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Promoting A Culture of Mobility Through A Nurse-Driven Mobility Algorithm: A Quality

Improvement Project

By

Shannon Cardinal, BSN, RN

Bachelor of Science in Nursing, University of New Hampshire, 2017

CAPSTONE PROJECT

Submitted to the University of New Hampshire in Partial Fulfillment of the Requirements for the

Degree of Master of Science in Nursing

September 2018

ii

DEDICATION

I would like to dedicate this project to my fiancé, best friend, and biggest supporter since

starting this journey. I could not have become a registered nurse or a clinical nurse leader

without you!

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ACKNOWLEDGEMENTS

I would first like share my appreciation for my chair, Dr. Elizabeth Evans, for constant

support throughout this research project. Her guidance and encouragement aided in my success.

I would next like to acknowledge my preceptor, Stacy Ficara, for her constant wisdom,

support, and guidance throughout my preceptorship. She resembled everything a CNL should be

and made for a great role model. My future successes as a CNL will be owed to her.

Lastly, I would like to thank my parents. Without their endless support, encouragement

and patience, finishing this degree would not have been possible.

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TABLE OF CONTENTSLIST OF TABLES………………………………………………………………………………..vi

ABSTRACT…………………………………………………………………………………......vii

INTRODUCTION……………………………………………………………………………...…1

GLOBAL PROBLEM…………………………………………………………………….1

LOCAL PROBLEM………………………………………………………………………2

AVAILABLE KNOWLEDGE………………………………………………………...….3

RATIONALE……………………………………………………………………………...7

GLOBAL AIM…………………………………………………………………………….8

SPECIFC AIM…………………………………………………………………………….8

METHODS………………………………………………………………………………………..8

CONTEXT………………………………………………………………………………...8

INTERVENTION…………………………………………………………………………9

MEASURES……………………………………………………………………………..10

ANALYSIS………………………………………………………………………………11

ETHICAL CONSIDERATIONS……………….………………………………………..12

RESULTS………………………………………………………………………………………..12

DISCUSSION……………………………………………………………………………………14

LIMITATIONS………………………………………………………….......…………...15

IMPLICATIONS FOR THE CLINICAL NURSE LEADER…………...………………………15

RECOMMENDATIONS………………………………………………………………...16

CONCLUSION………………………………….……………………………………………….16

REFERENCES…………………………...……………………………………………………...17

APPENDICES.…………………………………………………………………………………..19

v

LIST OF TABLES

Table 1…………………………………………………………………………………………….3

Table 2…………………………………………………………………………………………….9

Table 3…………………………………………...………………………………………………10

Table 4…………………………………………………………………………………………...12

Table 5………………………….………………………………………………………………..13

Table 6…………………………………………………………………………………………...14

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ABSTRACT

Introduction: Immobility related to hospitalization can lead to various negative physical and psychological effects, as well as hinder discharge planning and functional ability after hospitalization. Early mobility protocols in the acute care setting have been proven to positively impact patient functional level. Despite these successes, various nurse barriers have been identified that prevent patient mobilization. Through the implementation of a nurse-driven mobility algorithm, a culture of mobility can be formed, addressing nurse barriers and improving patient mobilization efforts. Aim: The aim of this quality improvement project was to introduce a culture of mobility on the unit through an early mobility algorithm. Methods: Lewin’s Theory of Change was the theory to guide this project. This project began with a pre -survey to identify nurse barriers and perceptions to patient mobilization. Consistent with Lewin’s theory of change, education was provided on “culture of mobility” and a nurse-driven algorithm was then implemented June 4th, 2018. To evaluate outcomes of the algorithm, a post survey was distributed. The pre and post survey data was then compared to identify changes in the culture of mobility on the unit and to reinforce and “freeze” new mobility habitsResults: The implementation of a nurse- driven mobility algorithm showed an increase in nurses mobilizing their patients from 39% to 44%. The percentage of nurses who felt physical therapy should be the primary healthcare providers to mobilize their patients decreased from 50% to 22%. Communicating mobility efforts during handoff increased to 100%. Despite these results, the percentage of nurses who wait for physical therapy to mobilize their patients slightly increased by 1%. These results indicate more education and efforts are needed to promote a culture of patient mobility.Discussion: A process to promote a culture of mobility through a nurse-driven mobility algorithm was successfully implemented at the microsystem level in a population of medical surgical patients. Due to negative nurse perceptions and attitudes towards early mobility being the major barrier, it is important mobility barriers are addressed. By implementing nurse-driven algorithms, a culture of mobility can be formed.Implications for Clinical Nurse Leader: The Clinical Nurse Leader (CNL) acts as a lateral integrator by involving multiple members of the interdisciplinary care team to improve patient outcomes. The CNL also acts as a knowledge manager and patient advocate by disseminating evidence -based practice to staff and implementing it at the microsystem level, as well as ensuring quality care.

Keywords: culture of mobility, mobility algorithm, early mobilization

1Running head: PROMOTING A CULTURE OF MOBILITY

PROMOTING A CULUTRE OF MOBILITY THROUGH A NURSE-DRIVEN MOBILITY ALGORITHM

Hospitalization can lead to decreased mobility and functional decline, especially for

the elderly. It can cause accelerated bone loss, dehydration, malnutrition, delirium, sheering

forces on the skin, incontinence, hospital-acquired pressure ulcers and falls. Additionally,

functional decline, defined as the inability to perform usual activities due to reduced muscle

strength and weakness, has been identified as the leading complication of hospitalization for

the elderly. Deconditioning from a patient’s baseline can occur as early as day 2 of

hospitalization. Without proper mobilization, a patient can lose up to 5% of muscle mass

daily. Aside from the medical complications associated with poor mobility, physical

inactivity can also lead to longer lengths of stay, mortality, nursing home placement,

increased healthcare costs, and readmission rates (Pashikanti & Von Ah, 2012). In order to

improve patient outcomes and reduce patient complications and healthcare spending, early

mobility must be a priority within the acute care setting.

Global Problem

With patient outcomes drastically related to patient mobility, it is pivotal that

interventions aimed at positively influencing early mobility are initiated. In order to

successfully initiate early mobility programs, barriers to early patient mobility must be

understood. A study by Brown, Williams, Woodby, Davis, and Allman (2008) described

nurse, patient, and physician barriers to early mobility. Through qualitative interviews,

multiple perceived barriers were identified, the most common including: having symptoms,

weakness, pain, and fatigue. Others included having an intravenous line, urinary catheter, and

being concerned about falls. Nurses were more likely to site lack of staff to assist, as well as

2PROMOTING A CULTURE OF MOBILITY

lack of ambulatory devices more commonly than patients, and nurses and physicians were

more likely to attribute low mobility to lack of patient motivation. With multiple

interdisciplinary team members involved with patient mobility, it is important that individual

barriers are understood in order to address those barriers and initiate improvement. It is

evident that nurses, physicians, and patients each have different obstacles to mobilizing.

Education and awareness is essential to implement successful early mobility efforts. By

having nurses understand patient barriers, interventions can be provided to increase the

likelihood of patient participation. Providing education to nurses on the importance of early

mobility, barriers including “lack of staff and equipment” and “urinary catheters/intravenous

lines” will not be determining factors to getting patients moving!

Local Problem

At the site of this quality improvement project, nurse barriers to patient mobility were

studied specifically. A pre-survey was conducted to understand potential staff barriers to

patient mobility. See Appendix A. The results were underwhelming, and no specific barrier

(including education, lack of training/knowledge, supplies) were ascertained. The results of

the survey can be found on Table 1. 61% of staff either disagreed or strongly disagreed that

they mobilized their patient’s enough throughout the day, while 89% of staff agreed or

strongly agreed that it’s important for all patients to be up in the chair for all meals and

mobilized. Additionally, 55% of nurses agree or strongly agree that they often wait for

therapy to mobilize their patients first and half of staff were either neutral or agreed that

therapy should be the primary care provider to mobilize patients. Interestingly, 94% of staff

agree or strongly agree that they have received training on how to safely mobilize their

patients, and only 16% of nurse’s report not feeling confident or safe in their ability to


mobilize their patients. Free text barriers to lack of mobility included staffing and time most

frequently. These results do not indicate a knowledge barrier, but rather a practice barrier.

Promoting a culture of mobility through nurse-driven mobility algorithms will make nurses

accountable for mobilizing their patients, as well as make mobility a part of their daily

workflow. Since it is proven that nurses understand best-practice for mobility, and how to

safely ambulate, incorporating mobility into the culture will help make mobility a priority.

Through promoting a culture of mobility, patients effected by the lack of mobility will have

positive outcomes. Additionally, unit length of stay, hospital-acquired pressure ulcers, falls,

and additional safety measures will begin to decrease.

Table 1.


Available Knowledge

The purpose of this literature review was to understand nurse barriers to early

mobility in efforts to implement successful early mobility interventions. Databases explored

to collect data included CINAHL Complete, Cochrane Database of Systematic Reviews,

Health Source: Nursing/Academic Edition, MEDLINE, and PubMed. A search conducted in

each database included the following search terms: “nurse barriers”, “nurse perception” and

“early mobility”. Overall, 11 articles were yielded. The search was narrowed by full text

articles with data published within the last five years. This search yielded 8 results.

Additional key words were used including “medical-surgical patients” and “nurse obstacles”.

This final search yielded 5 results. The remaining articles were identified by criteria

specifically addressing nurse perceptions on medical-surgical units.

As discussed above, the study by Hoyer, Brotman, Chan, and Needham (2015)

explores perceived nurse and physical therapists’ barriers to mobility for hospitalized

patients. The biggest difference in responses included lack of time to mobilize patients.

Nurses report much less time in their workday to mobilize patients as compared to physical

therapists. Physical therapists also report more confidence and training related to safe

mobility as compared to nurses. However, both disciplines agreed that increased mobilization

will lead to more work for nurses. Additional barriers included lack of communication on

patient mobility and physical functioning, as well as the perceived notion that rehabilitation

therapists are the primary care provider to mobilize patients. Overall, nurses reported

significantly higher perceived barriers to patient mobility as compared to physical therapists,

including increased workload and less time to dedicate to mobility. Although compared to

rehabilitation staff, nurses do have additional responsibilities aside from mobility which most


certainly is a significant barrier, patient mobility should be made a priority. By providing

examples and education of benefits from mobilizing patients, perceived nursing barriers may

be reduced (Hoyer, Brotman, Chan & Needham, 2015). Additionally, more experienced

nurses perceive fewer barriers to patient mobility, supporting the possible positive effects of

training and experience to increase the value of patient mobilization and physical functioning

preservation. It is also important to note that when compared to medical-surgical units,

intensive care units did not perceive patient acuity or safety as a barrier to early mobility, but

rather having adequate staffing and time. These results indicate the importance of quality

improvement efforts to address perceived barriers while implementing early mobility

initiatives. Adopting a “culture of mobility” on the unit can help address nurse perceptions of

lack of time and staffing by incorporating mobility into regular practice, instead of an

additional task deferred for more important responsibilities (Hoyer, Brotman, Chan &

Needham, 2015).

The study by Dermody and Kovach (2017) also explored potential barriers to the

promotion of patient mobility. Despite knowledge of the benefits of mobility for patients, and

the important of promoting mobility to prevent physical decline, nursing are insufficiently

promoting mobility for their patients. In this study, 84% of nurses viewed promotion of

mobility as a priority, and 94% agreed that mobilization three times a day may lead to better

health outcomes, as compared to those not regularly ambulated. However, some nurses

believed a physical or occupational therapy should be the primary care provider to mobilize

patients, and a majority of nurses (61%) believe staffing is inadequate to promote mobility.

Additionally, 89% of nurses felt mobility would increase their workload, and 47% indicate

lack of time as a barrier to improving patient mobility (Dermody & Kovach, 2017). These


findings suggest that nurse attitudes, rather than insufficient knowledge may be a major

contributor to patient immobility. “Hospital organizations must… strive to create a culture of

mobility” (Dermody & Kovach, 2017, p. 6). Additionally, nurses must be involved in

developing mobility interventions and standardized protocols and procedures to increase

nurse-promoted mobility efforts.

Specific mobility interventions include mobility algorithms and assessment tools .In

order to increase patient mobility within the acute care setting, mobility protocols and

algorithms have been devised to address potential barriers to patient mobility. According to

Pashikanti and Von Ah (2012), nurse-driven mobility protocols are proven to decrease length

of stay in hospitalized patients, as well as maintain or improve function status from

admission to discharge.

The study by Friedman and Stilphen (2014) also discuss the importance of promoting

a culture of mobility on the unit to increase patient activity. 83% percent of measured

hospital stay is spent lying in bed, despite 80% of these patients being independent before

hospitalization, and only 8% actually having appropriate bed rest orders. Loss of function,

ambulation, and mobility is associated with an increase in length of stay, increase in

admissions to nursing homes, falls during and after hospitalization, and continued loss of

independence after hospital discharge. Additionally, there was a decrease in length of stay

and more discharges to home if the patient received exercise while in the hospital (Friedman

& Stilphen, 2014). To address the barriers of immobility, a “culture of mobility” must be

established to encourage mobility as a part of practice. A culture of mobility includes:

standardized order sets and protocols to aid in early mobility, all providers, patients, and

family members being accountable for mobility (including need to spell out all first time


physical therapy(PT), occupational therapy (OT), registered nurses (RNs), proper scripting

for nurses to encourage and involve patients in mobility, critical thinking and appropriateness

while ordering therapy consults, and a generalized understanding that early mobility is part of

general practice. “Mobilization should be as important to the patient as eating and

drinking…” (Friedman & Stilphen, 2014, p. 48).

Lastly, as described by Czaplijski, Marshburn, Hobbs, Bankard and Bennett (2014),

patients are frequently placed on bedrest upon admission without valid medical reasons.

Also, patient ambulation was found to be task of nursing care most frequently omitted from

the work day. Also, this culture of immobility lead to the responsibility of ambulation to shift

from nursing to PT/OT, creating delays in therapy workflow and patient treatment. Changing

to a culture of mobility requires fundamental changes to the current thought, practice, and

approach to early mobility.

Overall, understanding nurse barriers and perceptions to early patient mobility is

essential to implement effective quality improvement initiatives. Introducing a culture of

mobility helps address barriers to patient mobilization, including lack of time and lack of

staffing by making mobilization a priority and part of daily practice. Nurse-driven algorithms

and protocols have been successful in increasing patient functioning and in creating a culture

of mobility. The question that guided this quality improvement project was: Does

implementing a nurse-driven mobility protocol promote a culture of mobility on a medical-

surgical unit?

Rationale

The theoretical framework used in this quality improvement project was Lewin’s

Theory of Change. This change framework includes three different stages: unfreeze, change,


and refreeze. This theory focuses on the change subjects to positively impact change success.

Through properly identifying the problem and preparing the organization to accept the

change, the status quo can begin to break down. During the change phase, in this case

process implementation, people begin to act in ways that support the change. The refreeze

process consists of sustaining the change. Displaying post-survey data on the success of the

change will help solidify the new practice.

Global Aim

The global aim of this quality improvement project was to increase the awareness of

early mobility importance as well as to address nurse barriers to patient mobility by adapting

a culture of mobility on the medical surgical unit.

Specific Aim

The specific aim for this project was to form a culture of mobility on the medical

surgical unit by implementing a nurse-driven mobility algorithm.

Methods

Context

The site for this quality improvement project was a 24 bed, intensive care cardiac

step- down unit. The primary population includes, but is not limited to, patients over 65

admitted for chest pain, coronary artery bypass grafting, congestive heart failure

exacerbation, sepsis, and arrhythmias. The interdisciplinary care team involved for the care

of these patients includes registered nurses, licensed nursing assistants (LNAs) and critical


care technicians, cardiologist, hospitalists, physical, occupational, and speech therapists, and

nutritionist. The current process for mobilizing patients is not standardized and is currently

deferred to therapy or omitted all together. In Table 2. the current process for patient

mobilization is displayed. The orange “X” indicates where the quality improvement

intervention will take place. Ideally, patient mobility will be headed by RNs/LNAs, with

therapy staff to aid and provide professional recommendations. In a “culture of mobility”,

nurses and therapy will work together to mobilize patients and return them to previous

physical functioning. Mobility will become part of everyday practice and be incorporated

into the daily workflow. Eventually, all patients will be mobilized in a fashion that mimics

their baseline functioning.

Table 2.

Intervention

Prior to the intervention, a survey was conducted for registered nurses and licensed

nursing assistants from April 6th, 2018- April 20th, 2018 to understand the barriers to patient

mobility. Based on the available knowledge and the results of the survey, a nurse-driven

algorithm adapted by Colborn, et al (2016) was implemented over a period of 10 weeks (June

4th, 2018- July 23rd) to promote a culture of mobility on the unit, and to increase patient

mobility. See Table 3. Education was provided to staff prior to the introduction of the

algorithm at staff meetings, as well as in the form of a poster and handouts. The subject of

this education included the definition and clinical significance of a culture of mobility, the

importance and benefits of early mobility, and the use and benefits of the algorithm. After


implementation, a post survey was conducted to measure any improvements on early

mobility and the possible formation of a culture of mobility on the unit. The post survey

collection processes took place from July 2nd, 2018-July 16th. Results of the survey were

shared on the unit by July 23rd, 2018.

Table 3.


Measure

Nurses were assessed using the Likert scale survey to determine the agreeability to

patient mobility standards. The survey was created in reference to a study conducted by

Fridman (2017) and was identical to the pre-survey utilized. See Appendix A. The validity

and reliability were established through collaboration with a nurse leader. The survey

contains ten questions, each scaled on a score of one (strongly disagree) to five (strongly

agree). To score this measure, the sum of responses for each question was calculated and

then divided by the total number of responses. Each score reflected the percentage of level of

agreeability for that category. To collect this data, the surveys were made available on July 2,

2018 to all staff up until July 16, 2018.

Analysis

The outcomes were displayed in various ways. First, the results from the surveys

were entered into Excel spreadsheets to identify trends. The information was separated in

relation to the intervention, specifically pre and post data, and formed into bar graphs shown

in Table 1 and 4. Lastly, a paired two sample T-Test was used to determine statistical

significance.


Table 4.

Ethical Considerations

Ethical concerns related to this quality improvement project were thoroughly

considered. While periods of observation involved direct patient contact, data collection did

not include patient information. Institutional review board approval for this project was not

necessary, as no personally identifiable patient information was collected or removed from

the confines of the hospital. No conflicts of interest related to this project were identified.


Results

Data was collected over 24 nonconsecutive days. This process yielded 27 surveys, 18

from the pre -intervention phase, and 9 from the post intervention phase. Pre and post

percentages for each question was then entered into bar graphs to allow for comparison and

determine if a culture of mobility was formed through the implementation of the nurse-driven

mobility algorithm (Table 5 and 6). Although data revealed an increase in the formation of a

culture of mobility concerning the subjects of mobilizing patients enough throughout the day,

physical and occupational therapy being the primary care provider to mobilize patients, and

the communication of patient mobility during handoff, there was no change concerning

waiting for PT/OT to mobilize patients. Additionally, the results for each question were not

found statistically significant due to the p-value > 0.05.

Table 5.


Table 6.

Discussion

Mild improvement in a culture of mobility from pre and post data show a nurse-

driven mobility algorithm can help to promote a culture of mobility. Although none of the

results were statistically significant, data analysis revealed that with a majority of staff using

the nurse-driven algorithm to assist them with mobility, percentages of agreeability to the

questions “I feel I mobilize my patients enough throughout the day” and “I always

communicate my patient’s mobility status during handoff” increased. Additionally, the

percentage of staff who agree to the question “A physical therapist or occupations therapist

should be the primary care provider to mobilize my patients” decreased, showing the most

significant percentage change of 33%. The question “I believe it is important for all patients

to be up in a chair (unless bedrest/bedfast at baseline) and mobilized” showed no change.

This outcome was expected since the intervention and education did not focus specifically on

mobility importance, since a high level of importance was already the majority (89%). The


percentage of nurses who agreed to waiting for therapy to mobilize their patients first slightly

increased by 1%. The lack of positive change in this measure indicates more knowledge and

effort is needed to continue to promote a culture of mobility. These measures are pivotal to

promoting a culture of mobility, and responsibility, shared ownership and communication are

important to ensuring best practice for mobility efforts. Continued promotion of a culture of

mobility will improve patient functional status as well as associated outcomes.

Limitations

Limitations for this study include a small sample size. Of the 27 surveys received,

only 9 were from the post intervention phase. Additionally, the majority of staff that

answered the post survey were LNAs, compared to pre- surveys which was a majority of

RNs. This could have skewed results regarding education, training and act of mobilizing

patients. Other limitations include the high turnover rate on the unit, making many of the

staff who answered the pre-survey not present for the post surveys. Also, not all staff were

present for the education, making them unaware of the intervention and goals of the project.

Clinical Nurse Leader Implications

There are many implications for the clinical nurse leader as it relates to quality

improvement and patient outcomes. In this quality improvement effort, the clinical nurse

leader acts as a lateral integrator by coordinating and collaborating with the interdisciplinary

team. The CNL also acts as an educator and coach by providing evidence-based practice

recommendations as well as continued support and mentoring during the intervention phase.

The CNL is also a knowledge and outcomes manager by disseminating the results of the


improvement effort and initiating improvements to patient care to improve outcomes. Lastly,

the CNL acts as an advocate, not only for patients by supporting and initiating improvements

in patient care through EBP, but for staff by including them in the decision -making process

and formulating a plan to benefit patients and staff alike.

Recommendations

Based on the results of this quality improvement project, continued improvement is

needed to promote a culture of mobility. Additional components of the culture of mobility

framework should be introduced and implemented, including order sets, proper scripting, and

appropriateness of ordering therapy consults. Additionally, partnerships with the physical

therapy team should be initiated to further include the interdisciplinary care team. Lastly, a

PDSA cycle should be performed to identify areas for improvement and next steps.

Conclusion

Statistics show poor patient outcomes related to immobility. Research suggests the

major barriers to patient mobility are related to nurse attitudes, rather than patient

physiological contraindications. A culture of mobility helps form positive thinking around

patient mobility and encourages mobility as a general part of practice. Through the

involvement of the interdisciplinary care team, order sets and protocols, a culture of mobility

can ensure all patients are mobilized appropriately, leading to positive outcomes (Friedman

& Stilphen, 2014).


References

Brown, C., Williams, B., Woodby, L., Davis, L., & Allman, R. (2008). Barriers to mobility

during hospitalization form the perspectives of older patients and their nurses and

physicians. Journal of Hospital Medicine. 2(5), 305-313.

Colborn, B., Daly, H., Hilbert, K., Gordon, R., Shank, J., Singh, E., Wus, L. (2016). Culture

of Mobility. Retrieved on April 21, 2018, from http://jdc.jefferson.edu/rmposters/3/

Czaplijski, T., Marshburn, D., Hobbs, T., Bankard, S., &Bennett, W. (2014). Creating a

Culture of Mobility: An Interdisciplinary Approach for Hospitalized Patients.

Hospital Topics. 92(3), 74-79. doi: 10.1080/00185868.2014.937971.

Dermody, G., & Kovach, C. R. (2017). Nurses' Experience With and Perception of Barriers

to Promoting Mobility in Hospitalized Older Adults: A Descriptive Study. Journal Of

Gerontological Nursing, 43(11), 22-29. doi:10.3928/00989134-20170518-01

Friedman, M. & Stilphen, M. (2014). Creating Value by Establishing A Culture of Mobility

in the Hospital Setting. Retrieved on April 24, 2018, from

http://c.ymcdn.com/sites/www.acutept.org/resource/resmgr/CSM/Establishing_a_Cult

ure_of_Mo.pdf

Hoyer, E. H., Brotman, D. J., Chan, K., & Needham, D. M. (2015). Barriers to Early

Mobility of Hospitalized General Medicine Patients: Survey Development and

Results. American Journal of Physical Medicine & Rehabilitation / Association of

Academic Physiatrists, 94(4), 304–312.

http://doi.org/10.1097/PHM.0000000000000185


Pashikanti, L. & Von Ah, D. (2012). Impact of Early Mobilizations Protocol on the Medical-

Surgical Inpatient Population An Integrated Review of Literature. Clinical Nurse

Specialist CNS. 26(2), 87-94.


APPENDICES

Appendix A

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