WSU REPOSITORY MSN/DNP Standardized Nursing Education on the Early Mobilization of Mechanically Ventilated Patients Project Title by Carlee Greene 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 Ogden, UT 4/26/24 Date Carlee Greene, BSN, RN, MSN Student 4/26/24 Student Name, Credentials Date (electronic signature) Tressa Quayle, PhD, RN 4/26/2024 MSN Project Faculty Date (electronic signature) 4/26/2024 Anne Kendrick (electronic signature) DNP, RN, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Standardized Nursing Education on the Early Mobilization of Mechanically Ventilated Patients Carlee Greene, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purpose/Aims: Evidence-based practice demonstrates that mechanically ventilated patients should be mobilizing. This project aims to increase mobilization rates of mechanically ventilated patients in an Intensive Care Unit (ICU) in the Western United States to at least fifty percent of clinically appropriate patients. The goal is also to improve registered nurses’ (RNs) attitudes toward and confidence in mobilizing these patients. Rationale/Background: Early mobilization while mechanically ventilated has decreased the length of stay, ventilator days, and ICU delirium (Escalon, 2020; Marra et al., 2017). Literature suggests that providing nursing education specific to the early mobilization of mechanically ventilated patients may improve RNs’ attitudes and confidence, increasing mobilization rates (Dagnachew et al., 2023; Dubb et al., 2016; Kim et al., 2018; Zhang et al., 2022). Methods: A multi-faceted educational approach will provide RNs in an ICU with adequate training and resources to safely mobilize mechanically ventilated patients. The Iowa Model will serve as a framework for guiding this project through an ethically sound and successful implementation with sustainable results. Results: At the end of implementation, it is anticipated that RNs’ attitudes and confidence toward mobilizing mechanically ventilated patients will improve. Similarly, mobilization rates for these patients will increase to at or above fifty percent. Conclusions: Mechanically ventilated patients should be mobilizing when clinically appropriate. By providing adequate education, ICU RNs may have a more positive outlook toward mobilizing mechanically ventilated patients and feel confident doing so. Likewise, the mobilization rates of this population will increase. 3 Keywords: early mobility, mechanically ventilated patients, intensive care unit, nurse education, nurse attitudes, nurse confidence, perceived barriers 4 Standardized Nursing Education on the Early Mobilization of Mechanically Ventilated Patients Registered nurses are vital in mobilizing mechanically ventilated patients in the intensive care setting. Some benefits shown by the early mobilization of mechanically ventilated patients include fewer days on the ventilator, decreased intensive care unit (ICU) and hospital stay, and reduced severity of ICU delirium (Escalon, 2020; Marra et al., 2017). Studies show that nurses’ attitudes and beliefs toward mobilizing mechanically ventilated patients are often negative (Kim et al., 2019; Wang et al., 2020; Zhang et al., 2021). Similarly, research suggests that nurses have limited knowledge of the subject without specific training and lack the confidence to mobilize safely. The literature demonstrates that education can impact nurses’ attitudes and knowledge regarding early mobility. In a qualitative cross-sectional survey, nurses given early mobilization training demonstrated greater knowledge and positive attitudes in applying it to their patient care (Zhang et al., 2021). Another study showed that increased knowledge of early mobility coincided with a more positive attitude (Dagnachew et al., 2023). Based on this evidence, one way to improve nurses’ attitudes, knowledge, and confidence surrounding early mobility hinges upon their education. Statement of Problem At a facility in the Western United States, the current mobilization rates for mechanically ventilated patients are 15% for the day shift, 31% for the night shift, and 23% combined (Intermountain Health, 2023). Research demonstrates the importance of early mobility in mechanically ventilated patients; however, many registered nurses display a negative attitude toward it because of perceived barriers (Kim et al., 2019; Wang et al., 2020; Zhang et al., 2021). 5 A literature review by Dubb et al. (2015) highlighted several categories of barriers that can affect mobilization, including patient-related, culture-related, process-related, and structural. For example, patient-related barriers consist of deep sedation, hemodynamic instability, or the use of medical devices. A lack of knowledge contributes to a culture where early mobility is not a priority. Structurally, there may be limited or inadequately trained staff, no mobility protocol in place, or time constraints. Similarly, if there is a breakdown in the process and team members do not understand their roles, protocols are not understood, or there is a lack of coordination among team members, mobility may not be seen as important (Dubb et al., 2015). In response, Dubb et al. (2015) highlighted how education on mobility, mobility protocols, and expectations can decrease and eliminate many of these barriers. In a systematic review conducted by Krupp et al. (2018), studies showed that the nurse’s role in mobilizing ventilated patients must be clear. Nurses may view mobility as a task that falls under the scope of physical or occupational therapy. Getting nurses on board with mobilizing begins by defining their role in the process and setting expectations. Studies with effective results utilized a mobility protocol that quickly identified which patients were appropriate to mobilize (Linke et al., 2020). Mobilizing these patients requires a collaborative approach on a multi-disciplinary level to change mobilization practices. Another significant barrier to mobilization is the over-sedation of mechanically ventilated patients. In the past, intubating a patient equated to sedating them; however, current evidence demonstrates that this is no longer the best practice (Escalon, 2020). Patients with the least amount of sedation necessary for the situation can engage in higher levels of mobilization faster (Hodson et al., 2022). Providers and nurses must work together to identify the appropriate level of sedation for each patient. Nurses must also use critical thinking to titrate sedation 6 appropriately for the patient. Thinking critically includes using analgesia over continuous sedation if it is ordered and the patient can tolerate it (Chanques et al., 2020). Addressing barriers and making the nurse’s role in mobilizing mechanically ventilated patients clear may aid in empowering and encouraging nurses to have a more positive outlook toward early mobilization. (Dubb, 2015; Escalon, 2020). The goal is that they will have the confidence and desire to mobilize their patients. Therefore, this project aims to provide ICU nurses at a facility in the Western United States with a standardized education course highlighting the importance of early mobilization of mechanically ventilated patients and the role of the registered nurse in mobilizing safely. The standardized education course will address common barriers, create a unit-specific protocol to determine patients appropriate for mobilization, and develop an expectation of adhering to the mobility protocol. The aim is to increase the rates of mechanically ventilated patients on the unit being mobilized out of bed to 50 percent within six months and improve nurses’ attitudes towards and confidence in mobilizing these patients. Significance of the Project Nurses need education and motivation to mobilize their mechanically ventilated patients to increase early mobilization rates (Dagnachew et al., 2023; Zhang et al., 2021). Registered nurses learn best from a multi-faceted approach that includes teaching strategies and lectures to build a strong foundation for mobilizing, allowing nurses to receive information passively and actively apply it in hands-on situations (Horntvedt et al., 2018; King et al., 2022). In addition, continuing education in the form of e-learning is beneficial in improving nurses’ knowledge (Rouleau et al., 2019). Including multiple formats supports educating and reinforcing nurses’ knowledge with different methods. 7 Current knowledge demonstrates that nurses are more likely to mobilize their patients when their role in mobilization is clearly understood (Krupp et al., 2018). Because mechanically ventilated patients are complex and have many members on their care team, it is crucial that each team member involved also understands their role. Practical mobilization projects attribute success to creating a consistent workflow and fostering interdisciplinary collaboration (Escalon et al., 2020; Linke et al., 2020). This project fits with previous work because the goal of increasing mobilization rates and improving nurses’ attitudes will be accomplished through education. Many will benefit from the implementation of this project. Through a multi-faceted educational approach, nurses will have the knowledge and skills to safely mobilize their mechanically ventilated patients. Patients will benefit from mobilizing by reducing lengths of stay and ICU delirium. For nurses to successfully mobilize mechanically ventilated patients, they must understand why it is essential (the purpose), and their role must be clear (Krupp et al., 2018). Through this project, interdisciplinary collaboration will be fostered and encouraged. Creating an educational program that yields these desired outcomes begins with reviewing the current evidence and best practices. Review of the Literature This literature review explores current literature regarding the Iowa Model framework, nurse education, and its effects on mobilization rates of mechanically ventilated patients in ICUs. This review addresses the clinical question: For intensive care unit nurses, does implementing a standardized education course on the early mobilization of mechanically ventilated patients increase the mobilization rates to at least 50 percent, show increased staff confidence, and 8 improve nurses’ attitudes toward mobilizing ventilated patients over six months? This section includes a review of the Iowa Model framework and a synthesis of the literature. Framework The Iowa Model will be the guiding framework for this project. The model involves identifying an issue, reviewing current evidence, and implementing a change. Several checkpoints prompt reflection before moving forward or making significant adjustments (Buckwater et al., 2017; Cullen et al., 2022; Melnyk & Fineout-Overholt, 2019). The first step in the model is to identify a triggering issue or opportunity for improvement. It should be based on existing data, show an opportunity for improvement, and have application in the clinical setting (Melnyk & Fineout-Overholt, 2019). This project has identified a need to increase mobilization rates for mechanically ventilated patients at a facility in the Western United States. The next step in the model is to identify a question or purpose. Once a purpose or question is identified, the end goal can then be clearly defined, and boundaries can be set for the project. This project aims to increase mobilization rates of mechanically ventilated patients in the ICU and improve nurses’ attitudes and confidence towards early mobility. After identifying the purpose, it must be determined if this project is a priority and aligns with organizational goals (Buckwater et al., 2017). Organizational buy-in and resource availability are essential to ensure the success of this project (Melnyk & Fineout-Overholt, 2019). Forming a team is the next step in the Iowa model. Different perspectives and collaboration from all team members are vital in promoting evidence-based practice (EBP) delivery (Melnyk & Fineout-Overholt, 2019). After forming a team, the evidence is synthesized and appraised. If there is sufficient evidence, the findings will create the foundation of the implementation pilot group. Pre-pilot and post-pilot analysis provide valuable feedback on 9 changes that should be considered before implementing the change on a large scale or if the project should be implemented at all (Buckwater et al., 2017). This step will provide feedback on the effectiveness of educational interventions related to early mobility before implementing them hospital-wide. If it is appropriate to move forward, the project will be integrated into practice to create change. Finally, the results will be disseminated (Melnyk & Fineout-Overholt, 2019). Strengths and Limitations The Iowa Model helps guide clinicians from a clinical problem to a sustainable EBP change (Buckwater et al., 2017; Cullen et al., 2022; Melnyk & Fineout-Overholt, 2019). This strength of the model allows potential barriers or problems to be identified and addressed early in the project. Another strength of this model is that it focuses on pilot testing to ensure that desired outcomes are achievable before full implementation (Buckwater et al., 2017). However, this can also be a limitation because of the time requirements this model needs for the pilot study before implementation. Another limitation is the resources needed to conduct an adequate literature review and synthesis of the evidence. While there are some limitations, the Iowa Model provides a robust framework for implementing sustainable change. Analysis of Literature A synthesis of the literature on the early mobilization of mechanically ventilated patients will be reviewed in this section. This literature review explores current literature regarding the early mobility of mechanically ventilated patients and common barriers to implementing early mobilization in hospitals, specifically ICUs. The aim of reviewing the research was to determine if there has been success in increasing early mobilization rates of mechanically ventilated patients by providing a standardized nursing education on the topic. Several search strategies 10 were used during this process. This section will discuss the search strategies and the themes identified in the literature synthesis. Search Strategies Current evidence was identified by conducting a literature review through Weber State University’s OneSearch and Advanced Search (which spans multiple databases), PubMed Central, and Elsevier. Only articles from 2015-2023 were included in the review. This span of years allowed for the synthesis of the most current evidence. The search included keywords of mobility, early mobility, mobility protocol(s), mechanically ventilated, intubated patients, intensive care unit (ICU), nurses, nurse education, and teaching strategies. Boolean phrases were developed from the mentioned keywords to widen the search. Synthesis of the Literature The available literature was synthesized by reading, organizing, and comparing to create themes. Three major themes were identified from the reviewed literature. First, establishing early mobility protocols aids in increasing mobilization rates. Second, nurses with limited knowledge of early mobility tend to display more negative attitudes and lack confidence in mobilizing. And third, a significant barrier to early mobilization is over-sedation. Establishing Early Mobility Protocols Aids in Increasing Mobilization Rates Current literature places value on establishing and implementing early mobility protocols for mechanically ventilated patients in the ICU (Dagnachew et al., 2023; Escalon et al., 2020; Krupp et al., 2018; Linke et al., 2020). In a quality improvement project, Linke et al. (2020) demonstrated how utilizing multiple disciplines to create a mobility protocol ensures that steps are not overlooked. In this project, a protocol started by evaluating the patient for hard stop, meaning unsafe to mobilize, or yield criteria, meaning they need further evaluation. This 11 protocol type identifies when a patient can advance to the next mobilization level, enabling each team member to understand expectations. Comparatively, Escalon et al. (2020) highlighted how implementing the Mount Sinai mobility protocol for critically ill patients increases mobilization rates. This protocol details each team member’s role and outlines exclusion criteria. The results of this study demonstrated how providing education through protocols leads to increased mobilization and decreased length of stay. Creating protocols that outline specific goals for each team member can increase mobilization rates. Similarly, a quality improvement project conducted in three adult ICUs at an urban academic hospital highlights the positive effects that standardized protocols have on mobility rates (Linke et al., 2020). The project implemented three phases and measured mobility rates during each phase. In phase one, mobility practices remained the same. Phase two involved raising awareness with emails, posters, and word-of-mouth education. Phase three consisted of the implementation of a formal mobility protocol. A notable increase in mobilization rates between phases two and three demonstrates the value of standardizing practice through protocols. Likewise, the literature demonstrates that when early mobilization happens often and successfully, it is nurse-driven (Escalon et al., 2020; Krupp et al., 2018). For this to be effective, nurses must know their role in the protocol and understand the importance of early mobility (Dubb et al., 2016). As nurses clearly understand their role and the importance of early mobilization, this allows for the elimination of perceived barriers, the development of clear communication, and the efficient utilization of team members (Escalon et al., 2020; Zhang et al., 2022). Nurses are responsible for ensuring the patient is ready to mobilize and communicating with the rest of the team that the patient meets mobilization criteria. (Dagnachew et al., 2023; 12 Dubb et al., 2016). Clear communication and understanding of roles encourage safe early mobilization. The literature revealed that protocols are beneficial to increasing early mobilization rates of mechanically ventilated patients (Dagnachew et al., 2023; Escalon et al., 2020; Krupp et al., 2018; Linke et al., 2020). Mobility protocols aid with appropriately and safely advancing a patient to a higher activity level (Escalon et al., 2020; Linke et al., 2020). Protocols allow each team member to clearly understand their roles in the process (Dagnachew et al., 2023; Dubb et al., 2016). The literature supports that educating nurses on unit mobility protocols may help increase early patient mobilization rates. Nurses with Limited Knowledge Display Negative Attitudes Towards Early Mobilization The research revealed that many ICU registered nurses display negative attitudes toward the early mobility of mechanically ventilated patients (Dagnachew et al., 2023; Dubb et al., 2016; Kim et al., 2018; Zhang et al., 2022). Nurses’ negative attitudes toward early mobilization correlate with a lack of education (Dagnachew et al., 2023; Zhang et al., 2022). Daganchew et al. (2023) emphasized that those with more positive attitudes regarding early mobility had three times more knowledge than those with poor attitudes. According to the Knowledge, Attitudes, and Practices (KAP) Model, people’s practices or behaviors are determined by their knowledge and attitudes (Zhang et al., 2022). Based on these findings, providing education may increase nurses’ knowledge of early mobility and promote positive attitudes. In a cross-sectional survey conducted by Zhang et al. (2022) gauging the attitudes and perceptions of nurses on early mobility, out of 512 nurses, less than half ranked early mobilization as being important or very important. Nearly sixty-eight percent of respondents reported a negative or neutral attitude towards early mobility. Only half of the participants 13 received a passing score on the section regarding knowledge about early mobilization. This study demonstrated that those with a higher level of knowledge and understanding about early mobility also had more positive attitudes and viewed early mobility as a priority. Likewise, another cross-sectional survey by Kim et al. (2019) questioned 151 nurses about perceived barriers regarding early mobility. The factors that emerged as the most significant issues were nurses’ knowledge and attitude-related issues. Results demonstrated that those with more education on early mobility reported fewer perceived barriers to mobilizing. In addition, Dagnachew et al. (2023) found that knowledge levels doubled when early mobilityspecific training was provided. Equally, Dubb et al. (2015) identified inadequate staff knowledge as a culture-related barrier. Strategies mentioned to combat this barrier included education and training. Based on current literature, a possible way to improve nurses’ attitudes surrounding early mobility is to increase their knowledge. A Significant Barrier to Early Mobility is Over-Sedation The evidence demonstrates that over-sedation of mechanically ventilated patients is a significant barrier to initiating early mobility (Dubb et al., 2016; Escalon et al., 2022; Hodsen et al., 2022; Zhang et al., 2022). Over-sedation prevents patients from being actively involved in physical therapy. Additionally, according to Marra et al. (2017), deep sedation in the first fortyeight hours following intubation is associated with delays in extubating, high incidences of needing a tracheostomy, and an increased risk of death. Providing nurse education on ways to minimize sedation safely may aid in increasing mobilization rates. Combatting over-sedation is necessary to mobilize mechanically ventilated patients safely. A method the literature identified for accomplishing this is sedation interruption or a sedation vacation (Hodsen et al., 2022; Marra et al., 2017). This means turning off sedation and 14 seeing how the patient responds. Ideally, this is done with spontaneous breathing trials (SBTs). The nurse and provider observe the patient during this trial while the sedation is paused. If necessary, sedation is restarted at half the rate it was running (Marra et al., 2017). The sedation is then titrated as needed. Team collaboration is imperative for these trials to be successful. Offering education on how these trials should go can provide nurses with support and encouragement in minimizing sedation. Another method to combat over-sedation is adequate analgesia (Chanques et al., 2020; Kim et al., 2019; Marra et al., 2017). Along with sedation vacations, analgesia breaks should also occur. These should happen when infusions of opioids and sedatives are continuously given (Chanques et al., 2020). This allows adequate assessment of the necessity for the medications, reduces medication accumulation, and prompts the transition to PRN or as-needed intravenous (IV) pushes. Providing sufficient pain relief aids in using the least amount of sedation necessary. Using the least amount of sedation contributes to mobilizing mechanically ventilated patients earlier (Dubb et al., 2015; Hodsen et al., 2016). Creating a culture of using the least amount of sedation necessary whenever possible starts with adequately educating nurses on how to do so safely. This significant barrier can be overcome by educating nurses and decreasing over-sedation to increase mobility in mechanically ventilated patients. Summary of Literature Review Findings and Application to the Project A detailed review of the current literature yielded several perceived barriers to early mobilization. The literature suggested that implementing an early mobility protocol can eliminate some of these barriers as it creates clear roles and encourages team communication and collaboration while increasing mobilization rates. Relatedly, negative nurse attitudes toward early mobility correlate with limited education. The literature demonstrated that providing nurse 15 education on early mobility revealed more positive attitudes. Likewise, the barrier of oversedation can be addressed by providing sedation vacations and appropriate analgesia. The literature synthesis provided information to substantiate this MSN project’s potential to improve nurses’ attitudes towards early mobilization and improve mobilization rates at a hospital in the Western United States. The project will use the information from the literature to create evidence-based education and training for ICU nurses on why early mobilization of mechanically ventilated patients must be a priority and how to accomplish it safely. Project Plan and Implementation This section will present the plan for implementing the MSN project. It will include a description of the interdisciplinary team and an overall timeline for the project. A description of deliverables relevant to the education of bedside nurses regarding the early mobility of mechanically ventilated patients will be provided. Plan and Implementation Process This project aims to increase mobilization rates in mechanically ventilated patients through education. The intended recipients of education are bedside nurses employed in an ICU in the Western United States. The project manager and assistants will create a pre-and postsurvey, educational materials, and skills day agenda. A committee consisting of unit management, educators, physical and occupational therapists, and bedside nurses will meet to outline educational expectations and decide upon the appropriate mobility protocol and mobility scale to utilize. This committee will approve the surveys, educational materials, and skills day agenda. A pre-survey will be developed to determine a baseline of ICU registered nurses’ knowledge and confidence regarding early mobility. Educational flyers will be posted throughout the unit. Nurses will be emailed a learning 16 module on early mobility that must be completed. To apply this knowledge, a rotation during the ICU’s quarterly skills day will focus on mobilizing a mechanically ventilated patient. Six months after implementation, a post-survey, consisting of the same questions as the pre-survey, will be emailed to each registered nurse. The implementation process will begin once educational expectations are decided, and materials are approved. The committee will meet every two weeks throughout project implementation to discuss the project’s progress and evaluate if adjustments should be made. A pre-survey will be sent to each registered nurse in the ICU at the start of implementation. This survey will provide a baseline of nurses’ understanding for comparison in six months. The next step is to provide educational materials on early mobility. Information flyers will be posted throughout the unit. An educational video PowerPoint will then be sent to each nurse. This PowerPoint will become part of new-hire education, ensuring new team members receive education on mobilizing. To conclude implementation, a post-survey will be sent to the nursing staff. This will be the same as the pre-survey. Results from both will be compared. These results and mobilization rates will be evaluated six months after implementation to determine if education on early mobility affected RNs’ attitudes and confidence in mobilizing and if mobilization rates improved to at least fifty percent. Any necessary adjustments will be made for future project success. Interdisciplinary Teamwork For this project to be successful, each care team member must work together and understand their part. Those directly involved in patient care, as well as those away from the bedside, all have something to contribute. The unit and upper management must provide 17 resources and support. In addition, if leadership identifies and promotes early mobility, nurses and others at the bedside may also see the importance of the project and be more engaged with it. Likewise, team members involved in direct patient care will be a significant factor in increasing the rates of early mobilization of mechanically ventilated patients. Providers will play a crucial role in helping and supporting nurses to use minimal sedation. Occupational and physical therapists will determine how the patient can move when they mobilize for the first time. These therapists will provide valuable feedback that will enable the team to help the patient progress to higher levels of mobility. In addition, sharing this knowledge with the night shift nurses will prepare them to mobilize safely, as no physical or occupational therapists are available at night in this facility. Similarly, respiratory therapists will be present to manage the ventilator safely during mobilization. Their presence will allow quick intervention if oxygen requirements change during mobilization. Additionally, their presence allows a team member to be focused entirely on the ventilator and endotracheal tube, helping ensure the tube does not accidentally become dislodged while mobilizing. In addition, patient care technicians (PCTs) can offer assistance in preparing for and while mobilizing. PCTs can assist the patient, change linens, or grab supplies. Having several staff members in the room will allow for care bundling, giving the patient adequate time to rest and recover after mobilizing. With support from management and through the utilization of project materials, nurses will be adequately educated to mobilize their patients safely, and early mobilization rates may increase. Increasing these rates may lead ventilated patients to spend fewer days on the ventilator, experience less ICU delirium, and stay in the hospital for a shorter time (Escalon, 18 2020; Marra et al., 2017). Educating nurses and increasing mobilization rates both contribute to the end goal of providing quality care and improving patient outcomes. Description and Development of Project Deliverables Nurses learn best from a multi-faceted approach. The literature demonstrates that educating nurses on the early mobility of mechanically ventilated patients in several forms is appropriate (Horntvedt et al., 2018; King et al., 2022). For the implementation of this project, nurses will be provided with educational materials and opportunities to apply the information hands-on. This section will outline the deliverables relevant to this project’s success. Pre- and Post-Survey. Beginning project implementation with a pre-survey will provide the necessary information to determine if there is a gap in nursing knowledge related to early mobility. Identifying this gap demonstrates room for improvement, and the project should move forward (Buckwater et al., 2017). The project manager will create a pre-survey of questions about the early mobility of mechanically ventilated patients, including when they should be mobilized, the benefits of early mobilization, and how to mobilize safely. Nurses will also be asked to rank themselves on their attitudes and beliefs of importance regarding early mobility, along with their confidence in mobilizing these patients (see Appendix A). This same survey will be administered at the end of implementation to evaluate whether RNs’ attitudes surrounding and confidence in mobilizing mechanically ventilated patients improved. Educational Materials. Once the knowledge gap has been identified through the presurvey, the next step of project implementation is providing educational materials. The process will occur in two steps. First, flyers promoting early mobility will be hung throughout the unit (see Appendix B). Next, a learning module will be sent to each nurse with the bi-monthly staff newsletter (see Appendix C). This module will be in a recorded PowerPoint that nurses can re- 19 watch as often as they need to understand the patient benefits of early mobilization and how to mobilize safely (Rouleau et al., 2019). Skills Day. A rotation will be implanted into the intensive care unit’s quarterly skills day. An agenda will be created for this skills day (see Appendix D). This skills day will allow time for nurses to simulate mobilizing a mechanically ventilated patient. A mobility champion will be present during each simulation to provide feedback and answer questions. Mobility protocols and expectations will be reviewed during this time. The skills day will be offered once every quarter, and staff must attend twice a year. Following completion of the simulation, each nurse must submit a signed pass-off sheet to the unit educator (see Appendix D). Timeline A proposed timeline for this project will span roughly eight months, as depicted in the project’s estimated timeline (see Appendix E). Four weeks will be dedicated to planning and preparing for project implementation. During this period, a mobility committee will be formed. This committee will appoint a project manager and assistants. They will be responsible for creating and presenting the deliverables for this project. The committee will provide feedback and approve or deny the deliverables. Current mobility rates will be reviewed during these meetings and in every succeeding bimonthly meeting. Bi-monthly meetings will allow the mobility committee to evaluate progress or setbacks and make adjustments as necessary. Project implementation will start during week five. A pre-survey will be sent to each registered nurse in the ICU in the unit’s bimonthly staff newsletter. Mobility champions from the day and night shifts will also be identified. They will be invited to bimonthly meetings and serve as resources for the unit. During week seven, the pre-survey results will be reviewed with the mobility committee to determine if there is a knowledge gap. Assuming there is a gap and the 20 project is necessary, the next step in implementation will be posting informational flyers throughout the unit. Charge nurses will be instructed to review this information in each pre-shift huddle. Beginning in week nine, a video PowerPoint will be sent to the registered nurses on the unit in the bimonthly staff newsletter. In week eleven, a simulation mobilizing a mechanically ventilated patient will occur during the ICU’s quarterly skills day. Through week twenty-eight, the mobility committee will continue to meet every other Wednesday. The post-survey will be emailed to all registered nurses in week twenty-nine. Six months from the start of implementation, the mobility committee will compare the results from the pre- and post-survey to see if there was an improvement in nurses’ attitudes and confidence regarding early mobility. The mobilization rates before and after implementation will also be compared to determine if mobilization rates improved. Throughout implementation, the progress of the project will be evaluated. Feedback and suggestions from staff will also be considered. Education and hands-on application will enable nurses to be confident and see the importance of mobilizing. The hope is that early mobility will become a priority and happen regularly in the unit. Project Evaluation The effectiveness of the project will be evaluated based on two outcomes. The first outcome includes improved registered nurses’ attitudes and confidence toward mobilizing mechanically ventilated patients. Secondly, increasing at least fifty percent of mechanically ventilated patients being mobilized out of bed will demonstrate project effectiveness. Results from the pre-and post-survey will be compared to assess if registered nurses have improved attitudes toward mobilizing mechanically ventilated patients and are comfortable and 21 confident. A better average score on multiple-choice questions will show that the project effectively educated registered nurses about why mechanically ventilated patients should be mobilized. Similarly, an average increase in registered nurses’ self-rating of how confident they are mobilizing a mechanically ventilated patient and the importance of doing so will support project effectiveness. Overall, increased scores demonstrate improved attitudes and confidence toward early mobilization, indicating that the project was effective. In addition, bedside registered nurses will report mobility scores of mechanically ventilated patients on the unit to the charge nurses daily on both day and night shifts. Mobility scores should be reported on all patients; however, mobilizing mechanically ventilated patients out of bed will be counted as mobilizing. Mobilizing out of bed equates to having a mobility score of at least five on the JH-HLM scale (Johns Hopkins Medicine, n.d.) (see Appendix F). Mechanically ventilated patients who are appropriate to mobilize should do so twice daily, once on the day shift and once on the night shift. The mobility scores will be reviewed biweekly by the mobility committee. Day and night shift mobility rates will also be compared. At the end of six months, the project will have been significant if at least fifty percent of mechanically ventilated patients are mobilized out of bed twice daily. Ethical Considerations Several ethical considerations will be taken into account when implementing the project. The first aspect to be considered is the safety and well-being of the patients. Because there is risk in mobilizing critically ill patients, nurses must receive the proper education and training and demonstrate professional competence to adequately assess the readiness to mobilize in addition to continuous reassessment. Similarly, patients and their families have the right to informed consent regarding the risks and benefits of early mobilization. Therefore, all registered nurses on 22 the unit will be provided sufficient education for mobilizing mechanically ventilated patients safely. Each nurse will also be trained to professionally educate patients and their family members about the risks and benefits of early mobility. However, patients and their families still have the right to refuse mobilization after the risks and benefits have been thoroughly explained. Likewise, registered nurses and the interdisciplinary team must respect the patient’s autonomy and dignity even when mobilizing. Patient-specific preferences, such as cultural beliefs and values, will be heard and respected. Each patient will receive equitable access to early mobilization interventions regardless of ethnicity, insurance coverage, socioeconomic status, or other related factors. In comparison, ethical considerations surrounding nurses must also be considered. Adequate training and education will be provided along with continued project support and resources regarding the best evidence-based practices for early mobilization. Feedback and suggestions from registered nurses and the interdisciplinary team will be encouraged. All registered nurses on the unit are anticipated to participate in project implementation. Nurses cannot opt out of this project because the goal is to make early mobility a part of necessary patient care. The surveys, learning module, and skills day will be part of each nurse’s quarterly required education. Addressing these ethical considerations will prepare RNs to safely and effectively mobilize mechanically ventilated patients. Patients and their family members will understand the risks and benefits of mobilizing. In addition, patient confidentiality will be upheld, and their beliefs and practices will be respected. Discussion 23 The early mobilization of mechanically ventilated patients can result in fewer days on the ventilator, decreased intensive care unit and hospital stay, and reduced severity of ICU delirium (Escalon, 2020; Marra et al., 2017). Registered nurses play a pivotal role in implementing early mobility (Kim et al., 2019; Wang et al., 2020; Zhang et al., 2021). This MSN project aims to increase mobilization rates of mechanically ventilated patients by improving nurses’ attitudes and confidence in mobilizing through educating registered nurses on the importance of early mobility and how to do it safely. This section will discuss the dissemination of the project results, nursing significance, implications, and additional recommendations. Evidence-based Solutions for Dissemination Following the analysis of results from the pre-and post-surveys and trends in mobility rates over six months, a report will be compiled that the project lead will present to administrative stakeholders. If appropriate, this report will also be shared with similar facilities within the organization to further their early mobilization efforts. This report will also be shared with bedside registered nurses during the next ICU staff meeting to show progress. Additionally, a poster presentation will share the development and implementation of the project with peers and faculty at Weber State University. Significance to Advance Nursing Practice Registered nurses have a centralized role in caring for mechanically ventilated patients (Dagnachew et al., 2023; Dubb et al., 2016; Linke et al., 2020). This allows them ideal positioning to champion early mobility efforts in a critical care setting, thus promoting positive patient outcomes. However, nurses must have the proper education and training to utilize this position effectively (Dubb et al., 2016). This education is based on current evidence and best practices. Studies show that providing nurse education for early mobility has improved nurse 24 attitudes and confidence regarding mobilization (Dagnachew et al., 2023; Zhang et al., 2021). When registered nurses are given the necessary tools and resources, they are better prepared to make informed, evidence-based decisions regarding early mobility. Providing nurses with adequate education and training to promote early mobility can positively influence nursing practice. Likewise, this project requires interdisciplinary collaboration. Teamwork and effective communication must be fostered for success. When this environment exists, the quality of the care given improves along with patient outcomes (Krupp et al., 2018; Linke et al., 2020). Interdisciplinary collaboration and improving the quality of care are vital to advancing nursing practice. Implications There are many strengths evident in this MSN project. Nursing education is most effective from a multi-faceted approach (Horntvedt et al., 2018; King et al., 2022). This project approaches educating nurses from several different avenues, including e-learning and hands-on applications. The deliverables can be utilized as references and resources for nurses to review. Several evaluation and assessment methods are used, including mobility rates and nurses’ reflections on their attitudes toward early mobility. Likewise, interdisciplinary collaboration is promoted along with evidence-based practices. Lastly, the Iowa Model served as a framework for the project, prompting frequent reassessment and evaluation to implement a sustainable change. Comparatively, there are limitations to this project that must be addressed. A significant barrier to overcome may be staff resistance. Registered nurses and other involved members of the team must realize the benefits of early mobility and demonstrate buy-in to the project. 25 Without this, mobility rates may not improve. Likewise, nurses are often faced with time constraints during a twelve-hour shift. If mobility does not become a priority, time may not be allocated for mobilizing. Buy-in from frontline staff will contribute to the overall sustainability of the project. Ongoing support and resources must be available for the project to become a regular practice. Staff resistance and a lack of buy-in can be addressed by educating registered nurses and providing up-to-date information on the current best practices. In addition, patient safety concerns might limit this project. Even with proper education, the project's outcome could be affected if patients or family members refuse to mobilize because of a safety issue. Despite these limitations, this project could increase mobilization rates in the ICU and significantly improve patient outcomes. Recommendations The long-term effects of mobilizing mechanically ventilated patients discharged after a hospital stay requiring intubation are not fully understood. It would be beneficial for more research to be done that demonstrates a relationship, or lack thereof, between early mobility and improved long-term effects. The literature review showed a connection between the early mobilization of mechanically ventilated patients and improvements in time on the ventilator, ICU and hospital length of stay, and instances of ICU delirium (Escalon, 2020; Marra et al., 2017). This information can be used to develop further early mobility protocols for those intubated and the entire inpatient population. Conclusions Mobilizing mechanically ventilated patients can significantly impact days spent on the ventilator, ICU and overall hospital length of stay, and ICU delirium (Escalon, 2020; Marra et al., 2017). Registered nurses are uniquely positioned to ensure early mobilization is performed 26 safely (Dubb et al., 2016; Escalon et al., 2020; Krupp et al., 2018). Because of perceived barriers, nurses often display negative attitudes toward and are not confident in mobilizing these patients (Kim et al., 2019; Wang et al., 2020; Zhang et al., 2021). If implemented correctly, this project will provide registered nurses with adequate education and resources to help them understand the importance of early mobility and gain the confidence to mobilize safely. In turn, mobilization rates on the unit will improve. 27 References Buckwater, K., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A. M., Rakel, B., Steelman, V., Tripp-Reimer, T., & Tucker, S. (2017). Iowa Model of Evidence-Based Practice: Revisions and Validation. World Views on Evidenced-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223 Chanques, G., Constantin, M., Devlin, J. W., Ely, E. W., Fraser, G. L., Gélinas, C., Girard, T. D., Guérin, C., Jabaudon, M., Jaber, S., Mehta, S., Langer, T., Murray, M. J., Pandharipande, P., Patel, B., Payen, F., Puntillo, K., Rochwerg, B., Shehabi, Y., . . . Kress, J. P. (2020). Analgesia and sedation in patients with ARDS. Intensive Care Medicine, 46(12), 23422356. https://doi.org/10.1007/s00134-020-06307-9 Cullen, L., Hanrahan, K., Edmonds, S. W., Reisinger, H. S., & Wagner, M. (2022). Iowa Implementation for Sustainability Framework. Implementation Science: IS, 17. https://doi.org/10.1186/s13012-021-01157-5 Dagnachew, T. K., Berhe, Y. W., Mustofa, S. Y., & Chekol, W. B. (2023). Clinicians' knowledge and attitude towards early mobilization in intensive care units in Ethiopian tertiary hospitals: A multi-centre study. SAGE Open Medicine, 11. https://doi.org/10.1177/20503121231172348 Dubb, R., Nydahl, P., Hermes, C., Schwabbauer, N., Toonstra, A., Parker, A., Kaltwasser, A., & Needham, D. (2016). Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units. Annals of the American Thoracic Society, 13(5). https://doi.org/10.1513/AnnalsATS.201509-586CME Escalon, M., Lichtenstein, A., Posner, E., Spielman, L., & Delgado, A., Kolakowsy-Hayner, S. (2020). The effects of early mobilization on patients requiring extended mechanical 28 ventilation across multiple ICUs. Critical Care Explorations. 2(6). https://doi.org/10.1097/CCE.0000000000000119 Hodsen, C., Bailey, M., Bellomo, R., Brickell, K., Broadley, B., Buhr, H., Gabbe, B., Gould, D., Harrold, M., Higgins, A., Hurford, S., Iwashyna, T., Neto, A., Nichol, A., Presneill, J., Schaller, S., Sivasuthan, J., Tipping, C., Webb, S., & Young, P. (2022). Early active mobilization during mechanical ventilation in the ICU. The New England Journal of Medicine. https://doi.org/10.1056/NEJMoa2209083 Horntvedt, M., Nordsteien, A., Fermann, T., & Severinsson, E. (2018). Strategies for teaching evidence-based practice in nursing education: A thematic literature review. BMC Medical Education, 18. https://doi.org/10.1186/s12909-018-1278-z Intermountain Health. (2023). Mobilization rates of mechanically ventilated patients [Excel Spreadsheet]. Microsoft Corporation. Johns Hopkins Medicine (n.d.). Activity and mobility promotion (JH-AMP). https://www.hopkinsmedicine.org/physical-medicine-rehabilitation/educationtraining/amp/toolkit Kim, C., Kim, S., Yang, J., & Choi, M. (2019). Nurses' perceived barriers and educational needs for early mobilisation of critical ill patients. Australian Critical Care, 32(6), 451–457. https://doi.org/10.1016/j.aucc.2018.11.065 King, O., West, E., Lee, S., Glenister, K., Quilliam, C., Shee, A. W., & Beks, H. (2022). Research education and training for nurses and allied health professionals: A systematic scoping review. BMC Medical Education, p. 22. https://doi.org/10.1186/s12909-022-03406-7 Krupp, A., Steege, L., & King, B. (2018). A systematic review evaluating the role of nurses and processes for delivering early mobility interventions in the intensive care unit. Intensive and 29 Critical Care Nursing, 47, 30-38. https://doi.org/10.1016/j.iccn.2018.04.003 Linke, C. A., Chapman, L. B., Berger, L. J., Kelly, T. L., Korpela, C. A., & Petty, M. G. (2020). Early Mobilization in the ICU: A Collaborative, Integrated Approach. Critical Care Explorations, 2(4). https://doi.org/10.1097/CCE.0000000000000090 Marra, A., Ely, E. W., Pandharipande, P. P., & Patel, M. B. (2017). The ABCDEF Bundle in Critical Care. Critical Care Clinics, 33(2), 225. https://doi.org/10.1016/j.ccc.2016.12.005 Rouleau, G., Gagnon, P., Côté, J., Payne-Gagnon, J., Hudson, E., Dubois, A., & Bouix-Picasso, J. (2019). Effects of E-Learning in a Continuing Education Context on Nursing Care: Systematic Review of Systematic Qualitative, Quantitative, and Mixed-Studies Reviews. Journal of Medical Internet Research, 21(10). https://doi.org/10.2196/15118 Wang, J., Xiao, Q., Zhang, C., Jia, Y., & Shi, C. (2020). Intensive care nurses' knowledge, attitudes, and perceived barriers regarding early mobilization of patients. Nursing in Critical Care, 25(6), 339–345. https://doi.org/10.1111/nicc.12507 Zhang, H., Liu, H., Li, Z., Li, Q., Chu, X., Zhou, X., Wang, B., Lyu, Y., & Lin, F. (2022). Early mobilization implementation for critical ill patients: A cross-sectional multi-center survey about knowledge, attitudes, and perceptions of critical care nurses. International Journal of Nursing Sciences, 9(1), 49–55. https://doi.org/10.1016/j.ijnss.2021.10.001 30 Appendix A Pre- and Post-Survey Pre-Survey: https://forms.gle/crg2mmgtrxE6tqen9 31 32 Post-Survey: https://forms.gle/YjRTrxdMJwAhxAFY9 33 34 Appendix B Unit Flyers https://create.piktochart.com/output/62980978-3-learning-styles 35 https://create.piktochart.com/output/c0bee7b31a0a-movement-is-medicine 36 Appendix C Early Mobilization of Mechanically Ventilated Patients Nurse Training Module https://1533221.mediaspace.kaltura.com/media/NURS6802GreeneCMobiltyEducation/1_h0nej2 xu 37 38 39 40 41 42 Appendix D Skills Day Agenda Skills Day Agenda Simulation: Mobilizing Mechanically Ventilated Patient • Three RNs and one PCT per group o One RN acts as the patient in bed o One RN acts as RT o One RN acts as RN o One PCT acts as PCT o Mobility Champion present to assist Two RNs, acting as RT and RN, will assist another RN, acting as a mechanically ventilated patient, in standing up at the side of the bed. A mobility champion will be in the room to answer questions and assist through the simulation if necessary. Each RN must participate in this simulation and pass it off twice yearly. The completed pass off form will be given to the unit educator. Skills Day Pass-Off Sheet Simulation: Mobilizing Mechanically Ventilated Patient I participated in skills day and simulated mobilizing a mechanically ventilated patient. Signature: _________________________________ Date: ________________ 43 Appendix E Project Estimated Timeline Weeks 1-2 Weeks 3-4 Weeks 5-6 Weeks 7-8 Weeks 9-10 A mobility committee consisting of ICU unit management, educators, physical and occupational therapists, and bedside nurses will meet to outline educational expectations and decide upon the appropriate mobility protocol and scale. Current mobilization rates of mechanically ventilated patients will be reviewed. Mobility rates will be reviewed during each meeting. A project manager and assistants will be appointed. The project deliverables will be identified. The project manager will begin creating these deliverables. The committee will meet on the first and third Wednesday of every month. The deliverables will be presented and approved or revised by the committee. The pre-survey will be sent to each nurse on the unit in the bimonthly staff newsletter. Bedside nurses from the day and night shifts will be identified to act as mobility champions. The committee will review the results from the pre-survey. A knowledge gap demonstrates that the project should move forward. Flyers will be hung throughout the unit in common areas, bathrooms, breakrooms, and on the huddle board. Charge nurses will review these during pre-shift huddles. Video PowerPoint will be sent to each nurse in the bimonthly staff newsletter. Weeks 11-12 Quarterly ICU skill day will be held. A rotation where nurses simulate mobilizing a mechanically ventilated patient will take place. Mobility champions will be present to assist and answer questions. Weeks 13-28 Mobilization rates will be reviewed at each mobility committee meeting during this time. Suggestions for charting, reporting, and further improving rates will also be discussed. Weeks 29-30 A post-survey will be sent out to each nurse on the unit in the bimonthly staff newsletter. Weeks 31-32 The mobility rates and survey results from now will be compared with those from six months ago. If favorable, the project will continue. If there is a decline in mobility rates, nurse attitudes or confidence, the course of the project will be reevaluated. 44 Appendix F JH-HLM Tool (Johns Hopkins, n.d.).