Improving Patients' Early Mobility Through Innovative Interprofessional Education Using Educational Neuroscience Theory

Ambulation is one of the most frequently reported components of unfinished nursing care, yet early mobilization can prevent patient deconditioning. This project was designed as an interprofessional mobility training program by using educational neuroscience theory to engage learners in appreciating the need for early ambulation and change behaviors. This article reviews one initiative that incorporated neuroscience and learning science in the teaching methodologies to achieve high rates of successful educational outcomes. [J Contin Educ Nurs. 2021;52(8):362-366.].

Designing a nurse-delivered delirium bundle: What intensive care unit staff, survivors, and their families think?

BACKGROUND

Implementation of quality improvement interventions can be enhanced by exploring the perspectives of those who will deliver and receive them. We designed a non-pharmacological bundle for delirium management for a feasibility trial, and we sought to obtain the views of intensive care unit (ICU) staff, survivors, and families on the barriers and facilitators to its implementation.

OBJECTIVE

The objective of this study is to determine the barriers and facilitators to a multicomponent bundle for delirium management in critically ill patients comprising (1) education and family participation, (2) sedation minimisation and pain, agitation, and delirium protocol, (3) early mobilisation, and (4) environmental interventions for sleep, orientation, communication, and cognitive stimulation.

METHODS

Nine focus group interviews were conducted with ICU staff (n = 68) in 12 UK ICUs. Three focus group interviews were conducted with ICU survivors (n = 12) and their family members (n = 2). Interviews were digitally recorded, transcribed, and thematically analysed using the Braun and Clarke framework.

RESULTS

Overall, staff, survivors, and their families agreed the bundle was acceptable. Facilitating factors for delivering the bundle were staff and relatives' education about potential benefits and encouraging family presence. Facilitating factors for sedation minimisation were evening ward rounds, using non-verbal pain scores, and targeting sedation scores. Barriers identified by staff were inadequate resources, poor education, relatives' anxiety, safety concerns, and ICU culture. Concerns were raised about patient confidentiality when displaying orientation materials and managing resources for early mobility. Survivors cited that flexible visiting and re-establishing normality were important factors; and staff workload, lack of awareness, and poor communication were factors that needed to be considered before implementation.

CONCLUSION

Generally, the bundle was deemed acceptable and deliverable. However, like any complex intervention, component adaptations will be required depending on resources available to the ICU; in particular, involvement of pharmacists in the ward round and physiotherapists in mobilising intubated patients.

Early Mobilization of Mechanically Ventilated Patients

Critically ill patients requiring mechanical ventilation are least likely to be mobilized and, as a result, are at-risk for prolonged complications from weakness. The use of bed rest and sedation when caring for mechanically ventilated patients is likely shaped by historical practice; however, this review demonstrates early mobilization, with little to no sedation, is possible and safe. Assessing readiness for mobilization in context of progressing patients from passive to active activities can lead to long-term benefits and has been achievable with resource-efficient implementations and team work.

[EVIDENCE BASED NURSING: EARLY AND SAFE PROTOCOL FOR ICU PATIENT'S MOBILIZATION]

Patients admitted to the ICU are at risk of immobility and an early and important physical deconditioning.

OBJECTIVE

To develop and to implement an early and safe protocol for ICU patients' mobilization.

METHODOLOGY

The Evidence Based Practice Model for Staff Nurses was used. It encompasses Assessment, Problem Identification, Planning, Implementation and Evaluation, Integration and Maintenance in Practice.

RESULTS

The research team (Advanced Practice Nurse and expert clinical nurses), along with the medical team and rehabilitation service, identified the need to develop the protocol. For its elaboration, a literature search on the data bases PubMed, CINA-HL and Cochrane Library was performed; a questionnaire was administered and structured observations were conducted. For the implementation training sessions were offered to nurses, posters were placed in the unit and protocol was included in the computer program. Finally, an assessment of the knowledge, perceptions and practices of nurses in the unit and a recording of adverse events related to the mobilization will take place.

CONCLUSIONS

The development and implementation of a protocol for early mobilization of ICU patients has facilitated the integration of this care in daily practice. This model of evidence-based practice allows nurses an active part in changing the culture in terms of the integration of research into practice.

STEP-UP: Study of the Effectiveness of a Patient Ambulation Protocol

Immobility in hospitalized patients, particularly the elderly, can lead to serious untoward events. A pragmatic ambulation program that could be incorporated easily into clinicians' practice routines significantly improved ambulation in hospitalized patients compared to usual care with no organized emphasis on ambulation.

A prospective study of early ambulation 90 minutes post-left heart catheterization using a retrospective comparison group

BACKGROUND

Despite a trend toward a reduction in bedrest time after left heart catheterization (LHC) in many Canadian centres, an evidence-based standard of practice has not been established. Canadian bedrest times range from two to four hours post-LHC. Two recent prospective non-randomized studies (n = 1,000) indicate safety of ambulation at 60 and 90 minutes post-LHC.

PURPOSE

The purpose of this study was to determine safety of ambulating patients at 90 minutes post-LHC sheath removal compared to the current practice of ambulation at three to four hours post-sheath removal.

DESIGN

The study was a prospective non-concurrent design with a retrospective control. METHOD/SAMPLE: Retrospective data from the APPROACH database and chart reviews were analyzed for a period of six months for the control group on the traditional three- to four-hour ambulation protocol (n = 402). Prospective data were gathered for six months for the experimental group (n = 193).

RESULTS

There was no difference in complication rates for the two groups.

CONCLUSIONS

The results suggest that early ambulation for selected patients at 90 minutes is safe and has the potential to increase both patient comfort and quality of care.

[Collaboration between science and practice: experiences of conducting a nursing intervention study]

In a five-year intervention study about the impact of pre-operative mobilisation training session of patients receiving an elective medial laparotomy experiences about the collaboration between practice (University Hospital Ulm) and science (Hessian Institute of Nursing Research) were made. During the project possibilities and borders of clinical nursing research became clear. A research question based on practice experiences of nurses helps to develop and maintain motivation to conduct a study at a nursing unit. There was a lack of nursing knowledge to develop the best possible design, e.g. outcome criteria for mobilisation and standardized assessment instruments. The cooperation with other health care professionals (human movement science, statistics) was important and without difficulties. In Germany, without doctors' agreement and common application it is impossible to conduct nursing intervention studies in hospitals. It is necessary to train nursing specialists with both scientific and clinical competence to explore systematically clinical research questions.

A mobility protocol for critically ill adults

Although the complications of immobility are well-described in the literature, critically ill patients are often subjected to prolonged periods of bed rest. Nurses, by virtue of their expertise in preventing iatrogenic complications, are in an ideal position to prevent the adverse outcomes associated with immobility. This article describes how nurses can use a mobility protocol to increase the activity of critically ill patients in a timely manner that may prevent the infirmity and suffering that is caused by unnecessarily long periods of bed rest.

Transforming ICU culture to facilitate early mobility

Growing interest in reducing costs for patients requiring long-term mechanical ventilation has led to development of different care delivery models. This article describes the development and implementation a respiratory care process model focusing on best practices and improvement in care, including early mobility. To implement the care process model, the authors had to make significant changes in the respiratory ICU (RICU), which included changes in how the RICU staff worked together. ICU culture was transformed in a way that resulted in improved and consistent care, including early mobility, while stabilizing or even decreasing cost. Involvement of front-line staff in early mobility and other components of the care process model resulted in the development of a culture of safety and teamwork.

Safety Issues That Should Be Considered When Mobilizing Critically Ill Patients

Mobilization is often used by physiotherapists for managing critically ill patients with the aim of treatment including improving respiratory function, level of consciousness, functional ability, and psychological well being, and reducing the adverse effects of immobility. In addition, mobilization may decrease the duration of mechanical ventilation and length of ICU or hospital stay. This article provides ICU practitioners with comprehensive guidelines that can be used to assess the safety of mobilizing critically ill patients. The main safety factors that should be addressed include intrinsic factors related to the patient (eg, medical background, cardiovascular and respiratory reserve, and hematological considerations) and factors extrinsic to the patient (eg, patient attachments, environment, and staffing).

Activity in the chronically critically ill

Although therapeutic activity prevents functional decline and reduces mortality, little is known about typical levels of activity among intensive care unit (ICU) patients. This report of a preliminary study describes typical therapeutic activity and compares the use of two measures of activity in a small sample of chronically critically ill adults. Type, frequency, and duration of therapeutic activity were measured simultaneously with direct observation and actigraphy. The only consistent activity documented was turning (frequency: 3 turns/8 hours; duration: mean average of 11 minutes). Analysis demonstrated acceptable agreement between the two measures of activity for both frequency and duration of therapeutic but not for type of activity. Congruence between measures for duration of activity was also supported. This study provides information for investigators and practitioners who are interested in measuring or implementing therapeutic activity in selected critically ill adults.

[Experiences and results from standardised observations of conventional and kinaesthetic nursing in a nuclear and radio-therapeutic ward]

In the Clinic for Nuclear Medicine and Radiotherapy, City Hospital Triemli (Zurich, Switzerland), a controlled observational study was carried out. The investigation aimed at comparing conventional and kinaesthetic nursing interventions with respect to the agility and body orientation of the patients, and with respect to their interaction with the nurses. The observations were limited to the interventions washing, positioning, and mobilizing and lasted 20 to 60 minutes. During this time, an experienced nurse, who did not belong to the nursing team, completed a checklist. The checklist items comprise operationalized criteria of the kinaesthetic concept by Hatch and Maietta, as well as two questions directed to the patients. Body motion and orientation were judged by a 12-items scale, identical for observations prior to and immediately after the nursing intervention. The interaction between patients and nurses was judged by means of a 10-items scale. Group 1 (13 patients) was observed during conservative nursing; group 2 (another 13 patients) was observed almost half a year later during kinaesthetic nursing. All observations were recorded with the same instrument. There was a general positive effect of the nursing interventions. Kinaesthetic nursing, however, only showed a trend towards better effects on the patients' agility, body orientation or interaction abilities in comparison to conventional nursing. The results are discussed with respect to a recently published study on objective measurement of kinaesthetic nursing effects. There is a certain discrepancy between the well-known positive valuation of kinaesthetic nursing by the nurses themselves and the measurable effects of the method. This discrepancy cannot simply be explained by sample size, type of measurement, or the nurses'experience with the method.

[Effects of kinesthetic mobilization in comparison with standard mobilization on respiratory function after coronary artery bypass and other relevant factors]

Presently no relevant nursing data exist in Germany on the effect of mobilization according to kinaesthetic principles on the physiological system, on locomotion and the sensory system. The effect of two different versions of mobilization was measured in a unicentric, open, randomized study with two parallel groups from December 1999 to October 2000 in the intermediate ICU for patients after heart surgery at Ulm University Hospital. The aim was, to show superiority of kinaesthetic mobilization, compared to empirically developed standard mobilization on patients after aortal coronary bypass surgery, with reference to respiratory function. The two protocols of mobilization were carefully coordinated with precise plans of action and timing. A total of 104 subjects were randomized to the two groups. In the kinaesthetic mobilization group (n = 52) median age was 67.5 years, ten (19.2%) were female and 42 (80.8%) were male. In the standard mobilization group (n = 52) median age was 69 years, eight (15.4%) were female and 44 (84.6%) were male. The main outcome variable was the respiratory minute volume 30 minutes after the second mobilization minus the respiratory minute volume prior to the second mobilization. The median change in respiratory minute volume was 0.4 ltr/min. (-5.1 to 3) in the group with kinaesthetic mobilization and median 0.3 ltr/min (-6.0 to +9.1) in the standard mobilization group. Superiority of kinaesthetic mobilization compared to standard mobilization could not be proven (p = 0.38). Also in the secondary outcome variables the kinaesthetic mobilization showed no superiority over standard mobilization. The respiratory minute volume data within points of measure show that subjects in the kinaesthetic group have less extreme results (> 12 ltr.). In the area < 5 ltr. there is a similar tendency. This may point out that regulation between movement of body, respiration and circulatory system occurs more continuous in kinaesthetic mobilization than the standard mobilization. A similar tendency was seen in the secondary outcomes variables. Subjectively nurses noted that kinaesthetic mobilization was less strenuous than standard mobilization, even though subjects in the kinaesthetic group showed more mobility restriction (37%) than in the standard group (15%). From before to after the first mobilization the percentage of subjects needing less pain medication was higher in the kinaesthetic group (35%), compared to the standard group (19%). There were no serious adverse events in either group. The concept of kinaesthetic mobilization showed no negative effect on subjects compared to empirically developed standard mobilization. There was no diagnosis of pneumonia and none of instabile sternum on any of the subjects in this study. Also, there was no negative effect on the sternum due to the light support arms gave to sitting up and rotating movements in the area of thorax and pelvis on subjects in the kinaesthetic group. The subjects early trust in their own varied movement and the possible effects of kinaesthetic mobilization in later phases of recuperation was not explored in this study.

[Movement as interaction--systemic-constructivist approach to movement and consequences for nursing care]]

The article starts off by analysing the problem that practice of nursing care and its training primarily keep to a mechanistic understanding of movement which is based on the scientific stimulus-response-model. Following this understanding it is argued that subjective dimensions of movement are thus neglected, ignoring patients' needs and demands. In order to reach a complex understanding of movement systemic and constructivist perspectives are introduced. Hence consequences for nurses' development of motorical propositions are developed. Interventions focussed on movements are to be designed as movement dialogues in which patients and nurses must find a consensus. In this process nurses' propositions can be seen as suggestions while patients' responses can be taken as counter suggestions.

Evaluation of 3-hour ambulation post cardiac catheterization

There is much variation in the length of immobilization for patients post cardiac catheterization. While it is generally agreed that a period of time on bedrest is necessary to prevent post procedural complications, the optimal duration remains unknown. The purpose of this study was to evaluate the effects of 3-hour ambulation post cardiac catheterization with a 7 french (F) arterial catheter on bleeding, hematoma formation, and vascular complications. Retrospective chart data were gathered for a period of 8 months for patients who were on the traditional 5-hour ambulation protocol, and prospective data were gathered for a period of 7 months for patients who received the 3-hour protocol. A total of 880 patients were included in the study, with 472 in the 5-hour ambulation group and 408 in the 3-hour ambulation group. The overall incidence of delayed bleeding and hematoma formation for the 15 month study period was 19.1%, with no occurrence of vascular complications in either group. Patients who received the 3-hour ambulation protocol experienced a significantly lower rate of bleeding and hematoma formation (13%) than patients who received the 5-hour ambulation protocol (24.4%) (p < 0.001). Ambulating patients 3 hours post cardiac catheterization with a 7F catheter was found to be safe, and thus has the potential to decrease hospital length of stay, as well as increase patient comfort.

Nursing the patient with an external fixator

External fixators are an effective way of fixing broken bones while at the same time optimising patients' mobility. In this article Julie Santy describes the major issues nurses need to be aware of to contribute effectively to patient care.

Utilization of the concentric circle model in clinical nursing: a review

In this article, I review applications of the concentric circle model in clinical nursing. The concentric circle model is based on the cross-sectional shape of the body extremities at several points, and can be used in the areas of both kinesiology and nutritional science. This model makes it possible to calculate the cross-sectional area of muscles from measurement of the circumference of the extremities and the thickness of adipose (fatty) tissue. Then, changes in muscle strength or nutritional status can be inferred or assessed from these data. This model requires only simple and non-invasive measurements, and this is a significant and essential characteristic for its use by nurses, both in clinical and research applications.