Digital Repository Masters Projects Spring 2025 Educating ICU Nurses toInitiate Early Mobilization in ICU Patients Madelynn Stephens Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Stephens, M. 2025. Educating ICU Nurses toInitiate Early Mobilization in ICU Patients. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Educating ICU Nurses to Initiate Early Mobilization in ICU Patients Project Title by Madelynn Stephens Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY 04/26/2025 Ogden, UT Date Madelynn Stephens BSN, RN, MSN Student 04/26/2025 Student Name, Credentials (electronic signature) Date JoAnn Tolman DNP-L, MSN-Ed, RN, CNE 04/25/2025 MSN Project Faculty Date (electronic signature) Anne Kendrick, DNP, RN, CNE (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. 04/26/2025 Date 1 Educating ICU Nurses to Initiate Early Mobilization in ICU Patients Madelynn Stephens, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: This project aims to improve nurses' confidence in initiating early mobility for all ICU patients by providing education and a mobility reference tool. Rationale/Background: Early mobilization in ICU settings is associated with numerous positive outcomes, including reduced risk of ICU-acquired weakness (ICU-AW), decreased length of hospital and ICU stays, and lower rates of delirium. However, barriers such as inadequate training and knowledge among nursing staff can hinder the implementation of these practices. Methods: A comprehensive literature review was conducted, analyzing studies on nursing education and early mobility in the ICU. A mobility reference tool for ICU nurses was implemented. And a pre-survey evaluated nursing confidence to initiate early mobility. An educational PowerPoint was presented to ICU nurses to introduce the mobility reference tool and the importance of early mobility. After 12 weeks, a post-survey was conducted to collect data on nursing confidence to initiate early mobility. Results: Nurses report increased confidence to initiate early mobility for critically ill patients after the implementation of a mobility reference tool and educational PowerPoint. Nurses also contributed recommendations to help improve mobility such as, securing mobility equipment, in sufficient quantity for the ICU, and training non-licensed staff on mobilizing ICU patients. Conclusions: Mobility education, and a mobility reference tool, can improve nurses' confidence and competence in initiating mobilization for ICU patients. The findings support the development of evidence-based programs tailored for ICU nurses, aiming to enhance their understanding of early mobility benefits This initiative can potentially improve patient care and recovery outcomes in the ICU setting. 3 Keywords: early mobility, mobility reference tool, nurse confidence, nurse education, ICU nurses 4 Educating ICU Nurses to Initiate Early Mobilization in ICU Patients According to the Society of Critical Care Medicine (2024), five million patients are admitted annually to an intensive care unit (ICU) for intensive or invasive monitoring. Early mobility in the ICU is a critical component of patient care. Early mobilization refers to initiating movement and physical activity for critically ill patients within the first 2 to 5 days of ICU admission (Alaparthi et al., 2020). Intensive Care Unit patients are usually confined to a bed, mechanically ventilated, and receiving intravenous (IV) sedation (Alaparthi et al., 2020). Bed rest for ICU patients negatively affects all body systems and creates residual problems such as decreased quality of life (Alaparthi et al., 2020). Patients who require treatment in an ICU are suffering significant long-term health problems related to their stationary and extended ICU stay. Patients are at risk of developing ICU-acquired weakness (ICU-AW), ICU delirium, mental-related problems, and physical health problems (Linke et al., 2020), such as ventilator-associated pneumonia, muscular atrophy, length of hospital stay, and decreased functional capacity (Alaparthi et al., 2020). Healthcare professionals, particularly nurses, are pivotal in facilitating early mobility to reduce these risks. However, the confidence level of the nurse to initiate mobility can significantly impact the implementation of mobility protocols (Charway, 2020). Nurses working in the ICU need more education to improve their confidence and initiate early mobilization of their patients. Initiating early mobility will help improve patients' physical and mental function and decrease the risk of developing long-term health issues. Statement of Problem According to a survey by O'Leary et al. (2020), many ICU nurses report feeling unprepared to assess patients for mobility interventions. The majority of the patient population is 5 critically ill, intubated, sedated, and on bedrest orders, increasing the risk of long-term injuries and illnesses (Rawal & Bakhru, 2023). Nurses must be more confident in initiating early mobility, to avoid missed therapies (Schallom et al., 2020). There are gaps in the routine orientation for ICU nurses, causing a lack of confidence and knowledge about when and how to mobilize and items to assess during therapies (Escalon et al., 2020). Nurses in the ICU lack specific education about mobility and need more education regarding early mobility for ICU patients with acute conditions. Some patients are excluded from early mobilization due to their current condition, although an active order for Physical Therapy (PT) and Occupational Therapy (OT) from the physician is in place. Nurses need to be more confident in discussing mobility orders during care conferences to recommend discontinuation and re-ordering at an appropriate time for the patient. Patients lack a crucial component to their recovery that significantly impacts their long-term health (Zhang et al., 2019). Therefore, this MSN project aims to provide focused education on mobility and a quick-reference tool for early mobilization for nurses to support the patient's recovery. Significance of the Project Implementing an educational program emphasizing early mobility's importance can transform ICU nursing practices (Masse, 2023). This MSN project is significant because it fills a gap in mobility education for ICU nurses and supports better patient outcomes. The project's success relies on the active participation and dedication of the ICU nursing staff. A mobility reference tool is a quick guide for nurses, with evidence-based recommendations tailored to individual patient needs. Nurses will know what patients to exclude from early mobilization, what to assess for when mobilizing their patients, and how to use the reference tool as a resource, 6 alleviating nurses' anxiety and increasing confidence related to patient mobility (Charway, 2020). Additionally, early mobility can decrease healthcare costs for the patient by decreasing the number of days spent in the ICU and hospital (Tipton et al., 2021). As the patient works with therapies and improves, their overall length of hospital stay shortens, and the patient can be discharged from hospital services quickly. The project benefits ICU patients by creating a quicker recovery and fewer post-ICU complications (Escalon et al., 2020). For example, there would be a decrease in the incidences of delirium, hospital and ICU stay length, ICU-AW, number of pressure injuries, ventilator-associated pneumonia, deep vein thrombosis (DVTs), and joint stiffness (Zhang et al., 2019). Further, patients in early mobility programs experience fewer complications, such as pressure ulcers and deep vein thrombosis (Zhang et al., 2019). Therefore, equipping nurses with the necessary education and tools for mobility is essential to improve patient recovery. Review of the Literature A literature review explored current research on improving nurses' confidence in implementing early mobilization for ICU patients. Since the early 19th century, early mobilization has been utilized as a form of rehabilitation for ICU patients (Alaparthi et al., 2020). The PICOT question guiding the literature review of this MSN project is: For nurses working in the Intensive Care Unit (ICU) (P), would implementing education about early mobility and a mobility reference tool(I), compared to no education or tool(C), improve the nurses' confidence to initiate early mobility for patients (O) over three months? The Evidence-Based Practice Change model provides the framework for the foundation of the implementation of this research project. 7 Framework This project utilizes the Evidence-Based Practice Change model as its guiding framework. As outlined by Dusin et al. (2023), this model draws on theoretical and research literature, research utilization, standardized language, qualitative and qualitative data, clinical expertise, and contextual evidence. This robust framework supports evidence-based changes and will guide the six steps of this project, allowing ongoing reevaluation and adaptation. The first step involves assessing the need for change and addressing the critical role of mobility in patient recovery (Melnyk & Fineout-Overholt, 2019). Prolonged ICU stays heighten the risk for complications, and a lack of nurse education on mobilization exacerbates these risks. Step 2 is locating the best evidence to support the change (Melnyk & Fineout-Overholt, 2019). This step is accomplished with a literature review on the timing and outcomes associated with early mobilization and the best methods to educate nurses. This information is further analyzed during step 3 to locate the most recent data on educating nurses and early mobility benefits (Melnyk & Fineout-Overholt, 2019). In Step 4, key stakeholders review proposed changes, including administration, managers and clinicians. Step 5 is implementing mobility education and a reference tool and evaluating the change (Melnyk & Fineout-Overholt, 2019). An evaluation of the processes, outcomes, costs, and development recommendations will take place with the stakeholders. After initiating the early mobilization education and reference tool, feedback from a survey of those involved guides further changes. Step 6 of the project is integrating and maintaining the change. This step, as outlined by Melnyk & Fineout-Overholt (2019), involves ongoing discussions with stakeholders, periodic monitoring of outcomes, and interpretation of results. As Dusin et al. (2023) emphasize, using 8 internal institutional data is vital in determining the success of the change. The stakeholders will continually monitor the ICU patient population and make necessary protocol changes to improve patient outcomes. This ongoing evaluation and protocol improvement is critical to adapt to the dynamic healthcare system. Strengths and Limitations The Evidence-Based Practice Change model has many strengths. One strength of the model is the reliance on clinical expertise and the best available evidence to create the proposed change (Dusin et al., 2023), which improves patient outcomes (Connor et al., 2023). Additionally, the model can provide a reliable framework to locate, interpret, implement, and review recent evidence-based practice changes to enhance ICU nurse confidence in mobilizing patients. However, this model also contains limitations that impose and limit decision-making processes. According to a survey conducted by Pitsillidou et al. (2021), nurses indicated that the biggest obstacle to initiating evidence-based changes was the need for more authority and drive for change. Another obstacle was that the evidence-based change did not apply to their environment (Pisillidou et al., 2021). In order to facilitate a change in the ICU, evidence-based practice must be specific to improving nurses' education regarding early mobility and improving patient outcomes. Additionally, this model lacks identifiable leadership, which poses a threat to the smooth transition of the proposed change. Securing buy-in from leadership will aid in overcoming this challenge. Analysis of Literature This review aims to explore the current literature regarding improving ICU patient outcomes by educating nurses about the importance of early mobility and implementing a 9 reference tool. Research showed that mobilizing ICU patients early in their hospital stay decreases hospital-acquired illnesses and long-term complications (Zhang et al., 2019). Educating nurses about the importance of early mobility in ICU patients and providing a mobility reference tool will help them mobilize the patients appropriately and confidently. Search Strategies A literature search identified evidence using Weber State University Stewart Library's OneSearch and Advanced Search, Google Scholar, and PubMed databases. A timeframe of 2019 to 2024 was created, and only articles written during that period were used to keep information current. The conducted search included keywords of early mobilization, ICU patients, ICU-delirium, nursing education, nursing confidence, education, invasive ventilation, non-invasive ventilation, physical therapy, occupational therapy, post-intensive care syndrome, early mobility, critically ill patients, ICU, ICU-acquired weakness (ICU-AW), quantitative, qualitative, a systematic review of, mortality rate, discharged, length of hospital stay, length of ICU stay, and nurses. Various Boolean combinations were used to widen the search and collect the necessary information. Synthesis of the Literature A literature review explores answers to the PICOT question: For nurses working in the Intensive Care Unit (ICU) (P), would implementing education about early mobility and a mobility reference tool(I), compared to no education or tool(C), improve the nurses' confidence to initiate early mobility for patients (O) over three months? The first theme identified was the benefits and importance of educating the nursing staff (Schallom et al., 2020; Masse, 2023). The second theme identified was that mobilizing ICU patients decreases the risk and rate of ICU-AW (Escalon et al., 2020; Zhang et al., 2019; Inonue et al., 2019). Third, early mobilization for ICU 10 patients decreases the days spent in the hospital and ICU (Tipton et al., 2021; Escalon et al., 2020). The last theme found was that utilizing early mobility for ICU patients helps reduce the frequency of developing delirium (Masse, 2023; Linke et al., 2020). Nursing Education Several studies found that educating nurses on the benefits of early mobility increased their confidence and improved overall patient outcomes (Schallom et al., 2020; Escalon et al., 2020). The most common barrier to evidence-based practice (EBP) implementation is nurses' education and work experience (Pitsillidou et al., 2021). Schallom et al. (2020) implemented an early mobility protocol at a medical center with a 132-bed ICU. Their implementation stage was staggered to allow for 2 to 4 months of education for nurses on the American Association of Critical-Care (AACN) screening criteria for early mobility in ICU patients. The ABCDEF (A2F) bundle uses evidence-based practices to improve patient outcomes by decreasing sedation, duration of mechanical ventilation, and incidence rates of ICU-AW and ICU-delirium (Masse, 2023; Schallom et al., 2020). Masse (2023) focused on utilizing the A2F bundle, properly documenting mobility, and implementing a mobility protocol specific to the patient population. Skill practice sessions, staff meetings, emails, and poster displays were the first education items for staff (Masse, 2023; Linke et al., 2020). Updates and refreshers through quarterly check-ins and weekly huddles continuously educated and refined the nursing staff's mobility skills (Connor et al., 2023; Masse, 2023). Staff education effectively enhances patient outcomes by improving nurses’ confidence (Masse, 2023). In a retrospective pre- and post-intervention data collection design by Linke et al. (2020), staff was required to enroll in a 2-hour educational class that focused on the adverse effects of bed rest, the benefits of early mobility, and how to safely mobilize ICU patients. The 11 class allowed for questions, real-time education, and demonstration of proper early mobility for ICU patients. The staff responded to surveys before and after the class to assess their confidence and comfort level in mobilizing ICU patients. After the class, Linke et al. (2020) found that 55.6% indicated they felt comfortable mobilizing ICU patients, and 69.5% indicated they had adequate resources for patient mobility. Fifty percent of the responses indicated that the most common barrier was the need for additional staff to mobilize complex patients (Linke et al., 2020). Intensive Care Unit-Acquired Weakness Evidence supports early mobilization as a preventative measure for ICU patients. Approximately 40% of ICU patients develop intensive care unit-acquired weakness (ICU-AW) (Inonue et al., 2019). Risk factors for ICU-AW include certain diseases and disorders, long duration of mechanical ventilation, immobility, and use of neuromuscular blocking agents and sedation (Inonue et al., 2019). ICU-AW is also worsened by extended periods of bed rest and high levels of sedation (Corner et al., 2019). High sedation levels threaten the implementation of early mobility for ICU patients (Escalon et al., 2020). Providing sedation breaks coordinated with therapy sessions allows patients to actively participate and discourages unnecessary high levels of sedation use (Escalon et al., 2020). Early mobility allows ICU patients to maintain a portion of their muscle strength while hospitalized and provides lung expansion, which decreases the risk of developing pneumonia (Silver et al., 2018). In three studies conducted with 190 patients, Zhang et al. (2019) found significant evidence to suggest that early mobilization within five days of admission decreased ICU-AW prevalence (p=0.013). Escalon et al. (2020) stated that patients on bedrest lose 5% of muscle mass per week from lack of mobility, and those with multiple organ failure lose 16% in 12 one week, which contributes to ICU-AW. A qualitative study interviewed fifteen past ICU patients regarding their stay in the ICU, their memories, and how their lives have changed after developing ICU-AW. From the interviews, several themes emerged. First, recovering from ICU-AW can be difficult and complex (Corner et al., 2019). Second, with lengthy hospital stays, procedures, and intense illnesses, patients had to adapt to their new bodies. Third, rehabilitation plays a vital role in this process, and early mobilization helped decrease the significant long-term effects (Corner et al., 2019). In partial contrast, some sources of evidence have not found a correlation between early mobilization and decreasing ICU-AW. Menges et al. (2021) reviewed 12 random control trials (RCTs) and found no statistical significance between early mobilization and standard mobilization (RR 0.90, p=0.54). However, they did see a 38% reduction in the rate of developing ICU-AW with early mobilization protocols compared to late mobilization (RR 0.62, p=0.06) (Menges et al., 2021). Length of Hospital and Intensive Care Unit Stay Early mobilization aims to decrease the days spent in the hospital and the ICU. The average length of stay in a United States of America hospital is roughly five and a half days (Tipton et al., 2021). Lengthy hospital stays increase the patient's chances of developing hospital-acquired patient complications (Tipton et al., 2021). By implementing early mobilization protocols within five days of admission, the patient's length of stay in the ICU decreased by 1.82 days, and their hospital stay was shortened by 3.90 days (Zang et al., 2019). In a comparative cohort study that involved 541 mechanically ventilated patients, Escalon et al. (2020) saw a 19%-20% decrease in patient's length of stay when involved in early mobility. Initiating early mobility within the first few days of admission to the ICU decreased the patient's 13 length of stay in the hospital (p<0.002), ICU (p<0.05), and readmission rates (Escalon et al., 2020). Decreasing the patient's length of hospital and ICU stay also decreases their risk of complications such as deep vein thrombosis (DVTs), ventilator-associated pneumonia, and pressure sores due to immobility and extended bed rest periods (Zang et al., 2019). However, Menges et al. (2021) and Linke et al. (2020) both had inconclusive results that early mobilization was responsible for decreasing the length of hospital and ICU stays. In the study conducted by Escalon et al. (2020), patients were not followed up after discharge, so the long-term results of early mobility were not known. Intensive Care Unit-Delirium Utilizing activity protocols in the hospital helps decrease the time from patient admission to time of movement, drastically reducing the frequency of developing delirium (Linke et al., 2020). Delirium is an acute cognitive disorder that involves fluctuating mental status and impaired attention that affects roughly 80% of ICU patients (Lange et al., 2022). Delirium is caused by high levels of sedation (Corner et al., 2019), untreated infections, improper sleep-wake cycles, reduced cholinergic activity, or excess dopamine and serotonin (Reznik & Slooter, 2019). Sedation vacations allow patient's bodies to normalize their sleep-wake cycles and actively participate in therapy sessions (Escalon et al., 2020). The A to F (A2F) bundle is an evidence-based pathway widely used to help combat ICU delirium (Masse, 2023). Studies have shown that greater compliance with the A to F bundle decreased rates of delirium and mortality (Lange et al., 2022). The D element of the bundle focuses on assessing, preventing, and managing delirium. A multidisciplinary team composed of nurses, respiratory therapists, physical therapists, occupational therapists, and patient care technicians work to mobilize all ICU patients (Masse, 2023). Mobilizing all patients, even those 14 mechanically ventilated, within five days of admission drastically reduces the incidence of delirium (Zhang et al., 2019). Tobar et al. (2017) found that occupational therapy utilization had a high rate of decreasing delirium rates. The focus was for ICU patients to participate in activities of daily living (ADLs), such as sitting at the edge of the bed, simulated eating, grooming, or sitting in an armchair (Tobar et al., 2017). This study found that occupational therapy significantly lowered the incidence of delirium (p=0.001) and created a higher level of functional independence (p=0.001). In contrast, Reznik and Slooter (2019) suggest avoiding high-risk medications such as benzodiazepines and anticholinergics and recommend trialing dexmedetomidine for agitation that accompanies delirium. Further, Inoue et al. (2019) found that sleep quality, length of sleep, and regular sleep-wake cycles were the only beneficial treatments in decreasing and treating delirium. Summary of Literature Review Findings and Application to the Project A detailed review of current literature regarding ICU early mobility revealed that early mobility creates positive outcomes for patients. The literature revealed that early mobility drastically decreases the risk of developing ICU-AW, hospital and ICU stay length, and ICU delirium. This information has helped substantiate this project's potential to improve nurse's education regarding the importance of early mobility for ICU patients and supports future implementation of this project. This project will use the information from the literature to create evidence-based education for nurses regarding the benefits of early mobility, what patients are exempt from early mobility, what to assess during therapy, and how to view the reference tool. 15 Project Plan and Implementation This MSN project aims to improve ICU patient outcomes by introducing early mobility. Early mobility decreases the risk and rate of ICU-AW (Escalon et al., 2020), days spent in the hospital and ICU (Tipton et al., 2021), and delirium (Linke et al., 2020). The project goal will be accomplished by educating nurses about the importance of early mobility and implementing a mobility reference tool. Plan and Implementation Process This project utilizes the Evidence-Based Practice Change model as its guiding framework. The model allows for ongoing reevaluation and adaptation to implement a research-based project (Dusin et al., 2023). Guided by the Evidence-Based Practice Change model, the project begins with the development of a mobility reference tool based on literature review and interviews. This reference tool informs nurses on the benefits of early mobility, what patients are exempt from early mobility, and what to assess during therapy. The next step involves scheduling a meeting with the project leader, the ICU manager, and the critical care medical director. This meeting will discuss the proposed project, deliverables, and the budget for education, to obtain buy-in for implementation . The project deliverables are a) pre-survey, b) an educational PowerPoint presentation for ICU nurses, c) a mobility reference tool, and d) a post-survey. After receiving approval, project implementation begins. A mandatory in-person class occurs for all ICU nurses. Two classes are available during one week to allow for schedule flexibility. Education includes a PowerPoint presentation on the new mobility reference tool, the benefits of early mobility, how to mobilize ICU patients, and a demonstration on how to mobilize ICU patients. A pre-survey is shared in the beginning of the PowerPoint presentation and emailed to any staff that did not attend. The pre-survey obtains data 16 on nurse confidence with initiating early mobility, utilizing a Likert scale of 1-10 (1 being the least/worst and 10 being the most/best). The class will be recorded and uploaded to the ICU’s shared resource for future access or if ICU nurses missed the in-person class. The reference tool is placed on all computers, nursing stations, and break rooms and sent through email to all ICU nurses. Three months after early mobility education, a post-survey is sent out and the data is collected to learn if the education improved nurse’s confidence to initiate early mobility for patients. The last step of the project is integrating and maintaining the change. The results from the post-survey and patient data will be collected and interpreted. The stakeholders and project leader will monitor the ICU patient population monthly and make necessary changes to the reference tool or provide more education. Any additional interventions will be discussed, addressed, and implemented if appropriate. Interdisciplinary Team The healthcare professionals contributing to the project include the ICU manager, project leader, critical care medical director, ICU physician lead, ICU unit educator, ICU staff nurses, charge nurses, Certified Nursing Assistants (CNA), Respiratory Therapists (RT), Physical Therapists (PT), and Occupational Therapists (OT). Effective teamwork fosters open communication among all members. Regular interdisciplinary meetings and discussions ensure that everyone is informed about patient progress and mobility plans, leading to more cohesive care. Each team member contributes specialized knowledge, allowing for a comprehensive approach to patient care. This exchange of information helps improve overall care quality. By fostering teamwork, hospitals can enhance communication, share knowledge, engage patients, and ultimately create a more practical approach to mobility in critically ill patients. This leads to 17 better clinical results and promotes a culture of collaboration and shared responsibility among the healthcare team. ICU Manager and Critical Care Medical Director. The ICU manager and critical care medical director play a major role in implementing a mobility reference tool and educating nurses regarding early mobility. They oversee the implementation process, ensuring that resources are available and that staff are trained, and track attendance for the meeting. They set the overall goals for improving mobility and patient outcomes in the ICU. They also provide clinical oversight and ensure that the mobility initiative aligns with best practices and evidence-based guidelines. Their support helps legitimize the program and encourages stakeholder buy-in. Project Leader. The project leader is a registered nurse and MSN student. The project leader communicates with all stakeholders and ensures everyone is informed and engaged throughout the implementation process. They work closely with the unit educator to create the PowerPoint presentation to provide the initial early mobility information to the staff. Throughout the project, they gather feedback from ICU staff nurses and other stakeholders to refine the mobility tool, ensuring it meets the needs of the ICU environment. They also establish measurable goals and timelines for the implementation to keep the project on track. ICU Physician Lead. The physician lead fosters teamwork among nurses and physicians, encouraging discussions around mobility interventions during rounds to ensure therapy orders are not missed and PT and OT see the correct patients. They also mentor staff in understanding mobility's clinical importance, helping bridge any gaps in knowledge or confidence. 18 ICU Unit Educator. The educator supports the use of the mobility reference tool effectively. The unit educator and project leader create the PowerPoint presentation and demonstration during the mandatory class. They create a supportive learning environment where nurses can practice mobility assessments and interventions to boost their confidence in using the tool. ICU Staff Nurses. Staff nurses are the primary recipients of the project and users of the mobility reference tool by applying it into their daily patient care routines. Their firsthand experiences with the tool provide critical insights that can be used to improve its usability and effectiveness. By actively engaging in mobility interventions, nurses advocate for their patients' needs and well-being to enhance their care quality. Charge Nurses. Charge nurses lead by example, promoting the use of the mobility reference tool and ensuring that it is part of the unit's culture. They oversee the execution of mobility plans, ensuring that all team members are aligned and that mobility interventions are performed consistently. During huddles, the charge nurse reminds the nurses to utilize the mobility reference tool and mobilize their patients if appropriate. Certified Nursing Assistants. Certified Nursing Assistants assist in patient mobility by helping with transfers, ambulation, and repositioning, making them essential in executing the mobility plan. Their interactions with patients can motivate and encourage them to participate in mobility activities, reinforcing the benefits of movement. Respiratory Therapists. Respiratory Therapists evaluate patients' respiratory status and provide recommendations for safe mobilization before, during, and after mobilization. They work with nurses to integrate respiratory considerations into mobility plans, ensuring patients remain stable during interventions. During any mobility with an intubated patient, RTs are 19 responsible for monitoring the airway, oral and deep-pharyngeal suctioning, and providing more oxygen if necessary. Physical Therapists. Physical Therapists provide specialized knowledge on movement strategies and exercises tailored to the needs of critically ill patients. They work alongside nurses to develop individualized mobility goals that enhance patient recovery and promote functional independence. Occupational Therapists. Occupational Therapists assess patients' ability to perform daily activities and design mobility interventions that promote independence and enhance quality of life. They educate nurses and other staff about the importance of occupational performance in mobility, fostering a holistic approach to patient care. OTs work with the family and patients to create a goal of accomplishing their normal everyday tasks, such as hygiene, work-related tasks, hobbies, and caregiver tasks. Description and Development of Project Deliverables This MSN project utilizes four deliverables to educate ICU nurses and aid implementation. The four deliverables are: a) pre-survey for ICU nurses, b) initiating early mobility PowerPoint presentation for ICU nurses, c) mobility reference tool, and d) post-survey for ICU nurses. This section will discuss the deliverables and how they improve ICU nurse confidence. Pre-Survey for ICU Nurses (see Appendix A). The first deliverable is a pre-survey created in Emaze. This survey is used to gauge nurse’s confidence and knowledge and provide opportunities for continuous improvement and education (Melnyk & Fineout-Overholt, 2019). A QR code for the pre-survey is shared at the beginning of the PowerPoint presentation and presented during the mandatory staff meeting for all ICU nurses. The survey contains seven 20 questions to gauge ICU nurse's confidence and knowledge of early mobility. Five questions use the Likert scale to collect numerical data, and two are open-ended for specific responses. Initiating Early Mobility PowerPoint Presentation for ICU Nurses (see Appendix B). The second deliverable is a PowerPoint presentation shared during the mandatory staff meeting for ICU nurses. The presentation educates nurses on the importance of early mobility and how it benefits patients by using evidence-based research (Linke et al., 2020). The presentation also introduces the mobility reference tool, how to use it, the expectations of the reference tool, and what personnel and equipment can be used during mobility for ICU patients. The PowerPoint presentation is emailed to all ICU nurses who could not attend the meeting and then uploaded to the online drive where all nurses can access it. Mobility Reference Tool (see Appendix C). The third deliverable is a mobility reference tool that provides quick reference information on the benefits of mobility, what patients are exempt from mobility, and what to watch for during therapy. The reference tool will be placed at all nursing stations, in the breakroom, and shared in huddle. In addition, the reference tool is emailed to all ICU nurses to be used as a future resource. The expectation is nurses will use the reference tool as a reminder to address mobility, discuss during rounds, and use it as a criteria checklist for patients who should and should not receive mobility (Masse, 2023; Linke et al., 2020). ICU physicians will be sent a copy of the tool and encouraged to discuss mobility during rounds. Post-Survey for ICU Nurses (see Appendix D). The fourth and final deliverable is a post-survey created in Emaze and given to all ICU nurses. The post-survey is used to gauge the improvement of ICU nurses' confidence and knowledge, monitor the outcomes of the project, and provide feedback for change (Melnyk & Fineout-Overholt, 2019). A QR code and link to the 21 post-survey are emailed to all ICU nurses 3 months after the initial class and implementation of the mobility reference tool. The post-survey shares almost identical questions as the pre-survey and utilizes a similar format, five questions using the Likert scale and two open-ended questions. Timeline The timeline for this project is estimated to be roughly 19 weeks from the initial creation of the reference tool to the post-survey (see Appendix E). The first week involves locating, analyzing, and utilizing evidence-based research to create the mobility reference tool. After the creation, a meeting between the project leader, ICU manager, and critical care medical director to discuss the reference tool, the current problem, and the benefits of the proposed project is scheduled. After receiving buy-in from the involved members, a mandatory meeting for all ICU nurses will occur in the following 2 weeks when a classroom or location is available. The meeting includes the pre-survey, introduction to the reference tool, and education on early mobility. The pre-survey has a two week deadline. After the educational meeting, the mobility reference tool is implemented and utilized. For the next 12 weeks, ICU nurses use the mobility reference tool to initiate and maintain early mobility for all appropriate patients. The project leader will round with all ICU nurses once a week and remind them to use the reference tool and answer any questions. All ICU physicians will be sent a copy of the reference tool and encouraged to discuss mobility during rounds. Concluding the 12-week period, a post-survey is sent to all ICU nurses, and a required completion date of 2 weeks is shared in the email. The last week involves collecting, analyzing, and interpreting all the data. Project Evaluation Evaluating a project's success is essential to assess its effectiveness and identify any necessary adjustments. Dusin et al. (2023) emphasized the importance of using institutional data 22 to measure the change's success accurately. Formative evaluation includes a pre-survey that measures ICU nurses' confidence and prior knowledge of initiating early mobility for ICU patients. Additionally, the pre-survey gathers formative qualitative data on barriers and suggestions regarding mobility. The post-survey (Appendix D) provides summative evaluation data concluding the 12-week implementation period of the reference tool. The two survey results will be compared to assess the success or failure of the mobility reference tool and identify any gaps by the project leader. From the surveys and qualitative feedback, the project lead will thoroughly assess the data and identify any trends. The project lead will communicate the findings to all participating stakeholders based on the survey results and individual input. Qualitative information helps to seek and understand rather than explain (Nassaji, 2020). Both surveys have two open-ended questions to allow nurses to share any current barriers they have encountered and provide suggestions for improvements before and after implementing the reference tool. ICU nurses are the frontline workers for mobilizing ICU patients, and their insight and knowledge regarding current barriers and suggested improvements are necessary to facilitate a successful implementation of the project. The project leader may contact all ICU nurses to ask further clarifying questions about the reported concerns or recommendations, but a response is not required since the survey is anonymous. After the project, an evaluation of the processes, outcomes, and development recommendations will occur in a meeting between the project leader and stakeholders (Melnyk & Fineout-Overholt, 2019). The project leader will share all data collected from the surveys, including the pre-survey scores, post-survey scores, and any identified trends. The project leader will also discuss any concerns or recommendations shared in the open-ended survey questions. If 23 the project succeeds, ongoing discussions with stakeholders and frequent outcome monitoring will help maintain the change. Ethical Considerations Ethical considerations are important when implementing a new change. Ethical consideration ensures that knowledge is obtained without compromising or at a person's or society's expense (Miteu, 2024). It creates a space where scientific inquiry can flourish responsibly (Miteu, 2024). Transparency is crucial in this project. Clear communication of the mobility tool's objectives, methods, and expected outcomes will be shared with all participants. Regular updates will be provided throughout the process, fostering trust and ensuring all stakeholders are informed of any developments or changes. Survey questions were created to collect data and with ethical considerations in mind. Participation in the pre and post-surveys will be voluntary. Nurses will be informed of their right to decline participation without any repercussions. For those who choose not to participate, we will respect their decision and ensure they continue receiving the same training and support as their colleagues. This commitment helps create an inclusive and supportive environment. To protect individuals’ privacy, all data collected from the surveys will be anonymized to ensure no personally identifiable information is linked to specific responses. Access to the data will be restricted to the project leader and authorized personnel involved in evaluating the project. To ensure non-discriminative behaviors, the training and resources provided will be inclusive and applicable to all ICU patients, regardless of their background, ethnicity, or socioeconomic status. The educational materials will be designed to accommodate diverse learning needs by considering varying levels of prior knowledge and experience among nurses. 24 The project leader will also actively promote an environment that values diverse perspectives and encourages open dialogue among staff. Personal bias must be avoided throughout the project to prioritize the project's success. The project leader may experience personal bias while implementing the project. The project leader might unconsciously favor specific approaches or interventions based on past experiences or personal beliefs. If the leader has a strong attachment to the project's success, they may downplay critical feedback or fail to acknowledge areas needing improvement. The project leader can uphold ethical standards, promote a positive work environment, and ensure the successful implementation of the mobility tool in the ICU by acknowledging and addressing personal bias (Yarborough, 2021). Discussion Early mobility has been shown to lead to shorter ICU stays (Tipton et al., 2021; Escalon et al., 2020) and reduce the risk of complications such as ICU-AW (Escalon et al., 2020; Zhang et al., 2019; Inonue et al., 2019) and delirium (Masse, 2023; Linke et al., 2020). The project targets essential aspects of patient care by addressing barriers like time constraints and knowledge gaps, ultimately benefiting patient recovery. The significance of this MSN project lies in its potential to enhance ICU nurses' confidence and knowledge about initiating early mobility, which is crucial for improving patient outcomes. This section will discuss the evidence-based solutions for dissemination, the significance of advancing nursing practice, implications, recommendations, and conclusions. Evidence-based Solutions for Dissemination After the implementation of the project, the data collected will be disseminated in several ways. The project leader will compile the information into a summary, which includes benefits of 25 ICU early mobility, trends and themes derived from the pre and post-survey, and feedback from ICU nurses. The project summary will be presented electronically via email to the ICU managers, ICU educators, administration team, and the critical care medical director, inviting feedback on the evaluation of the project and measures of success and the potential to continue the project. Further, the project summary and results will be presented to all ICU nurses during a staff meeting. A portion of this meeting will be blocked to allow for an additional discussion about the project and to encourage honest feedback. Finally, the project leader will create and share a poster presentation highlighting the project's results with peers and faculty at the Annie Taylor Dee School of Nursing at Weber State University. Should the project's results prove significant, publication in a relevant academic journal will be discussed. Significance to Advance Nursing Practice This MSN project can help ICU nurses improve their confidence in initiating early mobility for all ICU patients. Improving nurses' confidence enhances their professional satisfaction and plays a crucial role in the overall healthcare system's ability to provide effective and compassionate care (Schallom et al., 2020; Escalon et al., 2020; Masse, 2023). Further, implementing early mobility protocols can lead to better patient outcomes, including reduced length of stay (Tipton et al., 2021; Escalon et al., 2020), decreased risk of ICU-AW (Escalon et al., 2020; Zhang et al., 2019; Inonue et al., 2019) and delirium (Masse, 2023; Linke et al., 2020), and improved overall recovery. The project targets a critical aspect of patient care with wide-reaching implications by addressing the specific needs of ICU nurses, who often face challenges in initiating mobility due to time constraints, lack of knowledge, or uncertainty. The 26 project directly enhances patient care by equipping nurses with knowledge and tools to initiate mobility. Implications This MSN project has identified several strengths and limitations throughout the project. Strengths include using the Evidence-Based Practice Change model, as the framework for the project, and providing a structure for continuous evaluation, feedback, and changes (Melnyk & Fineout-Overholt, 2019). Further, staff education enhances patient outcomes by improving nurses' confidence (Masse, 2023). This project includes various educational materials for different learning styles, including reference tools, PowerPoint presentations, in-service training, and handouts. These materials are available in physical copies, emailed to all ICU nurses, and uploaded to a shared drive. This allows for easy future access to these educational resources for all ICU nurses. Limitations include sample size and buy-in. This project is implemented in one 26-bed ICU with roughly 60 ICU nurses. Due to the small sample size, conclusions may not be generalizable to all ICU nurses. However, the project can be utilized with future ICU nurses hired to the unit to create a larger population. Staff buy-in for new projects can create implementation issues related to resistance to change and unwillingness for additional meetings and education. To address these barriers, comprehensive educational materials will be provided that emphasize the significance of early mobility and what to assess during mobility to foster safe patient care. Emphasizing voluntary participation can promote nurse buy-in, but the project leader can strongly encourage participation to increase knowledge and improve patient outcomes. Ultimately, this project aims to improve patient outcomes by enhancing nurses' knowledge and confidence in initiating early mobility. 27 Recommendations This project explored how a mobility reference tool and education would improve ICU nurses' confidence in initiating early mobility for their patients. The literature review was focused on how education and early mobility improved overall patient outcomes. However, few research studies focused on when mobility should be initiated for ICU patients and what specific patient populations should be receiving early mobility. These patient populations could include those with cardiovascular surgeries, neurological injuries, orthopedic surgeries, substance-use withdrawals, and respiratory failure. Patients on bedrest lost 5% of their muscle mass per week from lack of mobility (Escalon et al., 2020). Researching the specific time during a patient's stay when mobility needs to be implemented before drastic changes in the patient would further add to the project and promote better patient outcomes. Conducting the project in multiple ICUs would create a larger sample size and benefit the project. In addition, the project was also solely focused on ICU nurses. Interdisciplinary professionals would benefit from the education provided in this project, and this addition would promote teamwork to achieve the goal of initiating early mobility for ICU patients. Research on the confidence of other interdisciplinary team members on initiating early mobility would be valuable in enhancing and building upon this project. Conclusions In conclusion, educating nurses is key to building their confidence and knowledge about early mobility to improve patient outcomes (Schallom et al., 2020; Escalon et al., 2020). Various studies emphasize that structured educational interventions can effectively prepare nurses to mobilize patients (Linke et al., 2020) safely. The evidence highlights the need for straightforward education programs that explain why early mobility is important, how to assess patients, and how 28 to use mobility reference tools. This project aims to develop straightforward educational resources to help ICU nurses initiate early mobility into patient care. Ultimately, the goal is to improve nursing practices and promote better health outcomes for ICU patients, emphasizing the critical role of early mobility in their recovery. 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What are the current barriers you have observed in mobilizing ICU patients? 2. What improvements can be made (i.e. equipment, personnel, therapy times, etc.) to improve mobility for ICU patients? 34 Appendix B Initiating Early Mobility PowerPoint Presentation for ICU Nurses 35 36 37 38 39 40 Appendix C Mobility Reference Tool 41 Appendix D Post-Survey for ICU Nurses Electronic Survey Link: https://app.emaze.com/@ALIQFZTLQ/online-survey Rate the following on a scale of 1 (worst) – 10 (best) 1. How would you rate the early mobility training you received? 2. How confident do you feel to initiate early mobility in ICU patients? 3. How would you rate your knowledge of what patients are exempt from therapy? 4. How would you rate your confidence in knowing what to assess on a patient during therapy? 5. How would you rate your knowledge of the benefits of early mobility? Open Answers 1. What barriers have you still observed that are preventing adequate early mobility for ICU patients? 2. What further improvements can be made (i.e. equipment, personnel, therapy times, etc.) to improve mobility for ICU patients? 42 Appendix E Proposed Timeline