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Implementing Prone Positioning for COVID-19 Patients Outside the Intensive Care Unit

Francisco, Mary Ann MSN, APN, AGCNS-BC, CCRN-K; Pierce, Nicole L. PhD, RN; Ely, Elizabeth PhD, RN; Cerasale, Matthew T. MD, MPH; Anderson, Daniela MD; Pavkovich, David MD, FACP, FAAP; Puello, Frances MD; Tummala, Sandeep MD; Tyker, Albina MD; D'Souza, Felicia R. MD

Author Information
Journal of Nursing Care Quality: April/June 2021 - Volume 36 - Issue 2 - p 105-111
doi: 10.1097/NCQ.0000000000000537


The 2019 coronavirus disease (COVID-19) has created a global health care threat not experienced since the 1918 Spanish flu pandemic. Given the novelty of severe acute respiratory syndrome, coronavirus 2 (SARS-CoV-2), commonly referred to as COVID-19, treatments are being tested and implemented in the clinical setting based on clinical judgment, evidence from related viral diseases, and data from both national and international sources where the pandemic initially appeared.1,2 Typically, implementation of a practice change takes careful planning involving meetings with multiple groups over time, with uptake of the change taking weeks or months.3,4 Because of the immediacy of this pandemic, one challenge faced by many medical centers is the need to quickly and effectively implement interventions for COVID-19 patients even as evidence and guidelines change rapidly over time.5 In addition, hospital-based health care providers experience significant stressors including real concern for personal safety, the safety of family and colleagues, inadequate personal protective equipment, and substantial fatigue.6

The most concerning complication of COVID-19 is respiratory compromise resulting from the development of SARS-CoV-2. In fact, nearly one-third of COVID-19 patients, particularly those who are elderly or have comorbid conditions, required admission to the intensive care unit (ICU) for treatment due to acute respiratory distress syndrome (ARDS).2 The landmark prone positioning in severe acute respiratory distress syndrome (PROSEVA) trial demonstrated that prone positioning decreased mortality in severe ARDS, presumably by promoting alveolar recruitment and reducing lung overdistension.7 It has since become an accepted part of the standard of care for intubated and mechanically ventilated ARDS patients.8–10

There are few published studies that describe proning nonintubated patients outside of the ICU setting to prevent ARDS and the subsequent need for mechanical ventilation and ICU admission.1,11,12 Despite this, prone position therapy is currently being used and studied in nonintubated COVID-19 patients in ICUs across the country and has been supported by numerous recently published case series and case reports.1,13,14 As a result, medical centers are beginning to implement self-proning strategies in which patients assume prone position themselves outside of the ICU to prevent ARDS. Studies have shown that early implementation of self-proning improves oxygenation and may potentially avoid intensive care and invasive ventilation.15,16 However, implementation processes for self-proning protocols in the non-ICU setting need to be optimized.

To quickly implement a self-proning protocol and improve patient outcomes, collaboration between providers and nursing staff is essential. The challenges of implementing and sustaining evidence-based practice (EBP) protocols are well documented in the literature.3,4 Examining how an organization's practice environment may impact unit climate and corresponding support for research and EBP uptake could address these challenges.17,18 Nurse managers are influential in developing and fostering the unit climate for EBP implementation by supporting a culture of inquiry, providing access to EBP education, and rewarding innovations that improve patient care through peer recognition.19–21 Examining the influence of unit climate and nurse characteristics during a period of rapid change and uncertainty can provide valuable knowledge, which can then be applied to enhance future intervention implementations.


The purpose of this quality improvement project was to examine how differences in the implementation climate of the 4 COVID-19 designated nursing units at UChicago Medicine (UCM) impacted the implementation of the self-proning protocol. The results of this project may shed light on the mechanisms behind successful uptake of rapid practice change and contribute to improved quality of care for patients with COVID-19 and respiratory symptoms.



Our 800-bed, urban, tertiary care academic medical center recognized the need to rapidly redesign nursing care units to care for COVID-19-positive patients. Initially, unit 1 was chosen to house the COVID-19-positive patients at our institution; this general medicine unit was accustomed to caring for patients with respiratory conditions. Subsequently, following organizational structure and published guidelines, 3 additional units were also rapidly converted to COVID-19 care units.22 All 4 nursing units have a capacity of 28 beds each and similar nurse staffing patterns.

During the COVID-19 pandemic, a protocol for patient self-proning outside of the ICU was developed on the basis of published evidence and approved for implementation in April 2020 (see Supplemental Digital Content, Self-Proning Protocol, available at: To evaluate the effectiveness of the initiation and implementation of the patient self-proning protocol, a quality improvement project was initiated to capture patient outcomes. This project received a formal Determination of Quality Improvement status according to UCM institutional policy. As such, this initiative was not deemed to be human subjects research and was therefore not reviewed by the institutional review board. In addition, clinical support was obtained from the nursing directors of the 4 COVID-19 nursing units. Data collected did not contain any identifiable private information and cannot be traced to individual patients, nurses, or managers, and are presented as aggregate data at the unit level.


Following approval, nursing staff were informed about the self-proning protocol. Educational methods were uniformly available to all 4 COVID-19 units, including an in-service video explaining the self-proning process, protocol tip sheets, patient education material (see Supplemental Digital Content, Patient Education, available at:, and copies of the protocol itself. However, emphasis was placed on in-person communication rather than written communication to inform staff of practice change. In addition to initial training, clinical nurse educators, unit managers, and physicians provided just-in-time education for staff when a COVID-19 patient eligible for self-proning was identified. They reviewed the protocol with staff, re-emphasized the patient benefits of self-proning, and answered questions. Unit huddles conducted every shift were also used to discuss the protocol and identify any issues with protocol implementation. Unit managers served as both resources and cheerleaders, encouraging and praising their staff when self-proning was performed appropriately. Nurses experienced with caring for self-proning COVID-19 patients also discussed the protocol with one another during change of shift report.


An established survey, the Implementation Climate Scale (ICS), was used to assess the culture of the 4 COVID-19 units during the implementation of the patient self-proning protocol. The ICS is a brief 18-item tool that measures 6 dimensions for EBP implementation: focus on EBP, educational support for EBP, recognition for EBP, rewards for EBP, selection for EBP, and selection for openness.23 Response format is a 4-point Likert scale with higher scores indicating greater value on consistently using EBP in nursing practice. The ICS has been used in a nursing population previously,18 with validation being done in substance abuse treatment groups24 and in child welfare organizations.25 In addition to the ICS, demographic (age, educational background, and length of time working as staff on the nursing unit) and process (perceptions about education received, benefit to patients, and the process of protocol implementation) data were collected from the respondents.

All registered nurses permanently assigned to 1 of the 4 COVID-19 units for the duration of the pandemic and working 20 hours a week or more were invited to participate via an anonymous survey. To best represent the climate of the 4 units, float nurses, agency nurses, and supplemental staff nurses were not invited to participate; these staff members did not consistently work on the COVID-19 units, and therefore their perceptions may not accurately reflect on the COVID-19 unit on which they were working. The survey was built in REDCap26 and distributed via e-mail 4 weeks after the implementation of the self-proning protocol. The survey was e-mailed multiple times during a 2-week period. Staff nurses and their managers were periodically reminded in person or via text messages to complete the survey.

In addition, data collected on the self-proning status and disposition of all adult COVID-19 patients admitted to the institution were used to determine how patient outcomes compared across units. All patients who were admitted directly to 1 of the 4 COVID-19 nursing units within the 6-week period after the self-proning protocol was approved were included for this analysis. Patients who were admitted to the ICU prior to arrival to the COVID-19 units were excluded from the analysis, as were pediatric patients.

Data analysis

Statistical analysis was conducted using SAS version 9.4 statistical software (SAS Institute, Inc, Cary, North Carolina). Descriptive statistics were calculated for all study variables, including nurse demographics, patient demographics, and ICS subscales/overall scores. Group differences at the unit level were examined using Fisher exact and Kruskal-Wallis tests. Significance was set at P < .05.


Eighty surveys were received from 183 eligible staff nurses working in the 4 COVID-19 nursing units. Two respondents did not indicate the unit of practice, resulting in their responses being eliminated from analysis, thus yielding an overall response rate of 42.6%. Across the units, response rates varied from 35.6% to 50.0% (see Supplemental Digital Content Table 1, available at: There were group differences in nursing experience (P = .038), with unit 3 having a higher proportion of very experienced nurses (≥16 years). Otherwise, there were no significant differences in nursing characteristics.

The majority of nurses on all units reported that they provided care for a self-proning patient and that they believed that self-proning benefited patients (see Supplemental Digital Content Table 1, available at: However, there were group differences in the perception of education received regarding the self-proning protocol (P = .029), with 50% and 25% of nurses from unit 3 and unit 2, respectively, stating that they did not receive education. Meanwhile, 90% of nurses from unit 1 and 86% of nurses from unit 4 reported that they received education (see Supplemental Digital Content Table 1, available at: There was also a significant difference (P < .001) in the perception of self-proning impacting nursing workflow, with nurses from unit 2 feeling that workflow was impacted to a greater extent than other units. When asked to what extent the self-proning process was beneficial to COVID-19 patients, 95% of nurses from unit 1 indicated that it was moderately to very greatly beneficial whereas 75% of nurses from units 2 and 3 and 82% of nurses from unit 4 thought that it was moderately to very greatly beneficial; however, this difference was not statistically significant.

Implementation Climate Scale

Beliefs and attitudes regarding the value of implementing EBP in nursing practice also varied by unit (see Supplemental Digital Content Table 2, available at: There were overall group differences in the ICS total (P = .033), with unit 1 reporting the highest overall score (median = 2.7); this indicates that, as a group, nurses on unit 1 believe that EBP is highly valued and used in their nursing practice. By contrast, unit 2 (M = 1.8) staff reported the lowest overall score of the 4 units. Of the 6 dimensions for EBP implementation measured, reward for EBP was the lowest across the 4 units, with each unit having a median score less than 1. Significant differences between the units were seen in 2 of the 6 subscales of the ICS: EBP education support (P = .016) and selection for EBP (P = .011), with unit 1 having median scores of 3.0 for both subscales and unit 2 reporting the lowest median scores at 1.7 and 1.3, respectively (see Supplemental Digital Content Table 2, available at:

Patient self-proning

During the period from April 27 to June 6, 2020, there were 198 COVID-19 patients admitted to the 4 nursing units (see Supplemental Digital Content Table 3, available at: Almost twice as many patients were admitted to units 1 and 2 than the other 2 units. Patients on all 4 units were eligible for the self-proning protocol between 38.7% and 58.3% of the time, with 41 (20.7%) patients self-proned at least once during their admission. While there were no statistically significant differences in self-proning among the units, units 1 and 4 had a higher proportion of eligible patients with a self-proning order (70.8% and 61.9%, respectively) relative to units 2 and 3 (48.4% and 43.8%, respectively). In addition, approximately a third of eligible patients on unit 2 self-proned while approximately half of eligible patients on other units (see Supplemental Digital Content Table 3, available at: Seven patients (3.5%) were transferred to the ICU; of these patients, 1 patient self-proned while on the unit, while 3 were not eligible for the self-proning protocol.

Length of stay varied significantly by unit. The median length of stay for the sample was 5.0 days (interquartile range: 3.0-7.0) with a range of 1 to 30 days. Units 3 and 4 had longer lengths of stay (6.0 and 6.5, respectively; P = .034) than units 1 and 2 (5.0 and 4.0, respectively). In addition, there was a significant group difference in disposition status. The majority (n = 141, 71.2%) of patients were discharged directly to their home with or without home care (see Supplemental Digital Content Table 3, available at: Unfortunately, 4 patients (2.0%) in this sample died; all 4 were not eligible for the self-proning protocol and therefore did not self-prone. No adverse events related to self-proning were reported for these patients.


Within 38 days of opening our first COVID-19 nursing unit, we safely and efficiently implemented a self-proning protocol to prevent the need for invasive ventilation and intensive care in COVID-19 patients across 4 nursing units. While the majority of nurse respondents worked full time, had BSN or higher degrees, and had 6 or more years of clinical practice, we discovered significant differences among the 4 nursing units related to unit culture that may have impacted the implementation of this protocol. Overall support for a climate of EBP was strongest on unit 1 and weakest on unit 4. Despite significant differences in ICS, rates of patient self-proning were not significantly different across units.

The importance of unit climate, however, is reflected in our findings. The highest overall ICS score was noted from unit 1; nurses on unit 1 rated their climate as being supportive of education for EBP, including selecting nurses with a background in EBP and having values supportive of EBP to a greater extent than other units. Unit 1 also had a higher percentage of eligible patients who had a self-proning order placed when compared with the other units. This enhanced adherence to the protocol may be due to the presence of and feedback from nurse managers, which influences the adoption of EBP as a key driver of unit climate.18,19 The nurse managers of this unit were actively engaged with their staff in implementing the protocol over the 6-week period. They provided round-the-clock support, collaborated with and coached staff in applying the protocol, and gave positive reinforcement to the nurses, thus nurturing a climate of EBP.

One solution often proposed to improve the implementation of EBP is staff education regarding the evidence supporting the change. On 2 of the COVID-19 units (1 and 4), nearly 90% of nurses identified receiving education about the self-proning protocol; conversely, 75% and 50% of nurses on the other 2 units (2 and 3, respectively) reported receiving education. This suggests that the approach to rolling out a new nursing care protocol with immediate implementation was influenced by education, interest, and the unit culture related to EBP. Widespread education about the protocol, belief in the effectiveness of the intervention, and a strong unit-based climate of EBP resulted in higher rates of eligible patients having self-proning orders and eligible patients successfully self-proning on units 1 and 4.

Attitudes and beliefs about the effectiveness of self-proning having a great or very great benefit to patients ranged from 37% to 54%, which suggests that beliefs about the effectiveness of this intervention may have contributed to the inaction we observed. Evidence for the effectiveness of self-proning is limited for non-ICU patients; perhaps this lack of evidence, along with the chaotic care environment, impacted the implementation of self-proning. However, several studies have shown that tradition and belief outweigh evidence in attempting to adopt a change in practice.3,20 This may be exacerbated on units with cultures that are less supportive of EBP. On unit 2, where fewer nurses reported receiving education and had less conviction about the effectiveness of the intervention, eligible patients were proned less than 30% of the time. Therefore, it may be beneficial to understand unit-based attitudes and beliefs to maximize the likelihood of adoption of a new practice change.

Unit differences in beliefs about the effectiveness of self-proning may also be related to knowledge about the patient population or trust in the prescribing providers. Nurses on units 1 and 4 were accustomed to a medically complex patient population, along with the medical physician team that provided care for the COVID-19 patients; in contrast, nurses on units 2 and 3 cared for neurology and surgery patient populations before becoming COVID-19 units. This familiarity with the medical team may also explain why rates of eligible patients having self-proning orders were higher on units 1 and 4 than on units 2 and 3.

The unit climate for EBP, therefore, appears to be an important and potentially modifiable variable to consider when planning a successful practice change. The organizational climate of this institution is also relevant. Evidence-based practice is practiced and valued in this Magnet-recognized organization, with a robust shared governance structure and resources for EBP implementation. Results from the reward subscale of the ICS were low across all 4 units possibly because staff nurses at our organization are represented by a collective bargaining unit and individual nursing rewards are limited by contract.


There were several limitations in regard to this quality improvement project. These data are descriptive in nature and limited to a 6-week “snapshot” of clinical practice on 4 non-ICU COVID-19 units in the midst of a dynamic pandemic. As such, we did not account for staffing patterns and acuity variations during the COVID-19 pandemic that may have impacted nursing workflow and the nurses' ability to assist patients with self-proning. This article represents a single institution's experience, during which resources and personal protective equipment were available and accessible. As a result, we did not see any impact on unit climate, and therefore implementation, based on resource shortages. This may not be the case in all institutions and therefore should be considered as a potential factor influencing implementation. There is also a possibility that there were patients who self-proned but documentation was lacking; however, nursing documentation of patient self-proning activities in the electronic health record was emphasized during the education phase and reinforced during daily unit huddles. In addition, we did not inquire about teamwork, or the influence of physician education regarding the self-proning protocol; both of these may have had significant impacts on the implementation of protocol. However, given that the medical teams across all nursing units received similar education, we feel that it was unlikely that there were significant differences. Finally, this was a single-institution experience that may not reflect the experiences of other institutions.

Implications for nursing practice

During the COVID-19 pandemic, nurses have experienced rapid change and variability while multiple potential treatments are being trialed on the basis of good clinical judgment, knowledge applied from related diagnoses, and knowledge gleaned from clinical experience. Nursing interventions, such as supporting patients with COVID-19 to self-prone outside the ICU, have shown promise. This quality improvement study provides beginning scientific support for the efficacy of this intervention. While further studies need to be done, especially with larger patient numbers, the patient group reported no adverse effects related to self-proning and more importantly appeared to have benefited from it. As we continue to see cases of COVID-19 and prepare for potential case increases, sharing our experience as transparently as possible is vital. This nursing intervention shows promise and can easily be adopted in other institutions. To that end, we are including our Self-Proning Protocol (see Supplemental Digital Content, Self-Proning Protocol, available at: Simultaneous to the protocol implementation, patient education materials were developed and distributed to eligible patients. Copies of the educational materials are included (see Supplemental Digital Content, Patient Education, available at:


Immediate implementation of a novel nursing intervention is possible, but attention to unit-based climate factors is key. Unit-level EBP climate influences implementation uptake, as staff engagement was strengthened when unit-level leadership and education were supported by a value for EBP. During the COVID-19 pandemic, at a time when nursing staff are exhausted and fearful, we safely and efficiently implemented a self-proning protocol to prevent the need for invasive ventilation and intensive care in COVID-19 patients across 4 unique nursing units.


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COVID-19; evidence-based practice; Implementation Climate Scale; non-ICU; prone positioning; SARS-CoV-2; self-proning protocol

Supplemental Digital Content

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