitation for critically ill children, departments should help PICU medical staff change their views on pulmonary rehabilitation and acquire relevant knowledge and skills, strengthen multidisciplinary cooperation, optimize external support, and create a good practice environment for the implementation and promotion of early pulmonary rehabilitation for critically ill children.

1 Introduction

The advancements in pediatric critical care management have significantly improved survival rates for children in the Pediatric Intensive Care Unit (PICU) and reduced mortality rates. However, factors such as mechanical ventilation, the use of sedatives and analgesics, and immobilization can lead to more than half of critically ill children experiencing Pediatric Post-Intensive Care Syndrome (p-PICS). This condition not only affects the course of their illness but also impacts long-term functional outcomes, resulting in a decline in the quality of life for these children (1, 2). As a result, prompt and efficient intervention strategies are essential for children in critical condition. Pulmonary rehabilitation (PR) is an all-encompassing method that includes exercise training, education, and changes in behavior. The aim is to improve the physical and mental health of patients while encouraging lasting commitment to health-promoting habits (3). Research on critically ill adult patients indicates that early pulmonary rehabilitation is linked to improved outcomes (4). However, the prevalence of pulmonary rehabilitation among critically ill children is low, and there is limited research focusing on pulmonary rehabilitation practices for this population. This may be attributed to several obstacles that hinder the integration of pulmonary rehabilitation into the daily activities of the PICU (5). Previous quantitative research has identified several factors that influence the implementation of early rehabilitation in PICU. These factors include the heterogeneity of children's ages and cognitive abilities, the absence of rehabilitation guidelines specifically for critically ill children, limited availability of rehabilitation resources, and caregivers' lack of awareness regarding the benefits and significance of early rehabilitation for this vulnerable population (6). Among these professionals, healthcare workers are the frontline personnel responsible for the care of children and the implementation of early PR for critically ill patients. They play a crucial role in decision-making and recommendations regarding PR treatments, and their understanding of these practices forms the foundation for effective rehabilitation in critically ill children. Therefore, this study aims to explore the barriers and facilitators influencing the decision-making behavior related to early PR recommendations among healthcare professionals in PICU. By adopting a qualitative perspective, the study seeks to gain a deeper understanding of the diseases, experiences, and behaviors involved, ultimately providing a reference for developing early PR programs for critically ill children.

2 Methods

2.1 Design

We conducted a qualitative, exploratory study using a semi-structured, one-on-one interview method. This study follows the Standards for Reporting Qualitative Research (SRQR) (Supplementary Appendix 1) to ensure transparency in the research report (7). This study was approved by the Research Ethics Committee of the Children's Hospital of Nanjing Medical University (approval number 202405014-1).

2.2 Conceptual model

To provide theoretical and practical guidance for this study, we utilized two complementary frameworks: the Capacity, Opportunity, Motivation-Behavior (COM-B) model and the Theoretical Domains Framework (TDF). The COM-B model, along with intervention functions and policy categories, is situated within the behavior change framework, aiming to identify deficiencies in target behaviors and summarize the factors that influence behavior (8). TDF is an integrated theoretical framework. In 2005, Michie et al. (9) systematically reviewed 33 behavior change theories and consolidated them into 12 domains within the TDF. In 2012, Cane et al. (10) revised the framework to include 14 theoretical domains: knowledge, skills, social/professional role identity, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, intentions, goals, memory/attention and decision processes, environment context and resources, social influences, emotions, and behavior regulation. These domains encompass individual, organizational, and societal levels, with the goal of establishing a comprehensive theory of behavior change to inform behavioral intervention research. The TDF can support the COM-B model in identifying specific and comprehensive factors related to target behaviors, with each domain of the TDF corresponding to a specific component of the COM-B model (11). These two theoretical frameworks have been effectively utilized to identify barriers and facilitators related to behavior, and in many instances, to design interventions (12, 13).

2.3 Setting, participants and sampling

This study was conducted at a tertiary children's hospital located in Nanjing, Jiangsu Province, China. Using purposive sampling, medical staff from PICU were selected as interview subjects. Inclusion Criteria: Participants must have a minimum of three years of work experience in PICU, as well as experience in rehabilitation training and practical rehabilitation for critically ill children. Informed consent and voluntary participation in this study are also required. Exclusion Criteria: Individuals who are rotating or in training positions, as well as those who are not on duty during the survey period due to sick leave, travel abroad, or other reasons, will be excluded from the study. The sample size will continue to be collected until data saturation is achieved, indicating that no new themes are emerging.

2.4 Date collection

Our research team comprises seven members: one chief nurse with 30 years of clinical nursing and nursing management experience, one deputy chief nurse with 15 years of rehabilitation nursing experience, one nurse supervisor with expertise in qualitative research, and four nursing graduate students who have completed training in qualitative research courses. Team members created a preliminary interview outline utilizing the COM-B and TDF frameworks by reviewing evidence from both domestic and international literature and consulting with clinical experts. We selected three medical staff members for preliminary interviews. Based on the results of these interviews, we optimized and finalized the interview outline. The complete interview guide can be found in Supplementary Appendix 2.

The interview took place in the PICU office. Prior to the interview, the interviewer introduced themselves, explained the purpose of the research, informed the interviewee that the entire process would be recorded, and provided participant information and informed consent forms. Consent was obtained and signed upon agreement. Each interview was conducted by the first author, with durations ranging from 20 to 50 min. The interview was considered complete when all key points outlined in the interview guide had been discussed and the interviewee had no further questions. Within 24 h after the interview, two researchers independently used iFlytek voice transcription software to transcribe the recorded audio verbatim into text.

2.5 Date analysis

We used NVivo.11 software to organize and analyze the transcribed text. First, two researchers independently and repeatedly read the transcribed text to familiarize themselves with the data. They employed Colaizzi's seven-step phenomenological analysis method for initial coding to generate initial themes (14). Then, identify sub-themes related to the initial theme, and subsequently map the initial codes back to the TDF according to the categories of barriers and facilitators. In certain instances, these codes may be mapped to multiple domains and summarized using the more straightforward COM-B model. In addition, the frequency percentage of each TDF theoretical domain categorized as barriers and facilitators under each theme was calculated separately to assess their significance. The coding results were cross-checked, and any discrepancies were discussed and resolved with a third researcher.

3 Results

3.1 Demographic characteristics

A total of 14 healthcare professionals from PICU participated in the interview study. This group included 6 registered nurses (comprising 2 nursing managers, 2 critical care specialty nurses, and 2 registered nurses), 5 PICU physicians, and 3 rehabilitation therapists. The coding of participants was organized based on the order of the interviews, with “N” representing nurses, “D” for doctors, and “T” for therapists. Detailed demographic information about the respondents can be found in Table 1.

Table 1

Table 1. General information of respondents (n = 14).

3.2 Themes

The interview results revealed four initial themes and thirteen sub-themes: knowledge and skill requirements for PR, implementation experiences of PR in critically ill children, communication and collaboration within the PICU rehabilitation platform, and external support for PICU pulmonary rehabilitation (see Table 2). These themes encompass all behavioral domains of the TDF and the three main components of the COM-B model (see Figures 1, 2).

Table 2

Table 2. Summary of barriers and facilitators.

Figure 1

Figure 1. Barriers and Facilitators related to the Theoretical Domain Framework (TDF). B, Barriers; F, Facilitators.

Figure 2

Figure 2. Domains of the TDF within the COM-B model.

3.2.1 Knowledge and skill requirements for PR

“Knowledge” refers to the concept of early PR for critically ill children and the essential information that medical staff in PICU should possess. It is a multifaceted factor in decision-making behavior and holds a paramount position (42% of the barriers and 33.3% of the facilitators). Interviewees indicated that the primary reason PR is not currently implemented in clinical practice is the absence of relevant theories to guide practical work. There is a significant demand for knowledge regarding the concepts, assessment, and specific practices of early PR. Some interviewees also noted that although they possess a basic understanding of PR, there is minimal training available in PR skills and no certification for qualifications, which hinders the translation of knowledge into practical abilities. The deficiency of evidence-based knowledge and skills has resulted in a lack of confidence in transforming practice. In addition, the proactive efforts of the PICU medical staff to acquire knowledge and skills in PR can facilitate early decision-making behaviors regarding PR recommendations for critically ill children within the department.

3.2.2 Implementation experiences of PR in critically ill children

The experiences of PICU medical staff during the implementation of PR can significantly influence their decision-making behavior regarding future recommendations. Interviewees noted that the objective physical conditions of critically ill children—such as unstable vital signs, the presence of tubes, and the effects of medication—along with subjective emotional states like separation anxiety from parents, fear of the PICU, and concerns about safety risks, all contribute to the challenges of implementing PR. To prevent adverse events, the medical staff decided to postpone the rehabilitation intervention, disregarding the principle of “early.”. At the same time, the ambiguous delineation of responsibilities among doctors, nurses, and therapists impedes the progress of rehabilitation efforts. As assessors and decision-makers, doctors are seldom engaged in the subsequent implementation and evaluation processes. It is worth contemplating whether they can dynamically assess the overall changes in children during the early stages of pulmonary rehabilitation. The nurse who has the most contact with the child is also responsible for a portion of the PR program. An additional consideration is whether the nurse should assume the responsibilities of the rehabilitation therapist in their absence.

3.2.3 Communication and collaboration within the PICU rehabilitation platform

“Social influence” includes social support and group conflict, which are mixed factors that affect recommendation decision-making behavior and hold an important position (62.5% of barriers and 42.9% of facilitators). Interviewees indicated that the multidisciplinary collaboration platform for PR is inadequate. They also noted that information sharing is insufficient and that there are discrepancies in understanding among various specialties. These factors make it challenging to develop the most effective pulmonary rehabilitation plan for the children. Additionally, due to the young age of children, there are differences in cognition and communication compared to adults, which also impact the implementation of PR.

3.2.4 External support for PICU pulmonary rehabilitation

The limitations of hardware, professionals, and funding are significant factors that impact early PR in critically ill children. The majority of interviewees felt that the PICU has a high workload and that basic nurse duties, drug administration, and invasive treatments take precedence over rehabilitative exercises. There is a high expectation for having a professional rehabilitation team stationed in PICU to provide more specialized pulmonary rehabilitation activities for the children.The interviewees also said that the number of existing rehabilitation equipment was small to support the implementation of some rehabilitation activities, and the operation was complex. They hoped that there would be more labor-saving and convenient methods to help children complete the training.

4 Disscussion

4.1 Changing perceptions, increasing PICU medical staff's early PR awareness and evidence-based skills

Traditionally, the focus of treatment in the PICU has been on resuscitation, the management of critical illness processes, and the reversal of organ failure.Therefore, critically ill children often use sedatives and are bedridden for long periods due to the need for safety, comfort, and hemodynamic stability.In recent years, early pulmonary rehabilitation during intensive care has become increasingly common. PICU medical staff are participants and guides in pulmonary rehabilitation, and their knowledge and professional skill levels directly influence the implementation of pulmonary rehabilitation in PICU.According to the study's findings, medical staff, nurses, and technicians all have some knowledge about PR, but their lack of comprehensive knowledge and high-level, evidence-based medical support has made them less inclined to advocate for early PR for children in critical condition. This is consistent with the findings of Nardo et al.'s quantitative study (15). PICU medical staff also lack systematic training and evaluation, which results in a lack of competence and trust in their ability to perform. All medical personnel involved in patient care should get formal pulmonary rehabilitation training, according to the American Thoracic Society's policy statement on enhancing the implementation, use, and supply of pulmonary rehabilitation (16). Therefore, on the one hand, it is necessary to strengthen research and evidence-based training to increase PICU medical staff's awareness of evidence-based practice. This can be achieved through high quality clinical research, continuous practice and validation to increase the level of evidence, and the development of clinical practice guidelines. On the other hand, various forms of knowledge and skills training in early PR for critically ill children should be implemented to deepen the understanding and application of early PR and to continuously improve cognitive levels and evidence-based practice skills.

4.2 Stimulate motivation, enhance the willingness of PICU medical staff to recommend early PR

PICU medical staff's willingness to recommend PR is diminished by a lack of self-efficacy stemming from insufficient skills and a lack of intrinsic motivation influenced by external environmental factors. Therefore, effective intervention strategies should be implemented to enhance behavioral motivation (1). Changes in motivation are a process of calculating risks, and risk-benefit analysis can influence motivation (17). Once individuals acquire the ability to develop, they should create a targeted action plan grounded in a comprehensive understanding of the risks and rewards associated with their proposed decisions. They should implement a monitoring system, enhance the effectiveness of rewards and punishments, and strengthen positive experiences. This approach will empower individuals to transition from thinking to execution of the action plan, consistently derive positive outcomes, and confidently engage in their practice (2). Research indicates that PICU medical staff derive a sense of professional value and recognition from patients' recovery and affirmation from their peers. This recognition, in turn, positively influences their professional behavior and fosters the development of their skills (18). Therefore, managers should proactively identify best practices for early pulmonary rehabilitation in PICU and effectively guide and motivate the remaining staff. This approach will enhance the willingness and enthusiasm of the PICU team to implement early pulmonary rehabilitation (3). Clarify the roles and responsibilities of each discipline, establish workflows and protocols, and ensure the smooth progress of pulmonary rehabilitation work.

4.3 Optimize the environment, improve the atmosphere for early PR recommendations in PICU

The PICU environment can influence the prevalence of lung rehabilitation. Firstly, in previous studies, nursing staff play a central role in rehabilitation activities, with nurses conducting 37% to 48% of rehabilitation activities (19, 20). However, in this study, nurses may delay or refuse to implement lung rehabilitation due to staff shortages and heavy workloads. In addition, there is a negative correlation between nurses' work-related stress and patient safety; as stress levels increase, the likelihood of adverse events and disputes also rises (21). Therefore, determining how to adjust the existing staffing structure of the PICU in the future to achieve optimal human resource allocation is a pressing challenge that managers must address. Secondly, fostering a culture of multidisciplinary collaboration in the PICU is essential for the project's success (22). The implementation of early PR depends not only on nurses but also necessitates the active participation of physicians, rehabilitation therapists, respiratory therapists, and other disciplines. Research indicates that utilizing a Multidisciplinary Team (MDT) can enhance the implementation rate of rehabilitation programs and improve rehabilitation outcomes (23). This study emphasizes the urgent need for multidisciplinary collaboration platforms. Furthermore, the current lack of equipment hampers existing PR activities, and the training methods available are insufficient. Therefore, managers should proactively introduce advanced rehabilitation equipment to enhance the efficiency of PR activities. Finally, it is essential to further improve the medical system and support related to children's rehabilitation in the future, instilling greater confidence in medical staff and the families of patients, and encouraging their commitment to recommending early pulmonary rehabilitation.

5 Conclusion

This study examines the barriers and facilitators influencing decision-making behavior related to early lung rehabilitation recommendations among medical staff in PICU. Utilizing the COM-B theory and the TDF, data were collected across four main themes and thirteen sub-themes. The identified barriers and facilitators were categorized into fourteen TDF domains and three COM-B modules. This qualitative analysis addresses existing research gaps and can serve as a valuable reference for the development and implementation of early pulmonary rehabilitation intervention strategies for pediatric patients in the PICU in the future. The current study excluded children with severe medical conditions; subsequent research should consider conducting interviews with this population to obtain valuable insights into their experiences with pulmonary rehabilitation. This approach would enhance the understanding necessary to confidently advocate for lung rehabilitation in the future.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding authors.

Ethics statement

The studies involving humans were approved by the Research Ethics Committee of the Children's Hospital of Nanjing Medical University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

WC: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. MenL: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. CL: Formal analysis, Resources, Writing – review & editing. MeiL: Funding acquisition, Project administration, Resources, Supervision, Writing – review & editing. XZ: Project administration, Resources, Supervision, Writing – review & editing. YZ: Data curation, Writing – review & editing. LZ: Data curation, Writing – review & editing. YY: Visualization, Writing – review & editing.

Funding

The author(s) declare that financial support was received for the research and/or publication of this article. This research was supported by the Nanjing Health Science and Technology Development Project (YKK22171).

Acknowledgments

We would like to thank the PICU medical staff who participated in this study. They gave up their valuable time to provide us with their views and experiences regarding pulmonary rehabilitation. This research would not have been possible without them.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declare that no Generative AI was used in the creation of this manuscript.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fped.2025.1535459/full#supplementary-material

Abbreviations

PICU, pediatric intensive care unit; p-PICS, pediatric post-intensive care syndrome; PR, pulmonary rehabilitation; SRQR, standards for reporting qualitative research; COM-B, capacity, opportunity, motivation-behavior; TDF, theoretical domains framework; MDT, multidisciplinary team; VAP, ventilator-associated pneumonia.

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