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SYSTEMATIC REVIEW OF PHYSIOLOGIC ASSESSMENT MEASURES FOR
MOBILITY READINESS OF ADULT PATIENTS IN CRITICAL CARE
Section 1: Nature of the Project
Introduction
Mobility is a necessary element of care provided to critically ill adults. Safe
patient mobility helps to ensure a patient does not experience complications due to
immobility. Patient mortality increases with complications. Patient safety and clinical risk
management is an element of clinical governance and includes identifying the
circumstances and opportunities that put patients at risk of harm and acting to prevent or
control risk (Asefzadeh et al., 2013). Early progressive mobilization of critically ill
patients is feasible, safe, and results in benefits including functional outcomes, and
reduced intensive care unit (ICU) and hospital length of stay (Hodgson et al., 2014).
However, weakness begins with serious illness, and effects from immobility and
weakness are associated with prolonged mechanical ventilation, ICU length of stay, and
1-year mortality (Latronico et al., 2017). Physical activity may mitigate weakness and
muscle damage from critical illness, but critically ill patients may have limits to their
activity tolerance (Amidei, 2012a). Despite knowledge of the harmful effects of
immobility on multiple body systems, the ICU is a challenging and difficult environment
where many barriers exist to mobilizing critically ill patients (Adler & Malone, 2012).
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At the practicum site for which this Doctor of Nursing Practice (DNP) project was
completed, critically ill patients’ mobility management orders would come from a
collaboration between the healthcare team on daily rounds based on the priority placed on
mobility, a process which led to inconsistent practice and patient outcomes.
Attending to the mobility of critically ill patients is challenging. The tenuous
dynamic status of critically ill patients and their physiological derangements can result in
adverse hemodynamic responses to activity and mobility (Adler & Malone, 2012). It is
not uncommon for deconditioned critically ill patients with limited physiologic reserve to
respond to activity and exertional stress with changes in hemodynamic status. Patient
changes include activity intolerance as fainting, changes in blood pressure and heart rate,
and inability to support their body weight (Amidei, 2012a). As such, this project sought to
identify evidence-based practices addressing enhanced and safe mobility in critically ill
patients.
Physiologic Stability and Functional Capacity
The physiologic stability and functional capacity of critically ill patients impact
mobility readiness and level. Nursing strives to incorporate levels of safe mobility in care
based on multiple assessments including physiologic concerns (Amidel, 2012a).
Professionals in nursing and health care endeavor to decrease the length of stay in the
ICU and hospital, increase positive patient outcomes, and decrease costs associated with
care. Guidelines have the potential to facilitate patient care decisions and the
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implementation of evidence-based practice concerning safe patient mobility, but due to
inconsistent adoption in clinical practice guidelines have limited impact and present a
health system challenge (Kastner et al., 2011). Having an evidence-based patient
guideline or tool for physiologic assessment measures for mobility readiness in critical
care at the practicum site may support collaborative efforts of critical care nurses and the
healthcare team to provide quality care and safe, effective mobility measures.
Problem Statement
Local Nursing Practice Problem
The current practice of mobility management comes from patient orders without
the adoption of an evidence-based physiologic assessment guide to support safe
mobility. Patient mobility management is affected by many variables, including patient
physiologic stability, alertness, and strength, and the experience and skill level of staff
caring for the patient. The current local nursing practice problem is that mobility
assessment and management differ based on the healthcare team members caring for
patients and the ICUs where patients receive care. The project site has assessment tools
for nurses to address some aspects of mobility management; however, comprehensive
nursing guidelines, including physiologic assessment, are not currently in use. The
nursing staff feel pressured to ambulate critically ill patients and have difficulty in
balancing the patient’s need to ambulate versus the benefit and safety of ambulation in
the presence of hemodynamic intolerance. The need to address safe mobility and
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physiologic assessment of patients before ambulation at the clinical site is evident due to
the negative impact of immobility on patient outcomes. The purpose of this systematic
review is to look at the current practice of physiologic assessment measures and then
utilize the findings to influence safe patient mobility in the ICU.
Local Relevance
Safe prescription of patient mobility includes comprehensive preassessment and
diagnostic information evaluation to improve outcomes and meet patient mobility goals
(Amidei, 2012b). However, mobilization therapy does not consistently address the
physiologic readiness of a patient when prescribing activity regimens (Eakin et al.,
2015). Hence, it is important to understand critical factors as physiologic stability to
implement and sustain safe mobility in critically ill patients successfully.
Multiple assessments and methods determine the severity of illness, care
requirements, and the efficacy of mobility treatments. Nursing strives to incorporate
appropriate levels of mobility in care based on multiple assessments and exclusions for
physiologic concerns (Amidei, 2012b). Physiologic stability may change during
mobility, and unsafe patient mobilization results in adverse patient outcomes that
increase patient recovery time. There are inherent complications related to physiologic
stability, patient safety, and functional outcomes associated with the mobilization of
critical care patients (Adler & Malone, 2012). For safe mobilization to occur in the ICU,
with minimal risk of adverse events, assessment of patient physiologic stability should
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occur before mobilization (Hodgson et al., 2014). Assessment of the right time and
readiness for mobilization includes a review of a patient’s physiologic and functional
capacity (Eakin et al., 2015). Physiologic stability and functional capacity of critically
ill patients also help determine mobility readiness and appropriate mobility levels
(Amidei, 2012b).
Purpose Statement
Incongruence exists in the literature and practice about when to use mobilization,
who should perform mobilization, and to what extent to apply mobilization. The purpose
of this systematic literature review is to examine and summarize the benefits of
evidencebased practice tools for physiologic assessment and stability in the mobilization
of critically ill patients. Also, to evaluate tools that are published and can improve the
mobilization of critically ill patients by nursing and other disciplines. A review of the
current body of evidence on physiologic assessment and stability in the mobilization of
critically ill patients will answer how research and quality improvement studies on the
mobilization of critically ill patients address physiologic stability in decisions to mobilize
patients and if there is a consistent, safe best practice. Additionally, this project may
contribute to the enhancement of better patient outcomes by identifying optimal critical
care patient populations that would benefit from physiologic assessment for mobility
readiness.
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Gap in Practice
Evidence-based practice is the standard nurses use to provide effective clinical
care. The gap in practice is that the ICU does not have a consistent, evidence-based
approach to assess or determine a patient’s readiness for mobilization, despite the benefits
of safety and quality outcomes associated with evidence-based practice. Based on current
practice, it is apparent that a clinical practice gap exists in determining a critically ill
patient’s readiness and safety for mobilization activities. This DNP project may provide
nurses and other disciplines with physiologic assessment measures to determine critically
ill patients’ mobilization readiness. A nurse-driven mobility readiness assessment
included in mobility management will support the provision of safe, efficient care and
assessment in the management of critically ill patient mobility.
Practice-Focused Questions
The purpose of this systematic literature review is to examine and summarize the
benefits of evidence-based practice tools for physiologic assessment and stability in the
mobilization of critically ill patients. The three questions were:
• What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
• What is the effect of using physiologic assessment measures on determining
patient readiness for safe mobility?
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• What is the effect of using physiologic assessment measures on the incidence
and safety of patient mobility events?
The following parameters guided the focus in answering the practice-focused questions:
• Population: Critically ill Adults 18 years and older
• Intervention: Systematic review of the literature for Physiologic Assessment
Measures for Mobilization Readiness
• Comparison: The normal routine for Mobility Assessment
• Outcome: In critically ill adults 18 years and older, does the intervention of
physiologic assessment measures for mobilization provide safe and effective
patient physiologic assessment measures for readiness for mobilization
therapy?
The systematic literature review evaluated whether adapting and implementing an
evidence-based practice assessment tool or guideline has been found to enhance nursing
practice related to mobilization of critically ill patients. The design of this systematic
review included the synthesis of the literature review research for systematic reviews,
quantitative studies, qualitative studies, and pilot studies.
Addressing the Gap in Clinical Practice
Currently, the nursing practice of critically ill patient mobilization relies on
provider order, or clinical judgment and experience. Providing a summary of current
research and quality improvement on physiologic assessment can guide nursing practice
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and other disciplines in addressing the gap in clinical practice of critically ill patients’
readiness for mobilization. Also, findings may guide nursing practice, improve patient
outcomes and safety, decrease unnecessary costs, and support nurses in making
assessments and decisions based on evidence. Findings from the systematic literature
review may encourage nurse participation in evidence-based clinical practice by
demonstrating how nurse-driven measures can positively impact patients at the unit,
organization, and system level. The optimal timing and progression of mobility and
factors influenced the ability to mobilize affect positive patient outcomes (Winkleman et
al., 2012). The systematic review may provide additional benefits to the critically ill adult
populations in other organizations’ nursing staff and other disciplines through
summarizing research on evidence-based physiologic assessments for mobility readiness
of critically ill patients.
Nature of the Doctoral Project
The nature of this DNP project was to provide a systematic review of
evidencebased research patient guidelines or tools for physiologic assessment measures
for mobility readiness in critical care. The project goal was to provide a guide for critical
care nurses in safe mobility assessments and decisions in the ICU. This DNP project can
lead to positive social change in nursing practice by identifying physiologic assessment
measures that support patients’ readiness for mobility measures and safety during
mobility activities. The review of safe early mobility management also identifies
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physiologic assessment measures to determine early mobility readiness and management
effectiveness, which can influence the care and mobility of critically ill adult patients.
Accordingly, this project can improve nursing practice, decrease the adverse effects of
patient immobility while promoting better outcomes, and create positive social change.
Sources of Evidence
Evidence-based mobility practice increases patient safety, improves clinical
outcomes, reduces healthcare-related costs, and decreases variations in patient outcomes
and care (SCCM, n.d.). The project focus included collecting current evidence on
physiologic assessment measures for patient mobility readiness in ICUs that support safe
patient handling and decrease adverse events. Sources included textbooks, critical care,
and nursing journals, and peer-reviewed journals presenting articles on patient mobility,
including the Journal of Critical Care, Intensive and Critical Care Nursing, Physical
Medicine & Rehabilitation Journal, Critical Care Research and Practice, and the
Journal of Safe Patient Handling & Movement. Using Walden Library resources,
peerreviewed articles also came from online databases like Medline, Cochrane, PubMed,
CINAHL, and Google Scholar. Official websites accessed included the Society for
Critical Care Medicine, the American Association of Critical Care Nurses, the Agency
for Healthcare Research and Quality, and the Institute for Healthcare Improvement.
Nurses, physical therapists, respiratory therapists, and providers provided additional
resource information including seminal work from 2016-2020.
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The decision for patient mobility avoids immobility and includes patient
assessments from admission to discharge. Immobility may affect a patient’s state of
health, and impaired health affects a patient’s physiologic and functional capacity
limiting the ability to mobilize (Amidei, 2012). A patient’s participation in mobility
depends on resources to support ambulation, changes in sedation to enable patient
participation, and patient assessments to determine the level of activity and ability to
mobilize (Eakin et al., 2015). Conditions caused by immobility are as disabling as the
patient’s admitted condition and mobility limits these conditions. Assessing the efficacy
of early mobility of patients with and without mechanical ventilation is predicated on
establishing a culture of mobility in the ICU (Corcoran et al., 2017). However, cultures
that support patient mobility continue to have variations in assessment, intensity, and
frequency of patient mobility (Corcoran et al., 2017). An early mobility bundle,
including physiologic patient readiness assessment tools for mobility on every patient
every day, lessens immobility complications and decreases variations in care (SCCM,
n.d.). Individualized mobility assessments are essential for safe patient mobilization.
The patient’s functional and physiologic status improves with mobility and
declines with immobility. ICU patients lose approximately 2% of muscle mass every 24
hours (Doherty & Steen, 2010). As a result, the patient experiences a significant
reduction in skeletal muscle force, indicating the assessment of physiologic and
functional capacity is an important step before mobilizing (Doherty & Steen, 2010).
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Determining the optimal timing and progression of mobility and factors influencing the
ability to mobilize affect the safe, functional recovery of critically ill adults (Winkleman
et al., 2012). Early mobilization restores function, and passive movement is appropriate
when a patient’s physiologic assessment identifies limitations to active involvement in
mobility (Stockley et al., 2012). Functional and physiologic capacity mobility
assessments vary and include the use of exclusion criteria, family reports of previous
mobility levels, and the use of a variety of balance and strength assessments to
determine a patient’s readiness for mobilization (McWilliams et al., 2015). Despite
evidence supporting early mobility benefits to a patient’s recovery, timing, frequency,
and application of mobility vary, affecting a patient’s recovery.
Approach
The John Hopkins Evidence-based Practice model (JHNEBP) was the
developmental framework for this systematic review. The JHNEBP model is an effective
problem-solving approach to clinical decision-making using healthcare evidence (Dang
& Dearholt, 2017). Accordingly, the generation of research evidence that is effective,
feasible, appropriate, and meaningful to specific populations helps identify and address
patient’s health care needs (Dang & Dearholt, 2017.). The JHNEBP approach ensures
research findings and best practices in evidence-informed patient care (Dang &
Dearholt, 2017). The JHNEBP model is in congruence with holistic nursing care
delivery and balances scientific and humanistic characteristics of health and its
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importance (Dang & Dearholt, 2017). The JHNEBP model integrates the best scientific
evidence with the best patient and practitioner evidence, considers internal and external
influences on practice, and encourages clinical reasoning in the application of evidence
to care of patients and populations (White et al., 2016). The model also ensures research
findings and best practices in evidence-informed care, including clinical assessment
measures, guidelines, protocols, or tools, which are solutions for translating research
into practice (Dang & Dearholt, 2017).
The organization and beginning analysis of the DNP project literature review
involved the creation of a synthesis matrix. The synthesis matrix provided an overview
of the current research and quality improvement projects relevant to the selected topic. A
synthesis matrix facilitated the examination of multiple articles and how they relate to
themes in the research or quality improvement (Clark & Buckley, 2017). Synthesized
information supported the integration of evidence-based physiologic assessment
measures into mobility readiness practice.
A logic model was used to interpret the information obtained on readiness
assessments for mobility. The logic model promoted system thinking by highlighting
relationships of mobility readiness details to the whole process of patient mobility along
with congruencies and inconsistencies (Anderson et al., 2011). The model was used to
scope the review, define and conduct the review, and facilitate the review relevant to
practice (Anderson et al., 2011). The model facilitated the synthesis of current
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knowledge on physiologic assessment measures for mobility readiness and early
mobility management
Identifying the scope of the review included the use of databases and search
engines to find outcomes and research; databases included the Cochrane Database for
Systematic Reviews and the Joanna Briggs Institute EBP database. Available evidence
searches engines to find evidence included PubMed, CINAHL Plus, Medline, and
ProQuest Health & Medical Collection. Key search terms and combinations of these
terms for further searches included activity, mobilization, functional capacity,
physiologic stability, rehabilitation, critical care, ICU, recovery, exercise, and
movement. The study considered peer-reviewed primary sources from 2010-2020 for
inclusion in the doctoral project prospectus and systematic review.
Connecting current evidence to the practice questions requires a detailed review
of sources to determine applicability (Walden University, 2017b). After searching and
evaluating evidence, an additional search ensured all points of view from available
peerreviewed sources were included that apply to the DNP project questions. The search
was exhaustive by using various search terms and phrase combinations that cover the
practice-focused questions and the target population. Plans included methods to identify
the integrity of evidence, including approaches to outliers, missing information, and
statistical analysis procedures used in the doctoral project to address the practicefocused
questions. Analysis and synthesis included identifying gaps that exist in the current
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literature and the strengths and weaknesses of existing literature. Established standards
were applied to appraise study quality, to assemble all relevant sources, and to identify
the basis of knowledge (Walden, 2017b). Clinical practice improvement
recommendations for patient mobility decisions came from the interpretation and
synthesis of the evidence.
Resources needed to complete the doctoral project included time and the support
of the writing center, library, and my DNP supervisory committee chair. Additionally,
the use of the DNP capstone resources and the DNP project mentoring course provided
the support needed to obtain data and resources needed to complete the DNP project.
Planning for protected daily time for my DNP project facilitated the completion of my
systematic review DNP scholarly project.
Significance
Nursing Practice
This DNP project holds significance to the field of critical care and nursing
practice, as it may help establish and motivate the local site to adopt evidence-based
measures for physiologic assessment to determine the mobility readiness of critically ill
patients. This DNP project also addresses the problem of the lack of and use of consistent,
evidence-based measures to assess and determine mobility readiness for critically ill
patients that would support a nurse-driven mobility guideline or tool. In the project site,
this issue has affected patient safety, patient outcomes, the patient’s length of stay, and
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hospital costs. Nursing practice is universally affected. The project may help identify
physiologic assessment measures that can guide clinical practice, nursing care, empower
decisions based on evidence, improve patient outcomes, decrease the negative outcomes
from immobility, and decrease unnecessary health care costs.
A review of published scholarly articles for this DNP project may help establish
physiologic assessment measures for critically ill patients’ mobilization. Also, the
literature review may help establish physiologic assessment measures for mobilization of
critically ill patients at the local practicum site. An example of an organization’s attempts
to address physiologic assessment includes a pilot in a surgical/trauma ICU using Stiller’s
safety mobilization guidelines for ICU clinicians and the Borg Rate of Perceived Exertion
scale (Zomorodi et al., 2012). A multidisciplinary team developed a mobilization protocol
comprised of activity events twice a day till discharge, documenting heart rate, blood
pressure, and oxygen saturation at baseline, 5 minutes, and 15 minutes after mobility
(Zomorodi et al., 2012). The flowchart and decision tree matched the outcomes assessed
by physical therapy, and the pilot concluded the severity of illness affects mobility
progression and participation contributed to patients’ length of stay, healthcare cost, and
ventilator-free days (Zomorodi et al. 2012). The pilot demonstrated there were significant
physiologic changes associated with immobility and critical illness to consider when
mobilizing critically ill patients (Zomorodi et al., 2012). The establishment of a guideline
containing evidence-based measures for physiologic patient assessment for readiness for
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mobilization may allow nurses at the local site to make informed decisions and advocate
for their patients. Additionally, a guideline may provide optimal patient care management
that will improve patient outcomes and decrease the occurrence of complications from
immobility and unsafe mobility activities. Accordingly, this may lead to decreased length
of stay in the hospital and ICU and increased nursing autonomy, as nurses may feel their
assessments and interventions surrounding mobility are positively impacting patient care
and outcomes.
Stakeholders
In the ICU, critically ill patients admitted conditions caused by immobility are
disabling and limit mobility. Nurses provide care to these patients that include the
management of mobilization to limit the effects of immobility and achieve optimum
patient outcomes. The challenges of early progressive mobility of critically ill patients
include the assessment of physiologic stability and readiness for mobility activities, of
which there is a lack of a gold standard to guide clinical practice.
The results of this DNP project may affect multiple stakeholders by addressing the
lack of evidence-based physiologic mobility assessment measures to determine mobility
readiness and nurse-driven practice implementation of these measures. Stakeholders
include nurses, physical therapists, occupational therapists, respiratory therapists, nursing
assistants, nurse practitioners, physician assistants, and physicians who provide care to
critically ill patients. Additional members of the healthcare team that may be affected
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include nurse educators, unit and professional governance council committees, the
mobility wellness bundle committee, organization practice boards, and nursing and
administrative management. Stakeholders also include the patient, their caregivers, and
family. Including them in the experience of care and individualized plan of care
development can improve care delivery as well as allow for collaboration with the
healthcare team. The nursing staff may gain new insight, assessment skills, and practice
knowledge in the management of patient mobility, activities associated with mobility,
and patient care. Patient impact includes decreased complications from immobility and
deconditioning. The systematic literature review provided the local organization with the
potential to improve patient outcomes, decrease costs and complications associated with
immobility, and reduce critical care and hospital length of stay.
Contribution of the Doctoral Project
The project contributes to nursing practice by enhancing knowledge and skill and
by providing effective physiologic assessment measures for mobility readiness of
critically ill patients prior to, during, and after mobility. The outcomes of this review may
also improve patient safety and outcomes, reducing ICU and hospital stay. The American
Association of Colleges of Nursing (2006) indicates the essentials of the DNP are to
design, implement, and evaluate therapeutic interventions based on nursing science
(p.16). The systematic literature review of physiologic assessment measures for early
mobility readiness and management of adult patients in critical care encompasses the
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DNP Essentials I, II, III, VI, VIII. It allowed me to analyze, collaborate with
intraprofessional and interprofessional teams during the integration of evidence-based
measures into practice. My DNP project synthesized the literature to provide
recommendations. It can guide, mentor, and support nurses to achieve excellence in
nursing during collaborations with the healthcare team about patient-specific mobility
measures for optimum outcomes (AACN, 2006). Additionally, the cost-effectiveness of
this practice initiative accounts for risk, safety, and improvement of health care outcomes,
including the decreased cost associated with adverse outcomes from immobility and
increased length of stay in the ICU and hospital (AACN, 2006).
Transferability
Evidence-based practice (EBP) is the integration of clinical expertise, patient
values, and needs, and the best evidence into the decision-making process for patient care
(White et al., 2016). The gap between recommended EBP and what is implemented can
lead to poor outcomes; therefore, the ability to integrate evidence into practice is key in
ensuring quality health care practice (White et al., 2016). EBP supports clinical decision
making because it offers solutions to improve health care quality and provide
costeffective care (Tucker, 2017). Physiologic assessment measures for mobility
readiness of adult patients in critical care may improve the safety and management of
critically ill patients mobilizing in ICUs with similar practice problems. The findings of
the systematic review can be shared with other critical care units locally within the health
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care organization and system, as well as locally within the state with other ICUs. The
DNP project provides an evidence-based practice evaluation for knowledge transfer for
nursing and other disciplines throughout all hospitals with ICUs in the state of the project
site.
Social Change Implication
The DNP project can create positive social change within the project site by
encouraging nurses to improve clinical practice through evidence-based practice
education and implementation. Evidence-based practice based on current research
improves patient outcomes and decreases health care costs. Adopting and supporting
nurse-driven measures for physiologic assessment for mobility readiness can enhance
nurse autonomy, as the measures identified empower nurses to collaborate with practical,
safe decision making in the mobilization of critically ill patients in the ICU. A systematic
literature review can also improve the safety and patient outcomes at the local practicum
site. The physiologic assessment measures may improve patient care and outcomes
related to mobility at the site, and measures can be potentially used globally in the
mobilization of critically ill patients in ICUs. Incorporating new evidence-based measures
will facilitate change in the decision-making process surrounding the mobilization of
critically ill patients in the ICU. Nurse-drive assessment measures for mobility
management improve nurse autonomy and satisfaction, improve patient safety, decrease
mechanical ventilation, and hospital and ICU length of stay (Corcoran et al., 2017).
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Accordingly, nurses can use assessment measures to determine mobility readiness guided
by evidence.
Summary
Immobility and unsafe mobility practices can lead to poor outcomes in patient
care practice. Effective physiologic assessment measures and management of
mobilization is essential for improving ineffective mobilization practices in the ICU.
Because of unsafe and poor patient outcomes that result from ineffective physiologic and
mobility assessment measures for critically ill patients, there is a need for evidence-based
guidelines to facilitate effective mobilization activities and decrease the incidence of
immobility that facilitate the best results for patients. Also, evidence-based guidelines
provides nurses with measures they can use when making clinical decisions in the care of
critically ill patients to decrease the negative effects of immobility. Evidence suggests the
use of a nurse-driven protocol to guide decisions with patient readiness criteria for
mobilization, the step-wise progression of mobility, and behavioral safety for out-of-bed
progressive mobilization is effective leading to sustained improvement in patients’ level
of mobility (Klein et al., 2018). Also, a nurse-driven early progressive mobility protocol
can sustain improvement in length of unit and hospital stay, depression, anxiety, and
hostility levels (Klein et al., 2018). With a summary of the evidence-based physiologic
assessment measures and methods to determine a critically ill patient’s readiness for
mobilization, intensive care nurses may possess the latest best practice measures.
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Evidence-based best practice knowledge on early mobility management may assist nurses
in managing patient mobilization activities based on current evidence. Nurses may no
longer rely just on personal judgment and experience when managing decisions
surrounding mobilization activities of critically ill patients. The systematic literature
review facilitates the use of evidence-based best practice measures in clinical practice
surrounding critically ill patient physiologic assessment to determine mobilization
readiness that improves patient safety.
Section 2: Background and Context
Introduction
Nursing care incorporating evidence-based practice will positively impact
patients, outcomes, and social change. Evidence-based practice is an innovative approach
to problem-solving in the care of patients, and the health care delivery system’s
complexity challenge nurses and other disciplines to identify and use evidence to guide
practice (White et al., 2016). Management of critically ill patients’ progressive mobility is
a complex process affected by many variables. The practice problem at the practicum
site was the current practice of mobility management comes from patient orders without
the adoption of an evidence-based physiologic assessment guide to support collaboration
between health care team members. Clinical practice may also vary based on the
individual nurse and disciplines caring for the patient. Evidence on early progressive
mobility demonstrated sustained improvement in patients’ level of mobility, length of
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ICU and hospital stay, depression, anxiety, functional status, and survivability (Klein et
al., 2018). However, mobilization therapy does not consistently address the physiologic
readiness of a patient during the prescription of activity regimens (Eakin et al., 2015).
Understanding the assessment of physiologic stability is needed to implement and sustain
safe mobility in critically ill patients successfully.
This doctoral project included three focused practice questions:
1. What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
2. What is the effect of using physiologic assessment measures on
determining patient readiness for safe mobility?
3. What is the effect of using physiologic assessment measures on the
incidence and safety of patient mobility events?
In critically ill adults 18 years and older, does the intervention of physiologic assessment
measures for mobilization provide safe and effective patient physiologic assessment
measures for readiness for mobilization therapy? The intent of this DNP project, a
systematic review of the literature, examined and summarized evidence-based practice
measure guidelines that can improve the nursing practice and interdisciplinary
collaboration of early progressive mobility of critically ill patients.
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Concepts, Models, and Theories
The concept of EPB in nursing is the basis of this DNP project. EPB in this
project includes the nurse applying knowledge to find a solution for a problem by
critically analyzing and applying current evidence to achieve a better understanding of
clinical decision making regarding critically ill patients’ mobilization in the ICU (Terry,
2018). The practicum site does not currently have an evidence-based physiologic
assessment measures guideline or protocol to determine critically ill patients’ readiness
for mobility, only an assessment for possible mobility level. Another concept included in
the systematic review is practice-based evidence, the knowledge generated from practice
as well as from research, which includes the importance of the environment in
determining practice recommendations (McEwen & Wills, 2014).
The JHNEBP model was the developmental framework for this systematic
literature review. The JHNEBP model is an effective problem-solving approach to
clinical decision-making using healthcare evidence in a systematic literature review
(Dang & Dearholt, 2017). Accordingly, the generation of research evidence that is
feasible, appropriate, and meaningful to specific populations helps identify and address a
patient’s health care needs (Dang & Dearholt, 2017). The model also ensures research
findings and best practices in evidence-informed care, including clinical assessment
measures, guidelines, protocols, or tools, which are solutions for translating research into
practice (Dang & Dearholt, 2017). The model incorporates the use of available evidence
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as a core component within the domains of professional nursing: nursing practice,
education, and research (Gawlinski & Rutledge, 2008). It is an appropriate model for
understanding the different forms of knowledge, and the guidelines for the model reflect
the “PET” process: practice question, evidence, and translation (Gawlinski & Rutledge,
2008). Evidence comes from the search and review of literature, literature is rated, and
recommendations for changes in processes of care are identified (Gawlinski & Rutledge,
2008). The JHNEBP model is in congruence with holistic nursing care delivery and
balances scientific and humanistic characteristics of health and its importance (Dang &
Dearholt, 2017). JHNEBP model goals include but are not limited to the use of evidence
to promote optimal outcomes, support rational decisions that reduce inappropriate
deviation, create a culture of critical thinking, and grow an environment where the
evidence supports clinical and administrative decisions (White et al., 2016). JHNEBP
model was developed by nurses to support EBP integration.
My DNP project included transitions theory, a middle range and situation-specific
theory. Meleis developed the theory encompassing the transition experience (Im, 2014).
The theory’s purpose is to describe, explain, and predict an individual’s experiences in
various types of transition (Im, 2014). The theory assumes all nursing phenomena involve
a type of transition (Im, 2014). Transitions theory includes understanding the nature of
and responses to change, facilitating the experience and responding to its different
phases, and prompting dynamic balance in health before, during, and at the end of a
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change event (Im, 2014). Transitions theory assumes nursing should play a central role in
facilitating smooth and successful transitions for those experiencing change (Im, 2014).
Transitions Theory includes the intervention made to facilitate transitions and promote
health and mastery of health-illness consequences (Im, 2014). Transitions Theory also
includes understanding the transition experience and that transitions may exacerbate
responses impacting health (Im, 2014).
Theory can guide and link practice to evidence. The theory knowledge gap exists
when the body of knowledge is unknown, accessible, or used as it should be in practice
(McEwen & Wills, 2014). Nursing practice can validate the theory, and the theory can be
a guide for making informed decisions that are grounded by practice (McEwen & Wills,
2014). In today’s challenging health care environments, nurses must continually seek to
evaluate, inform, and improve their practice by the integration of appropriate best
evidence (White et al., 2016). Evidence-based practice includes the integration of the best
evidence, clinical expertise, and patient preferences for clinical decision making (White
et al., 2016). The goal of this DNP project was to reduce clinical practice variation or
lack of physiologic assessment for evaluation of mobilization readiness of critically ill
patients.
Related Synthesis
The evidence-based model facilitates the application of evidence into clinical
practice and achieving best practice (Melnyk & Fineout-Overholt, 2015). The model
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applications include clinical practice, quality improvement, and education aspects of
nursing, and the model’s goal is to ensure the latest evidence and best practices quickly
and appropriately integrate into care (Melnyk & Fineout-Overholt, 2015). Assessing the
need for change or identifying a clinical practice gap includes an evaluation of the
existing evidence, synthesis, and integration of evidence into practice (Melnyk,
FineoutOverholt, 2015). The JHNEBP model was used to implement a daily ambulation
checklist for specified mobilization and venous thromboembolism (VTE) orders for high
to moderate risk patients (Anthony et al., 2017). Patients who experience less
mobilization and prolonged immobility experience less optimal outcomes (Anthony,
Bernard, & Butler, 2017). Surgery patients are at risk for VTE, and patients tend to limit
mobilization due to pain that may predispose them to venous stasis (Anthony et al.,
2017).
Transitions theory outcomes and potential for nursing therapeutics include the
patterns of response of the patient, which is fundamental to nursing (McEwen & Wills,
2014). Nursing therapeutics encompasses the assessment of readiness, preparation for the
transition, and role supplementation, the use of education and practice to facilitate
healthillness concerns (McEwen & Wills, 2014). The concept of situation-specific
transition theory on the transition to adult day health services, included the development
of inhibitors that included a mismatch between the elder’s functional ability and interests
and the activities available impacting mobility goals (Im, 2014). Additionally, the
27
situation-specific transitions theory was used as a framework to guide interventions
including mobility for people with heart failure and determine the effect of heart failure
education on knowledge and readmission (Im, 2014). The situation-specific, transitions
theory was appropriate for this systematic review of physiologic assessment measures for
mobility readiness of adult patients in critical care.
Clarification of Terms
The following terms provide clarity to this DNP project:
Mobilization: An interdisciplinary, goal-directed therapy used to facilitate
movement and improve outcomes that expends energy and includes physical and
psychological domains as well as various activities (Amidei, 2012-b).
Movement: A type of activity that is a functional pattern that allows individuals to
control their environment (Amidei, 2012-b). The capacity for movement is composed of
purposefulness, awareness of self, and continuity (Amidei, 2012-b).
Physiologic stability: A dynamic state, including the variability of physiological
parameters and their ability to regulate maintaining balance after exposure to a disruptive
element (Lebel, Alderson, & Aita, 2014).
Evidence-based nursing: A term that is used interchangeably with evidence-based
practice (White, Dudley-Brown, & Terhaar, 2016).
28
Evidence-based practice (EBP): “A paradigm and lifelong problem-solving
approach that involves the conscientious use of the best available evidence, with clinical
expertise and patient values and preferences to improve patient outcomes” (Melnyk &
Fineout-Overholt, 2015, p. 604).
Relevance to Nursing Practice
History of the Broader Problem in Nursing Practice
Evidence-based practice is fundamental to decision-making in clinical practice.
Organizations developing and supporting initiatives to promote the advancement of
evidence-based practice include Sigma Theta Tau International, the American
Association of Critical-Care Nurses, the Institute of Medicine, and the Magnet
Recognition Program of the American Nurses Credentialing Center. Because of the gap
between new knowledge and implementation of that knowledge to improve patient care
the American Association of Critical-Care Nurses provides resources for clinicians
including practice alerts and a hierarchal rating system for levels of evidence for nurses
to determine the strength of research studies, assess findings, and evaluate the evidence
for integration into best practice (Peterson et al., 2014). By the year 2020, 90% of clinical
decisions will come from accurate, timely, and up-to-date clinical information reflecting
the best available evidence (Institute of Medicine, 2009).
A systematic literature review of physiologic assessment measures for mobility
readiness of adult patients in critical care may change nurse-driven mobilization practices
29
locally, which could lead to a state-level change. Integrating the current science and best
evidence on physiologic assessment measures can reduce the unpredictable outcomes of
mobilization practices related to physiologic stability, patient functional capacity, and
patient safety (Adler & Malone, 2012). Acquiring evidence-based physiologic assessment
measures to determine mobility readiness for critically ill adult patients can facilitate safe
clinical decisions around patient mobility level, readiness, and frequency. Evidencebased
practice is an essential nursing competency (IOM, 2010). Integrating evidencebased
practice continues to be the challenge.
The Society of Critical Care Medicine published the ABCDEF, Bundle E,
addressing the physical effects of immobility critically ill patients face and strategies for
implementation of early mobility programs in any ICU (SCCM, n.d.). Bundle E provides
tools for comprehensive management of critically ill patients’ mobility, including a
mobility pathway with exclusion criteria for physiologically unstable patient types
(SCCM, n.d.). However, physiologic assessment measures are not present in the pathway
for patient mobility. Evidence identifies a lack of expert consensus and recommendations
on physiologic safety criteria for active mobilization (Hodgson et al., 2014).
Evidencebased physiologic assessment measures are overlooked by health care staff
when making mobility decisions.
Currently, the process to determine readiness for mobilization of critically ill
patients is specific to the organization, provider practice, physical therapist, or nurse.
30
Standardized evaluation of a patient’s mobility throughout hospitalization is necessary to
determine progression or regression and to ensure avoidance of further physical
debilitation (Anderson, Sparbel, Barr, Doerschug, & Corbridge, 2018). Using an
evidence-based protocol coupled with up-front staff education leads to staff
empowerment, a sense of security, confidence, and ownership of the practice which
sustains adherence to and practice of the program (Anderson et al., 2018). At the
University of Michigan, a standardized mobility protocol incorporated safe patient
handling and mobility pre-assessment guidelines, mobility standards, equipment
guidelines, and documentation tools to get patients moving (Dickinson, Taylor, & Anton,
2018). The protocol adjusted for all patient populations by modifying the inclusion and
exclusion criteria, and the activities are grounded in evidence to prevent complications,
promote mobilization, and prevent patient and staff harm (Dickerson et al., 2018). A
multidisciplinary team developed and implemented a mobility order set with an
embedded algorithm to guide the nursing assessment of mobility potential in ICU and
Intermediate Care settings at a large community hospital (Drolet et al., 2013). The
protocol assessments empowered the nurse to consult physical therapy or occupational
therapy for patient mobilization (Drolet et al., 2013). The nurse-driven assessments
resulted in an increased rate of patient ambulation in the first 72 hours of a hospital stay
(Drolet et al., 2013). Many studies recommended further studies of nurse-drive
mobilization management of critically ill patients
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Current Nursing Practice for Mobilization of Critically Ill Patients
The current state of nursing practice and assessment measures for readiness for
mobilization includes a provider request or order and the nurse’s or respiratory therapist’s
clinical experience and observation of patient’s during activity. There is inconsistent
evidence to guide the ICU staff with clinical problems related to the patient’s functional
capacity, tolerance, and dynamic stability. There is a need for nursing practice
improvement in physiologic assessment measures to guide safe patient mobility practice,
which could guide nurses in the multidisciplinary collaborative decision-making process
involved in patient mobility management and associated patient care. Physiologic
stability and functional capacity should be incorporated in the decision to mobilize a
patient and in determining the appropriate mobility level (Amidei, 2012; Eakin et al.,
2015). Determining the progression of mobility and factors influencing the ability to
mobilize affect the safe, functional recovery of adults (Winkleman et al., 2012). Cultures
that support patient mobility continue to have variations in assessment, intensity, and
frequency of patient mobility (Corcoran et al., 2017). The recommendation is an early
mobility bundle containing physiologic assessment measures for mobility on every
patient every day to lessen immobility complications and decrease variability in care
(SCCM, n.d.). Implementing physiologic assessment measures that incorporate
evidencebased practice is an effective approach in helping nurses and other professions
with decision-making on mobility readiness and level (SCCM, n.d.). Management of
32
mobility is complex and requires a consistent approach to application and timing to
maximize mobility benefits in a patient’s recovery.
Previous Strategies
Evidence shows critically ill patients are at risk for muscle weakness that often
results from the treatment the health care team is implementing to save a patient’s life
and the associated immobility. Immobility frequently results in reduced venous blood
flow in the pockets of venous valves, promoting inflammation and hypercoagulability
and risk for venous thrombosis (Engers et al., 2014). Mobility measures are
fundamentally important areas of critical care practice, and the adult clinical practice
guidelines from the Society of Critical Care Medicine, Bundle E, addresses early
mobility and exercise (SCCM, n.d.). The Bundle E element identifies strategies for
successful implementation of early mobility and prevention of physical deficits
associated with immobility (SCCM, n.d.). There are a variety of approaches used to
avoid patient immobility and muscle weakness based on physician preference, the
resources available, and the assessment of providers, nursing staff, and physical therapy.
Guidelines for mobility and assessment are beneficial in critically ill adult patient care
delivery and outcomes.
ICU patients lose approximately 2% of muscle mass every 24 hours (Doherty &
Steen, 2010). As a result, the patient experiences a significant reduction in skeletal
muscle force, indicating the assessment of physiologic and functional capacity is an
33
important step before mobilizing (Doherty & Steen, 2010). Determining the optimal
timing and progression of mobility and factors influencing the ability to mobilize affect
the safe, functional recovery of critically ill adults (Winkleman et al., 2012). Early
mobilization restores function, and passive movement is appropriate when a patient’s
physiologic assessment identifies limitations to active involvement in mobility
(Stockley, Morrison, Rooney, & Hughes, 2012). Functional and physiologic capacity
mobility assessments vary and include the use of exclusion criteria, family reports of
previous mobility levels, and the use of a variety of balance and strength assessments to
determine a patient’s readiness for mobilization (McWilliams et al., 2015). Despite
evidence supporting early mobility benefits to the patient’s recovery, timing, frequency,
and application of mobility vary, affecting a patient’s recovery. A nurse-driven guideline
or protocol that facilitates comprehensive physiologic assessment to determine mobility
readiness is needed to address the gap in determining patient readiness and safety.
Local Background and Context
Summary of Local Evidence
The practicum site for this project serves as a large academic teaching facility in
an urban area on the west coast. It consists of multiple critical care units on two
campuses. Due to the varied opportunities for experiences in critical care, educational
advancement, and translation of evidence into practice nursing and health care staff from
the United States and other countries seek opportunities to be part of the health care
34
team. Despite evidence-based practice and utilization of the latest evidence available to
provide patient care quality, consistent, evidence-based patient mobility practice,
including physiologic readiness assessment, remains an issue, and needs improvement.
An identified need is a consistent nurse-driven physiologic assessment to determine
patients’ readiness for mobility and mobility management. There is also a pressing need
to adapt nurse-driven physiologic assessment guidelines to determine mobility readiness
and management to support patient safety and the use of the latest available best
practices while enhancing nursing practice.
Institution Context
The practicum site provides health care services to adult, pediatric, and neonates
with acute and chronic conditions. The vision of the practicum site is to be the number
one health care provider on the west coast, providing quality evidence-based, innovative
care to patients, families, and the community. The practicum site believes in patient
advocacy, and evidence-based care focused on quality outcomes and patient and staff
safety. The unit for this DNP project’s intent is a 24-bed adult critical care unit. Safe
early mobility is essential for 100% of the critically ill adult patients admitted to the unit
to help facilitate the management of their underlying condition and minimize muscle
weakness and promote quality outcomes.
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State/Federal Context
The Evidence-based Practice Center Programs of the Agency for Healthcare
Research and Quality explore clinical issues focus on improving healthcare quality,
safety, efficiency, and effectiveness by synthesizing evidence and facilitating the
translation of evidence-based research findings (AHRQ, 2020). In 2019 two programs
exist on the west coast near my practicum site. Information from AHRQ’s research is
available to support informed healthcare decisions, improve the quality of healthcare
services, and to provide technical assistance to facilitate quality improvement tools
(AHRQ, 2020). Each state’s nurse practice act helps ensure the safe delivery of nursing
care. The safety and delivery of nursing care will improve by complying with the State
Board of Nursing Practice Act and using evidence-based practice.
Role of the DNP Student
Student Professional Context
I practice as an advanced practice nurse and nursing leader in an adult critical care
unit at a large academic teaching facility. My role includes but is not limited to
assessing, mentoring, collaborating, and providing leadership to promote the delivery of
quality care to adult critical care patients. My role provides me with the opportunity to
promote the physiologic assessment of patients to determine mobility readiness that
promotes the health and wellbeing of patients and improved patient outcomes while
supporting safe patient mobility. Promoting evidence-based practice and change to
36
improve quality patient care is a key role of a leader and an advanced practice nurse
(AACN, 2006). The project took place at a large academic teaching facility on the west
coast. The population served at this site includes critically ill adult patients with various
diseases requiring care in an intensive care unit, conditions related to medical
complications and surgery. The practicum site and DNP project have no relationship to
my employment.
Student’s Role in the Doctoral Project
My goal and focus during this DNP project were to investigate the current best
practices in literature for early mobility readiness assessments to facilitate the safe
mobility of critically ill patients. Additionally, what are the best evidence-based
practices available for the practicum’s site use that may improve mobility readiness
assessment, nursing confidence in collaboration with healthcare team on mobility
management, and safe mobility practices. Based on the evidence and information
reviewed, the summary of the evidence and recommendations may help enhance and
improve nursing patient mobility practice and assessment at the practicum site.
Collaboration and stakeholder buy-in are goals of this DNP project as well as facilitating
change that will improve patient care quality concerning patient mobility outcomes.
Student Motivation
As a leader and advanced practice nurse, I seek to used advanced communication
skills and collaboration to foster evidence-based practice change, which improves patient
37
care quality and also mentors and inspires others to be change agents valuing best
practice improvements. As both a clinical nurse specialist and leader, my role includes
utilizing evidence-based practice managing the care of complex and vulnerable
populations while educating and supporting interprofessional staff. My passion for
physiologic assessment needs to determine a patient’s early mobility comes from a need
expressed by my peers, colleagues, and my practice for a standard that maintains patient
safety during mobility management. This need instilled a desire to seek what current
evidence is known about the problem to help identify best practices for mobility
management for adult critically ill populations.
Potential Biases
Melnyk and Fineout-Overholt (2015) indicate bias is possible at any point during
a study, and positive results are more likely to be published than studies with negative or
inconclusive results. Bias prevents objective consideration reinforcing the need to be
aware of possible sources of bias. Potential bias for this DNP project is for this student to
note and consider stakeholder opinions and values about early mobility management.
Summary
Nurses care for patients with competence and diligence to provide excellent care
advocacy for patients. An evidence-based practice model facilitated the literature review
of physiologic assessment measures to determine patient mobility readiness and safe
early patient mobility management. The DNP project may result in the adoption of a
38
nurse-driven guideline for nurses to guide their assessment and practice around early
patient mobility. The following section will discuss and include the of evidence used to
guide the synthesis of the systematic literature review. The analysis and synthesis of
evidence for this DNP project will also be addressed in this section.
39
Section 3: Collection and Analysis of Evidence
Introduction
Early mobility management in the critically ill adult population is challenging
because multiple assessments and methods determine the severity of illness, care
requirements, and the efficacy of mobility treatments. The objective of this DNP project
was to investigate and synthesize evidence that can be used as a recommendation to
adopt a standardized mobility readiness assessment as part of early mobility
management in the ICU. During this project, I reviewed and identified evidence-based
physiologic assessments and approaches for early mobility management of critically ill
adults and the nurse’s role with regards to mobility management. The nursing staff at the
site were often overwhelmed when making decisions about whether patients are ready
for mobility or if they can be safely participating in the activity. Patients and families
depend on nurses to provide evidence-based care focused on quality outcomes healing
one patient at a time. This DNP project assists nurses in providing the safest care to
patients surrounding early mobility while collaborating with the healthcare team. In this
section, I provided the sources of evidence and an overview of the methodology used in
evidence searches, such as the process of selecting and exclusion criteria, as well as
analysis and synthesis of the system used to organize and record the evidence obtained.
40
Practice-Focused Questions
The current practice of mobility management at the practice site comes from
patient orders without the adoption of an evidence-based physiologic assessment to guide
to patient mobility management. Patients may be negatively affected by the lack of
evidence-based mobility readiness measures. The practice-focused questions for this
doctoral project include:
1. What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
2. What is the effect of using physiologic assessment measures on determining
patient readiness for safe mobility?
3. What is the effect of using physiologic assessment measures on the incidence and
safety of patient mobility events?
Population: Critically ill Adults 18 years and older
Intervention: Systematic review of the literature for Physiologic Assessment Measures
for Mobilization Readiness
Comparison: The normal routine for Mobility Assessment
Outcome: In critically ill adults 18 years and older, does the intervention of physiologic
assessment measures for mobilization provide safe and effective patient physiologic
assessment measures for readiness for mobilization therapy?
41
The project is significant to practice, as it is expected to reduce the variation in
physiologic assessment measures to determine early mobility readiness and management
for nursing and the health care teams’ practice with recommendations provided from the
systematic literature review.
Clarifying the Purpose
The purpose of this doctoral project was to evaluate and synthesize EBP on
physiologic assessment measures to determine early mobility readiness and management
best practice to make recommendations for adoption of a nurse-driven early mobility
management guideline in adult critical care. The approach aligned with the
practicefocused questions, as the evidence that was collected provided information that
supports a recommendation for EPB guidelines in the clinical nursing practice for
physiologic assessment measures to determine mobility readiness and management in
the critical care unit. The evidence-based data can provide a standard, already validated
measures for a nurse-driven early mobility physiologic assessment to determine mobility
readiness and management. As a result, this review can be implemented and used as the
best practice in early mobility management.
Sources of Evidence
The purpose of this DNP project included evaluating and synthesizing the best
available evidence relevant to nurse assessment for physiologic readiness for patient
early mobility and mobility management for recommendations to improve the existing
42
nursing and health care team practice surrounding the care of critically ill adult patients.
The source of evidence used to address the practice-focused questions was current
literature. A review of the literature indicated that physiologic assessment to determine
early mobility readiness and management is a worldwide challenge in healthcare. The
systematic review of literature included textbooks, both primary and secondary sources
of peer-reviewed journal articles and published guidelines from CINHAL, PubMed,
Cochrane Library, Joanna Briggs Institute, and Medline. I used Walden Library and
Google scholar to identify resources in these databases. Available evidence addressing
the context of the systematic review includes the ICU Liberation, ABCDEF bundle E on
early mobility and exercise. Bundle E focuses on the physical deficits that ICU survivors
face and strategies for implementation of early mobility programs in any ICU (SCCM,
n.d.). Resources and reports from clinical specialty organizations, such as the American
Association of Critical Care Nurses, the Society of Critical Medicine, the Agency for
Healthcare Research and Quality, and the Institute for Healthcare Improvement, were
also reviewed for relevant information. Nurses, physical therapists, respiratory
therapists, and providers provided additional resource information. The evidence
included qualitative, quantitative, and mixed methods studies.
Relationship of Evidence to the Purpose
The purpose of this DNP project was to evaluate and synthesize the best available
evidence to recommend a nurse-drive mobility guideline and assessment. The evidence
43
gathered from the literature provided the information needed to guide the
recommendation of the assessment and guideline. Multiple strategies assess mobility
readiness and help manage the early mobility of critically ill adults. An essential
literature search was exhausted to seek validation for the best practice concerning early
mobility readiness assessment measures and management.
Evidence to Address the Practice-Focused Questions
The collection and analysis of evidence facilitates the approach to decisionmaking
in evidence-based nursing practice. The articles selected came from a strategy search.
Keywords included early mobility, early ambulation, early mobilization, early
rehabilitation, assessment tools, assessment methods, assessing, guidelines, protocols,
practice guidelines, bundle, physiologic assessment, nurse-drive early mobility
management, ICU patient activity, hemodynamic stability, and evidence-based
guidelines for early mobility in critical care, early mobility patient interventions and
assessments, the effects of physiologic assessment measures on early patient mobility,
and physiologic assessment measures supporting safe patient mobility. Synthesizing all
evidence gathered will be crucial to obtaining information needed to answer the
practice-focused questions. The search procedure resulted in a total of 37 articles used
for this systematic review. The search procedure began by using CINAHL, and the
search keyword used was early mobility or early ambulation or early mobilization or
early rehabilitation.
44
Databases and Search Engines
The Peer-reviewed articles were accessed from on-line databases, such
as
CINAHL, Google Scholar, Walden Library, Joanna Briggs Institute, Medline, Cochrane
Database, and PubMed. Also, official websites such as the Society of Critical Care
Medicine, the American Association of Critical Care Nurses, the Agency for Healthcare
Research and Quality, and the Institute for Healthcare Improvement were assessed for
additional resources and evidence.
Key Search Terms and Combinations of Search Terms
Additional search terms included keywords such as critically ill patients’ mobility
and activity, hemodynamic stability mobility assessment, ICU Liberation, ICU patient
mobility management, nurse-driven mobility bundles or guidelines in ICU, physiologic
stability assessment measures before mobility in ICU, safe patient mobility in ICU,
evidence-based guidelines for early mobility in ICU, and early mobility in adult ICUs.
The Scope of this Review
Gathering relevant sources of information from the literature search relating to
critically ill adult patients’ physiologic stability assessment measures and early mobility
management provide evidence for the recommendation for nurse-driven evidence-based
guideline. The searches considered peer-reviewed primary sources from 2010-2021 for
inclusion in the systematic review. Article selection criteria included if the author(s)
addressed early mobility management and assessment for mobility. Also, the selection
45
considered articles relevant to the management of critically ill adult patients’ safe early
mobility. Articles were excluded if the articles were not relevant to early mobility
management, articles were not full-text articles, they were published before 2010, and if
they were not relevant to physiologic assessment measures or criteria to determine safe
early mobility.
Search Exhaustive and Comprehensive
The search was exhaustive, using various search terms and phrase combinations
that cover the practice-focused question and the target population. A review of abstracts
and articles’ reference lists occurred to ensure the search was exhaustive. The articles
selected were read in full to determine inclusion and exclusion based on the selection
criteria.
Institutional Review Board
The project is a systematic literature review, and the protection of human rights is
not an issue. An application for approval of the institutional review board from Walden
University was obtained to ensure that all rights are protected, 01-29-21-0758434.
Analysis and Synthesis
Systems used for Recording, Tracking, Organizing, and Analyzing the Evidence
Evidence was manually organized and documented in a Microsoft Word matrix
table. Table columns for each article include year published, author(s), title, purpose,
sample, design, and conclusions (see Appendix A). The project’s data organization
utilized the levels of evidence Melnyk hierarchy pyramid (Melnyk & Fineout-Overholt,
46
2011; see Appendix B for illustration). The search procedure began by using CINAH
and Medline, and the initial search keyword used was early mobility or early ambulation
or early mobilization or early rehabilitation. The initial search resulted in a total of 3599
articles, narrowed down to 614 full text articles, narrowed down to 150 references
available, and further narrowed to 129 articles for publication years from 2010-2020.
Review of the 129 articles for relevance to the project’s practice questions, and inclusion
criteria resulted in 37 relevant articles. A PRISMA flowchart diagram will show an
illustration of the article’s selection procedure (see Appendix C).
Analysis Procedure
The analysis procedure used in this DNP project resulted in the evidence obtained
and will be categorized based on the strength of the evidence. The strongest available
evidence was selected to recommend a nurse-driven early mobility management
guideline. Data analysis will support the recommendation of a nurse-driven early
mobility management guideline, including physiologic assessment measures to
determine early mobility readiness. The JHEBP evidence level and quality guide was
used to grade the strength of reviewed evidence (Dang, et al., 2022).
Summary
A review of the current body of evidence on physiologic assessment and stability
in the mobilization of critically ill patients will answer how research and quality
improvement studies on mobilization in critical care address physiologic stability in
47
decisions to mobilize patients and if there is a consistent, safe best practice. The goal of
this DNP project is to provide recommendations that can assist in addressing the lack of
nurse-driven early mobility management guidelines and physiologic assessment to
determine safe early mobility readiness of critically ill adult patients. Patient outcomes
and nursing practice in critical care units advanced by the evidence identified in this
systematic literature review. The DNP project addressing physiologic assessment
measures to determine early mobility readiness of critically ill adults and nurse-driven
safe patient early mobility management can improve safety in the healthcare
organization once implemented. The next section will include findings and
recommendations from the systematic literature review and their implications for the
practice-focused questions.
Section 4: Findings and Recommendations
Introduction
Nurses play a vital role in assessment and management of early mobility of
patients in the ICU. Early mobility management can be affected by multiple variables
including the experience level of the healthcare staff, assessment measures used to assess
mobility readiness, the level of nursing skills, as well as the patient’s physiologic and
hemodynamic response and status. The importance of EBP to the care nurse provide
includes improving the delivery of nursing care and patient outcomes. The gap between
implemented EBP and what occurs in practice can lead to poor outcomes; therefore, the
48
ability to integrate evidence into practice is key in ensuring quality health care practice
(White et al., 2016).
EBP supports clinical decision making because it offers solutions to improve
health care quality and provide cost-effective care (Tucker, 2017). The absence of
evidence-based safe mobility guidelines and mobility readiness assessments affects
patient care decisions and outcomes. Guidelines have the potential to facilitate patient
care decisions, but due to inconsistent adoption in clinical practice guidelines have
limited affect and present a health system challenge (Kastner et al., 2011). Fundamental
to the practicum site to facilitate quality outcomes is evidence-based nursing practice
aligned with the latest research. Evidence-based guidelines also provide a variety of
structures that help ensure safe effective nursing care delivery. Evidence-based nursing
practice enhances knowledge sharing and collaboration across disciplines in solving
complex patient problems and decisions. Providing a summary of current research and
quality improvement on physiologic assessment guides nursing practice and other
disciplines in addressing the gap in clinical practice of critically ill patients’ readiness for
mobilization. A gap in nursing practice exists when an evidence-based readiness
assessment and practice guideline to support nursing practice in the management of early
mobility is not available. The purpose of this project was to examine and summarize the
benefits of evidence-based tools for physiologic assessment and stability in the
mobilization of critically ill patients. Synthesis of evidence relevant to physiologic
49
assessment to determine mobility readiness and nurse-driven early mobility management
was completed to a improve the existing nursing practice of early mobility management
in the practicum site ICU.
The practice focused questions used to facilitate this DNP project
included:
1. What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
2. What is the effect of using physiologic assessment measures on determining
patient readiness for safe mobility?
3. What is the effect of using physiologic assessment measures on the incidence
and safety of patient mobility events?
Primary and secondary sources such as peer-reviewed evidence was used to support this
systematic literature review. Primary and secondary sources of peer-reviewed journal
articles and published guidelines were retrieved from Medline, PubMed, CNHAL,
Cochrane Library, and Joanna Briggs Institute. Available evidence used for the content of
the systematic review included the ICU Liberation, ABCDEF bundle E on early mobility
and exercise. Official websites of the Society of Critical Care Medicine, the American
Association of Critical Care Nurses, the Agency for Healthcare Research and Quality, and
the Institute for Healthcare Improvement were accessed for additional resources and
50
evidence. The systematic review also included textbooks. Articles meeting the inclusion
criteria were used in the review.
The key word search terms used were early mobility, early ambulation, early
mobilization, early rehabilitation, assessment tools, assessment methods, assessing,
guidelines, protocols, practice guidelines, bundle, physiologic assessment, nurse-driven
early mobility management, ICU patient activity, hemodynamic stability, and
evidencebased guidelines for early mobility in critical care, early mobility patient
interventions and assessments, the effects of physiologic assessment measures on early
mobility, and physiologic assessment measures supporting safe patient mobility. Other
key words included in the search included critically ill patients’ mobility and activity,
hemodynamic stability mobility assessment, ICU Liberation, ICU patient mobility
management, nursedriven mobility bundles or guidelines in the ICU, physiologic stability
assessment measures before mobility in the ICU, and early mobility in adult ICUs.
Findings and Implications
The literature resulted in a total 3599 articles; 2985 were excluded due to lack of
full text; however, abstracts were reviewed for relevant information. From the screening
process, 464 articles were removed for lack of available references. The eligibility
involving the recent timeframe yielded 150 articles, which were further narrowed to a
publication timeframe 2010 to 2021. The analysis resulted in (N = 37) articles meeting
criteria for the review selection procedure (see Appendix C). The inclusion criteria for
51
this systematic literature review included full-text articles addressing physiologic
assessment measures for mobility and articles relevant to early mobility guidelines and
protocols and barriers. Walden Library was contacted to explore access for full-text data.
Systematic Reviews were included in this literature review. Adler and Malone
(2012) conducted a systematic review of 15 studies on early mobilization in the ICU
using Sackett’s Levels of Evidence to rate the strength of the research of which one study
was Level 1 evidence, four were Level 2, one was Level 3, and nine were Level 4. The
studies included prospective and retrospective design of which included randomization.
The systematic review identified six criteria summarized from the literature for
terminating a PT/OT mobilization session. Termination criteria included parameters
concerning heart rate, pulse oximetry, blood pressure, respiratory rate, mechanical
ventilation, and alertness/agitation and patient symptoms (Adler & Malone, 2012).
Alaparthi et al. (2020) reviewed 56 studies in order to summarize the different aspects of
mobilization in the ICU of patients with or without mechanical ventilation. The review
identified safety measures including criteria for respiratory, cardiovascular, neurological
considerations, and others for early mobilization in the ICU. Other considerations were
identified as no unstable fractures or bony instability, not on continuous dialysis, no deep
vein thrombosis, body temperature <38.5, and no active bleeding (Alaparthi et al., 2020).
Alaparthis et al. (2020) also complied from studies red and green signals for active
mobilization of mechanically ventilated patients identifying which were for were for
52
exercises in bed and which were for exercise out of bed. Hodgson et al. (2014) reviews
analyzed safety criteria for active mobilization of mechanically ventilated critically ill
adults resulting in expert consensus using a red, yellow, green coding system to
operationalize adverse event risk. Red indicated significant risk during mobilization,
yellow indicated mobilization after measuring risk versus benefit, and green mobilization
could be performed with a low risk (Hodgson et al., 2014). The review also summarizes
strategies for overcoming barriers including hemodynamic instability as a barrier with
strategy being a stepwise approach (Alaparthis et al., 2020). Costa et al. (2017) reviewed
49 studies after analysis identified four barriers to ABCDE implementation for adult
patients in the ICU: patient related (instability and safety concerns), clinician-related
(lack of knowledge and staff safety concerns), protocol-related (unclear and cumbersome
protocols), and ICU contextual barriers (interprofessional team coordination). Patient
instability and safety concerns included hemodynamics, treatment-related adverse events,
and physiologic patient issues (Costa et al., 2017). Patient safety issues considered issues
as diarrhea, fatigue, leaking wound, patient weight or size, confusion, agitation, and
imminent death (Costa et al., 2017). Costa et al. (2017) identified use of the domains as a
potential differential diagnosis for implementation of the ABCDE bundle. Dubb et al.
(2016) synthesized data from 40 studies to identify barriers to early mobilization and
strategies to overcome barriers. The most common patient related barrier was
hemodynamic instability identified in 20 (50%) studies then vascular access devices,
53
tubes, and drains in 18 (45%) studies (Dubb et al., 2016). Strategies to address patient
related barriers for early mobilization included defining inclusion and exclusion criteria
for mobility, development and implementation of protocols, and interdisciplinary
collaboration (Dubb et al., 2016). Parry et al. (2017) analysis of 89 papers identified five
major themes patient physical and psychological ability to perform physical activity,
safety influences hemodynamic and respiratory physiologic stability culture and team
influences, motivation and beliefs about physical activity from patients, family, and
health care providers, and environmental influences (Parry et al., 2017). Development of
physiological stability guidelines for rehabilitation helped enable patient safety and
mobility (Parry et al., 2017). Reviews recommended protocols and a structured approach
or assessment to physiologic barriers to mobility using inclusion and exclusion criteria
based on patient assessment.
The remaining studies address the benefits of early mobility on patient outcomes
and patient mobility readiness measures. A non-randomized experimental pilot using a
mobility readiness protocol had eleven patients who passed and thirty-five patients who
failed the protocol for hemodynamic parameters including twenty-four with heart rate
above 120 beats per minute, seventeen with PEEP above 10cm H2O, and seventeen with
a PAO2 to FIO2 ratio smaller than 250 mmHg (Comradie et al., 2017). The readiness
protocol was found to be too strict when used to identify patients who could tolerate an
upright position using mean arterial pressure and oxygen consumption via venous oxygen
54
saturation (Comradie et al., 2017). Cooper et al. (2021) study of 105 patients in a
medical intensive care out of 191 orally intubated were eligible for out of bed activities
using criteria based on hemodynamic stability found mobility practice still nonexistent.
All mobility readiness criteria must be met prior to out of bed activities including RASS
score, mean arterial pressure, FIO2, Spo2, systolic blood pressure, no titration of
inotropic medications, and PEEP (Cooper et al., 2021). Colwell et al. (2018) used a
severity of illness scale from one to four to determine mobility readiness, achieved
mobilization in more than 50% of the patients, and mobility complications included
transient desaturation, tachypnea, and emesis. Staff reported the most significant mobility
implementation barrier was the perception of physiologic instability and the additional
staff need for mobility activities (Colwell et al., 2018). Drolet et al. (2013) study included
eall patients were screened for mobility readiness and exclusion criteria to determine
mobility readiness was incorporated on order sets with defined criteria to prevent patient
desaturation and excessive work of breathing.
Safe patient handling is elemental to many study guidelines and protocol when
determining readiness and activities. Dickinson et al. (2018) study of integrating a
mobility program and safe patient handling included patients being evaluated for
inclusion in the mobility protocol and exclusion criteria are used to determine the need to
withhold mobility. Mobility program assessment questions guide staff on mobility phase
and safe patient handling equipment use (Dickinson et al., 2018). Eakin et al. (2015)
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described overcoming safety and mobility barriers including hemodynamic instability,
rising vasopressor requirements, accidental removal of an endotracheal tube, and line loss
using a model that includes engaging, educating, executing, and evaluating. Engel et al.
(2013) from a retrospective analysis of data indicated mobility and treatment starts by
identifying if there are exclusion criteria present and if yes assess ability to tolerate and
participate in mobility activities and if no assessment criteria determine mobility level.
Hickmann e al. (2016) an observational study on mechanically ventilated patients and
non-mechanically ventilated used a mobility protocol with levels zero to four taking into
account RASS, Glascow, and muscular strength and mobility provided at least once in
81% of all patients within 24 hours of ICU admission. Limiting factors for the study
included instability for 709 patients during bed to chair mobilization with severe
physiological in 42, hemodynamic in 21, respiratory in 5 and neurological in 16
(Hickmann et al., 2016). Hodgson et al. (2014) a prospective observational study on an
ICU mobility scale from existing studies and the John Hopkins scale adding more levels
of mobilization and the levels of assistance required found the maximum level of
mobility not achieved by the cohort and measures to determine stability and readiness
were no included. John Hopkins Early Mobility Toolkit Your Work Plan for Translating
Evidence into Practice (2020) includes a medical screening algorithm to evaluate patients
for mobility beginning with the ability to open eyes to verbal stimulation and assessment
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for mobility to occur within 24 hours of admission including neurologic, respiratory, and
cardiovascular elements.
Klein et al. (2018) a prospective longitudinal study includes an early progressive
mobility protocol to guide nursing decisions with patient readiness criteria for identified
stepwise mobility progression including four progressive mobility milestones from 16
mobility levels. Krupp et al. (2019) an exploratory descriptive study looked at factors
nurses in the ICU consider when making decisions about patient mobility and concluded
mobility programs should begin as soon as the patient demonstrates physiologic stability
and observations of patient’s strength, mental status, and physiologic response to activity
influence maintaining or progressing mobility. An additional prospective study with a
nonexperimental design used a contrasted-group approach, inter-rater assessments, and
expert agreement approach to assess the Banner Mobility Assessment Tool (BMAT) for
Nurses in use provided evidence the tool is valid in assessing a patient’s mobility status
(Boynton et al., 2014). When consulted physical therapists guide the mobility plan of
care and progress completing mobility and gait assessments creating a disconnect
between actionable items for nursing and the desire to increase mobility (Boynton et al.,
2014). Lin et al. (2018) a prospective observational study of an early mobilization
protocol identified discontinuation of mobilization criteria was also a criterion for
readiness including hemodynamic and respiratory parameters as symptomatic heart rate,
blood pressure, arrhythmias, oxygen saturation, respiratory rate and mechanical ventilator
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asynchrony. Respiratory, cardiac, and consciousness parameters were identified for
advancing the protocol and the incidence of adverse events for all sessions was 2.2% out
of 587 (Lin et al., 2018).
Mobility goals should be included for patients eligible for activities. Messer et al.
(2015) a correlational descriptive study identified exclusion mobility readiness criteria
including unstable hemodynamic status, two or more vasopressors, neuromuscular
blockade, physician order for bedrest, and end of life. Dangling was the only specific
activity after nursing education that increased despite a goal of all patients who met
inclusion criteria receive a level of intervention besides turning (Messer et al., 2015).
Milano et al. (2014) used a decision tree flow chart after a physician gave medical
clearance to start mobility progression by a nurse or physical therapist using care boards
to document why, how it is done, and what the patient needs to do. Perme et al. (2014)
describes a mobility score assessment tool including potential mobility barriers as bed
mobility, transfers, gait, endurance, and functional status with high scores indicating few
mobility barriers and decreased assistance. Patients on low levels of vasopressors were
five times as likely to be mobilized and those on moderate doses were twice as likely to
be mobilized (Perme et al., 2014). Rebel et al. (2019), in their retrospective cohort study,
found patients were mobilized on one-third of vasoactive days found in 195 episodes of
mobilization patients were more likely to experience an adverse event with a low mean
arterial pressure, higher SpO2 and higher FiO2. The Society of Critical Care Medicine,
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ICU Liberation Bundle E (2013) identifies maximal activity includes hemodynamic
stability, an awake patient, and a patient that was walking before admission and absolute
contraindication to is hemodynamic instability defined as a patient on escalating doses or
multiple vasopressors. Sommers et al. (2016 a prospective observational reliability and
validity study indicated the assessment of patients in the ICU is complicated by
pulmonary and hemodynamic conditions needing medications and invasive equipment
with changing medical situations and the ability to perform mobility activities changes
within an hour due to fatigue and exertion. Whelan et al. (2018) a quasi-experimental
study used ten domains to measure physical function using the Chelsea critical care
physical assessment (CPAx) tool in the ICU graded zero to five to identify problems and
address. The CPAx tool is an outcome measure that responds to change designed to
assess physical ability, respiratory function, cough, bed mobility, supine to sitting on the
edge of the bed, dynamic sitting, sit to stand, standing balance, transferring from bed to
chair, and stepping and grip strength (Whelan et al., 2018). Zomorodi et al. (2012)
completed a pilot study included a mobility decision tree flow chart beginning with is
patient hemodynamically stable and if no mobility is not indicated and if yes evaluate if
vital signs stable in bed with rolling for bed linens changes and hygiene then begin
activity. Stiller’s safety for mobilization guidelines beginning with level one with six
total activity events and during mobility activities nurse’s role included monitoring blood
pressure, heart rate, oxygen saturation, and lines and tube safety (Zomorodi et al., 2012).
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Evidence-based programs for mobility support quality outcomes. The Agency for
Healthcare Research and Quality for Advancing Excellence in Healthcare Safety Program
for Mechanically Ventilated Patients, Nurse Driven Early Mobility Protocol (2019)
contains an ICU mobility screen with exclusion criteria and mobility to begin when the
patient meets criteria including follows the keys to prevent excessive work of breathing
and desaturation. Balas et al. (2012) indicates parameters used to assess patients’
readiness for mobility include neurologic, respiratory, circulatory, and central line
contraindications and patients not eligible or have activity halted for an adverse event are
reassessed every day and thus eligible begin activity. Boyton et al. (2014) looked at
clinical practice guidelines for mobility without determination criteria for patient
readiness and noted staff injuries decreased after implementation and increased nurse use
of mobility guidelines in patient activity. Clinical practice guideline for mobility along
with a mobility champion providing knowledge of the impact of immobility can support a
seven progressive step mobility plan for patients (Bruce & Forry, 2018). Campbell et al.
(2015) included contraindications for initiating and continuing mobility along with
detailed steps to prepare for mobility and offered evidence that high fidelity simulation
builds confidence in early mobility collaborations around patients that can occur during
mobility events.
Barriers, patient assessments, and patient conditions limit mobility activities.
Costa et al. (2017) identified ABCDE barriers including patient instability and safety
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concerns, clinician related including staff safety concerns, lack of knowledge, protocol
related, and ICU contextual barriers. Patient related issues include hemodynamics,
treatment related adverse events, and physiologic patient issues (Costa et al., 2017).
Costa et al. (2017) Identified barriers, grouped into four domains as a differential
diagnosis checklist to assess barriers to ABCDE implementation. Engel et al. (2013)
three medical center’s quality improvement mobility projects identified patient
assessment for exclusion criteria and if patient able to properly attend to tasks and
inclusion if patient verbal or manual stimulation with an identified RASS and further
considerations include patient remains alert, demonstrates trunk control, and vital signs
are acceptable. Klein et al. (2018) a quasi-experimental a quality improvement project
used an inpatient algorithm combining the John Hopkins Highest Level of Mobility Scale
and the Activity Measure for Post-Acute Inpatient Mobility Short Form to guide the
nursing team on setting mobility goals. The Activity Measure for Post-Acute Inpatient
Mobility Short form six questions quantify functional limitations based on direct
observation or clinical judgement of needed from another during activities as turning,
sitting on the edge of the bed, transfer from bed to chair, standing from chair, walking in
the room, and climbing three to five steps (Klein et al., 2018). McWilliams et al. (2015)
identified mobility for ventilated patients should include sitting on side of bed when
appropriate within the first five days allows assessment of sitting balance, exercise
capacity and physiological stability with six exclusion criteria and five restrictions to
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edge sitting. Before beginning activity, the protocol assessed for RASS score and/or
presence of contraindications to determine use of passive or active mobility measures
(McWilliams et al., 2015). Schallom et al. (2020) a staggered quality improvement
project using the American Association of Critical Care early mobility protocol begins
with step one screening for safety and evaluating patients every 12 hours for myocardial
and oxygenation stability, vasopressor use, vascular access, engaging to voice, and
neurological/ortho/wound stability findings included increased mobility levels. The four
mobility levels included goals at each level and measurements during phase one of the
project included CAM-ICU twice daily and the highest and lowest RASS score in
24hours (Schallom et al., 2020). Hemodynamic instability is one of the most common
perceived patient-related barriers limiting the practice of early mobilization (Alaprrthi et
al., 2020). Physiologic assessment to determine mobility readiness is a clinical risk
assessment focusing on improving quality and safety by identifying circumstances that
put patients at risk (Asefzadeh et al., 2013). Conradie et al. (2017) a nonrandomized
experimental pilot evaluated the feasibility of a protocol using hemodynamic parameters,
mean arterial pressure, and central venous oxygen saturation of eleven patients in the
baseline line position and then again at 0.3 and 10 minutes in a therapeutic upright
position found the protocol was to strict. One hundred and thirty-eight patients were
screened with 10 excluded for logistical reasons, 82 patients excluded based on exclusion
criteria, and 35 failed the protocol (Conradie et al., 2017). Reasons for failing the
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protocol included a heart rate above 120 beats per minute (n = 24), PEEP above
10cmH2O (n-17), and PaO2/FiO2 ratio smaller than 250mmHg (n = 17) (Conradie et al.,
2017).
Limitations/Potential Impact on Findings
Most of the studies resulted in improvement in patient’s outcomes with the
exception of a study where 35 patients failed the protocol and the most prevalent reason
was a heart rate above 120 beats per minute (n=24), a PEEP above 10cm H20 (n=17), and
a PAO2/FiO2 ratio smaller than 250 mmHg (n=17) (Comadie et al., 2017). Krupp et al.
(2019) also found variations in nursing practice including hesitancy to be the first to
mobilize a patient and most critically ill patients did not have a mobility goal, and
decisions to mobilize were based on a nurse’s decision instead of an established standard
of care along with nurse education about mobility does not increase the frequency of
patient mobility. Messer et al. (2015) study identified after education of MSICU nurses
the 39% of the 75 potential mobility events resulted in some type of mobility increased to
only 60% of the 85 potential and the goal of all patients who met inclusion criteria
receive some level of intervention besides turning was not met. Moraes et al. (2019)
found resistance to change until the proposed concept is consistent and reproducible in
low sample size and effect size. Zomorodi et al. (2012) a pilot study with a sample size
of three limited the interpretation of the results even though the study helped identify
efficacy of the protocol.
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Implication for Social Change
This systematic literature review supports the need for available evidence-based
nurse driven readiness assessment and guideline for nurses to collaborate with the
healthcare team in the management of safe early patient mobility. An adaption of a
mobility readiness assessment and evidence-based early mobility practice guideline will
result in the enhancement of nursing practice supporting quality patient outcomes. Nurses
will be able to monitor, assess, and measure the effects of interventions in the patient’s
care guided by evidence (White et al., 2016). This systematic literature review addresses
the gap between mobility readiness assessments and early mobility practice which will
ultimately improve the safety and out comes at the local clinical practicum site. This will
impact positive social change and nursing practice.
Recommendations
After analyzing and synthesizing the data collected in this systematic literature
review for the project it was concluded the project will have an influence on the nursing
practice at the project site. The recommendations concluded from this systematic
literature review revealed the need for additional studies on comprehensive mobility
readiness measures and management to be conducted using the adult critically ill patient
population. Further studies will help validate the implication of mobility readiness
assessments and safe early mobility management in the care of critically ill adult
population.
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Plan to Extend Beyond the DNP Project
The DNP project will be continued post the doctoral phase in collaboration with
the health care team and local IRB office to operationalize early mobility readiness
assessment and a nurse-driven guideline for early mobility for critically ill adult patients.
Furthering the project will require time and collaboration with key stakeholders. Next
steps will include piloting the project and evaluating the effectiveness of the project prior
to full implementation estimating six months to a year from pilot to full implementation
and continued follow thereafter.
Strengths and Limitations of the Doctoral Project
Knowledge gained throughout the project process is a strength of the doctoral
process. A large source of evidence and data with positive outcomes was found in the
literature in the critical ill adult population on early mobility and mobility readiness
including barriers. There is less evidence in the literature regarding the impact of
mobility readiness assessments impact on early mobility management in the adult
critically ill patient population. Benefits of the project include sharing of information with
stakeholders and frontline nursing staff as well as the leadership team within the project
site and critical care nursing associations. The project summary can be used to help
nursing leadership and healthcare staff with decision making on mobility initiatives in
improving clinical practice and patient care. Limitations of the project include the lack of
research studies on mobility readiness assessments impact on patient outcomes and
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delays in mobility in the critically ill patient population. This project benefit is validated
in the adult critically ill patient ICUs beyond the project site ICU.
Recommendations for Future Projects
This review identified the need for more studies on the impact of mobility
readiness assessment on critically ill patient outcomes with mobility guidelines. The
analysis and synthesis of the project found several studies demonstrated the lack of
evidence in early mobility management patient assessment for readiness to mobilize. The
results of the review concluded the adoption of an evidence-based practice mobility
guideline including readiness assessment improves positive patients’ outcomes and
nursing practice. Further research is needed in mobility readiness criteria since this
review produced lack of comprehensive guidelines in the adult critically ill population in
the ICU and studies comparing comprehensive guidelines.
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Section 5: Dissemination Plan
EBP is essential in nursing practice and researching incidence and validity of
early mobility management can help identify plans to effectively disseminate new
knowledge and information. Quality patient outcomes are dependent on translating new
knowledge into practice. Early mobility readiness assessments included in early mobility
guidelines is challenging due to limited published literature and the lack of consistent
nursing practice concerning early mobility. The purpose of this project was to evaluate
and synthesize evidence on mobility readiness assessments and nurse-driven early
mobility management, which could lead to a recommendation that would improve early
mobility management in the ICU. The findings of this project were intended to inform
nursing and healthcare leadership and provide recommendations for adopting EBP for
management of early mobility and mobility readiness assessment. The synthesis of this
project’s results can be disseminated to the practicum site leaders through the literature
review project.
Audiences for Dissemination
The nursing staff and healthcare team at the practicum site are the primary
audience for this project dissemination. Stakeholders involved in this project include the
Vice President of Nursing, the Director of Nursing, and the practicum site mentor. An oral
PowerPoint presentation will be used to disseminate the project findings and
recommendations to the intended nursing staff and leadership. Findings from the project
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may promote and support early mobility management and other changes in nursing
practice for the practicum site ICU. Collaboration and sharing knowledge learned from
the findings of this project with other ICU units includes a future poster presentation and
submission of an abstract to several critical care journals of interest.
Analysis of Self
My experience in the DNP program started with a need to grow and continue
lifelong learning postmasters, and a need to continue on a journey for self-improvement
and as a champion of EBP. Sharing and promoting EBP is a passion which ultimately
improves nursing practice and patient outcomes. Critical thinking and problem solving is
grounded in EBP. Collaboration with the healthcare team and nursing colleagues helped
identify my DNP project focus as I heard areas of concern and practice needs around
patient readiness assessment and mobility management. I have gained great appreciation
for EBP from my previous experience as a clinical nurse specialist and realize
evidencebased practice is not part of many nurses’ clinical practice. My DNP program
experiences have reinforced the importance of EBP throughout. My doctoral program
journey has provided growth for me professionally and personally.
My professional role in nursing is an advanced practice nurse and leader of an
ICU and an Intermediate Care Unit. Over the years of my career, I have worked as a staff
nurse in both ICU and PACU, a clinical nurse specialist in Critical Care, and as a nurse
leader. Each role has shaped my career and prepared me for where I am in nursing today
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as a professional and nurse leader. My goal through this program was to analyze existing
EBP concerning mobility management and patient readiness assessments for mobility to
adapt an evidence-based mobility management practice guideline that may assist in
decreasing variations in practice for adult critically ill patients. Resistance to change is an
ongoing issue in clinical practice and a challenge I anticipated because adopting EBP has
barriers despite improving patient outcomes. During DNP practicum experiences and
courses, I have learned and been exposed to strategies to address resistance to change.
My leadership experience has provided many opportunities to successfully implement
EBP.
Summary
Safe early mobility management is challenging yet essential component of care
for the adult critically ill patient population within the ICU. Patient outcomes and
complications depend on decreasing immobility and the deconditioning associated with
immobility in the ICU. During this project, I conducted a systematic literature review to
examine and summarize evidence that can be used to recommend a nurse-driven
guideline including readiness assessment for early mobility of critically ill adults in the
ICU. This systematic literature review can provide nurses with a tool useful in the
collaboration with the healthcare team to efficiently manage early patient mobility.
Research should be conducted to confirm these findings as well as to determine the
relationship between using evidence-based nurse driven assessment for mobility
69
readiness, early mobility guidelines, and patient outcomes. As the recommendations of
the project findings are provided to the practicum site, it rests with the practicum site to
implement the project.
Mobility is a necessary element of care provided to critically ill adults. Safe
patient mobility helps to ensure a patient does not experience complications due to
immobility. Patient mortality increases with complications. Patient safety and clinical risk
management is an element of clinical governance and includes identifying the
circumstances and opportunities that put patients at risk of harm and acting to prevent or
control risk (Asefzadeh et al., 2013). Early progressive mobilization of critically ill
patients is feasible, safe, and results in benefits including functional outcomes, and
reduced intensive care unit (ICU) and hospital length of stay (Hodgson et al., 2014).
However, weakness begins with serious illness, and effects from immobility and
weakness are associated with prolonged mechanical ventilation, ICU length of stay, and
1-year mortality (Latronico et al., 2017). Physical activity may mitigate weakness and
muscle damage from critical illness, but critically ill patients may have limits to their
activity tolerance (Amidei, 2012a). Despite knowledge of the harmful effects of
immobility on multiple body systems, the ICU is a challenging and difficult environment
where many barriers exist to mobilizing critically ill patients (Adler & Malone, 2012).
At the practicum site for which this Doctor of Nursing Practice (DNP) project was
completed, critically ill patients’ mobility management orders would come from a
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collaboration between the healthcare team on daily rounds based on the priority placed on
mobility, a process which led to inconsistent practice and patient outcomes.
Attending to the mobility of critically ill patients is challenging. The tenuous
dynamic status of critically ill patients and their physiological derangements can result in
adverse hemodynamic responses to activity and mobility (Adler & Malone, 2012). It is
not uncommon for deconditioned critically ill patients with limited physiologic reserve to
respond to activity and exertional stress with changes in hemodynamic status. Patient
changes include activity intolerance as fainting, changes in blood pressure and heart rate,
and inability to support their body weight (Amidei, 2012a). As such, this project sought to
identify evidence-based practices addressing enhanced and safe mobility in critically ill
patients.
Physiologic Stability and Functional Capacity
The physiologic stability and functional capacity of critically ill patients impact
mobility readiness and level. Nursing strives to incorporate levels of safe mobility in care
based on multiple assessments including physiologic concerns (Amidel, 2012a).
Professionals in nursing and health care endeavor to decrease the length of stay in the
ICU and hospital, increase positive patient outcomes, and decrease costs associated with
care. Guidelines have the potential to facilitate patient care decisions and the
implementation of evidence-based practice concerning safe patient mobility, but due to
inconsistent adoption in clinical practice guidelines have limited impact and present a
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health system challenge (Kastner et al., 2011). Having an evidence-based patient
guideline or tool for physiologic assessment measures for mobility readiness in critical
care at the practicum site may support collaborative efforts of critical care nurses and the
healthcare team to provide quality care and safe, effective mobility measures.
Problem Statement
Local Nursing Practice Problem
The current practice of mobility management comes from patient orders without
the adoption of an evidence-based physiologic assessment guide to support safe
mobility. Patient mobility management is affected by many variables, including patient
physiologic stability, alertness, and strength, and the experience and skill level of staff
caring for the patient. The current local nursing practice problem is that mobility
assessment and management differ based on the healthcare team members caring for
patients and the ICUs where patients receive care. The project site has assessment tools
for nurses to address some aspects of mobility management; however, comprehensive
nursing guidelines, including physiologic assessment, are not currently in use. The
nursing staff feel pressured to ambulate critically ill patients and have difficulty in
balancing the patient’s need to ambulate versus the benefit and safety of ambulation in
the presence of hemodynamic intolerance. The need to address safe mobility and
physiologic assessment of patients before ambulation at the clinical site is evident due to
the negative impact of immobility on patient outcomes. The purpose of this systematic
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review is to look at the current practice of physiologic assessment measures and then
utilize the findings to influence safe patient mobility in the ICU.
Local Relevance
Safe prescription of patient mobility includes comprehensive preassessment and
diagnostic information evaluation to improve outcomes and meet patient mobility goals
(Amidei, 2012b). However, mobilization therapy does not consistently address the
physiologic readiness of a patient when prescribing activity regimens (Eakin et al.,
2015). Hence, it is important to understand critical factors as physiologic stability to
implement and sustain safe mobility in critically ill patients successfully.
Multiple assessments and methods determine the severity of illness, care
requirements, and the efficacy of mobility treatments. Nursing strives to incorporate
appropriate levels of mobility in care based on multiple assessments and exclusions for
physiologic concerns (Amidei, 2012b). Physiologic stability may change during
mobility, and unsafe patient mobilization results in adverse patient outcomes that
increase patient recovery time. There are inherent complications related to physiologic
stability, patient safety, and functional outcomes associated with the mobilization of
critical care patients (Adler & Malone, 2012). For safe mobilization to occur in the ICU,
with minimal risk of adverse events, assessment of patient physiologic stability should
occur before mobilization (Hodgson et al., 2014). Assessment of the right time and
readiness for mobilization includes a review of a patient’s physiologic and functional
73
capacity (Eakin et al., 2015). Physiologic stability and functional capacity of critically
ill patients also help determine mobility readiness and appropriate mobility levels
(Amidei, 2012b).
Purpose Statement
Incongruence exists in the literature and practice about when to use mobilization,
who should perform mobilization, and to what extent to apply mobilization. The purpose
of this systematic literature review is to examine and summarize the benefits of
evidencebased practice tools for physiologic assessment and stability in the mobilization
of critically ill patients. Also, to evaluate tools that are published and can improve the
mobilization of critically ill patients by nursing and other disciplines. A review of the
current body of evidence on physiologic assessment and stability in the mobilization of
critically ill patients will answer how research and quality improvement studies on the
mobilization of critically ill patients address physiologic stability in decisions to mobilize
patients and if there is a consistent, safe best practice. Additionally, this project may
contribute to the enhancement of better patient outcomes by identifying optimal critical
care patient populations that would benefit from physiologic assessment for mobility
readiness.
Gap in Practice
Evidence-based practice is the standard nurses use to provide effective clinical
care. The gap in practice is that the ICU does not have a consistent, evidence-based
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approach to assess or determine a patient’s readiness for mobilization, despite the benefits
of safety and quality outcomes associated with evidence-based practice. Based on current
practice, it is apparent that a clinical practice gap exists in determining a critically ill
patient’s readiness and safety for mobilization activities. This DNP project may provide
nurses and other disciplines with physiologic assessment measures to determine critically
ill patients’ mobilization readiness. A nurse-driven mobility readiness assessment
included in mobility management will support the provision of safe, efficient care and
assessment in the management of critically ill patient mobility.
Practice-Focused Questions
The purpose of this systematic literature review is to examine and summarize the
benefits of evidence-based practice tools for physiologic assessment and stability in the
mobilization of critically ill patients. The three questions were:
• What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
• What is the effect of using physiologic assessment measures on determining
patient readiness for safe mobility?
• What is the effect of using physiologic assessment measures on the incidence
and safety of patient mobility events?
The following parameters guided the focus in answering the practice-focused questions:
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• Population: Critically ill Adults 18 years and older
• Intervention: Systematic review of the literature for Physiologic Assessment
Measures for Mobilization Readiness
• Comparison: The normal routine for Mobility Assessment
• Outcome: In critically ill adults 18 years and older, does the intervention of
physiologic assessment measures for mobilization provide safe and effective
patient physiologic assessment measures for readiness for mobilization
therapy?
The systematic literature review evaluated whether adapting and implementing an
evidence-based practice assessment tool or guideline has been found to enhance nursing
practice related to mobilization of critically ill patients. The design of this systematic
review included the synthesis of the literature review research for systematic reviews,
quantitative studies, qualitative studies, and pilot studies.
Addressing the Gap in Clinical Practice
Currently, the nursing practice of critically ill patient mobilization relies on
provider order, or clinical judgment and experience. Providing a summary of current
research and quality improvement on physiologic assessment can guide nursing practice
and other disciplines in addressing the gap in clinical practice of critically ill patients’
readiness for mobilization. Also, findings may guide nursing practice, improve patient
outcomes and safety, decrease unnecessary costs, and support nurses in making
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assessments and decisions based on evidence. Findings from the systematic literature
review may encourage nurse participation in evidence-based clinical practice by
demonstrating how nurse-driven measures can positively impact patients at the unit,
organization, and system level. The optimal timing and progression of mobility and
factors influenced the ability to mobilize affect positive patient outcomes (Winkleman et
al., 2012). The systematic review may provide additional benefits to the critically ill adult
populations in other organizations’ nursing staff and other disciplines through
summarizing research on evidence-based physiologic assessments for mobility readiness
of critically ill patients.
Nature of the Doctoral Project
The nature of this DNP project was to provide a systematic review of
evidencebased research patient guidelines or tools for physiologic assessment measures
for mobility readiness in critical care. The project goal was to provide a guide for critical
care nurses in safe mobility assessments and decisions in the ICU. This DNP project can
lead to positive social change in nursing practice by identifying physiologic assessment
measures that support patients’ readiness for mobility measures and safety during
mobility activities. The review of safe early mobility management also identifies
physiologic assessment measures to determine early mobility readiness and management
effectiveness, which can influence the care and mobility of critically ill adult patients.
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Accordingly, this project can improve nursing practice, decrease the adverse effects of
patient immobility while promoting better outcomes, and create positive social change.
Sources of Evidence
Evidence-based mobility practice increases patient safety, improves clinical
outcomes, reduces healthcare-related costs, and decreases variations in patient outcomes
and care (SCCM, n.d.). The project focus included collecting current evidence on
physiologic assessment measures for patient mobility readiness in ICUs that support safe
patient handling and decrease adverse events. Sources included textbooks, critical care,
and nursing journals, and peer-reviewed journals presenting articles on patient mobility,
including the Journal of Critical Care, Intensive and Critical Care Nursing, Physical
Medicine & Rehabilitation Journal, Critical Care Research and Practice, and the
Journal of Safe Patient Handling & Movement. Using Walden Library resources,
peerreviewed articles also came from online databases like Medline, Cochrane, PubMed,
CINAHL, and Google Scholar. Official websites accessed included the Society for
Critical Care Medicine, the American Association of Critical Care Nurses, the Agency
for Healthcare Research and Quality, and the Institute for Healthcare Improvement.
Nurses, physical therapists, respiratory therapists, and providers provided additional
resource information including seminal work from 2016-2020.
The decision for patient mobility avoids immobility and includes patient
assessments from admission to discharge. Immobility may affect a patient’s state of
health, and impaired health affects a patient’s physiologic and functional capacity
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limiting the ability to mobilize (Amidei, 2012). A patient’s participation in mobility
depends on resources to support ambulation, changes in sedation to enable patient
participation, and patient assessments to determine the level of activity and ability to
mobilize (Eakin et al., 2015). Conditions caused by immobility are as disabling as the
patient’s admitted condition and mobility limits these conditions. Assessing the efficacy
of early mobility of patients with and without mechanical ventilation is predicated on
establishing a culture of mobility in the ICU (Corcoran et al., 2017). However, cultures
that support patient mobility continue to have variations in assessment, intensity, and
frequency of patient mobility (Corcoran et al., 2017). An early mobility bundle,
including physiologic patient readiness assessment tools for mobility on every patient
every day, lessens immobility complications and decreases variations in care (SCCM,
n.d.). Individualized mobility assessments are essential for safe patient mobilization.
The patient’s functional and physiologic status improves with mobility and
declines with immobility. ICU patients lose approximately 2% of muscle mass every 24
hours (Doherty & Steen, 2010). As a result, the patient experiences a significant
reduction in skeletal muscle force, indicating the assessment of physiologic and
functional capacity is an important step before mobilizing (Doherty & Steen, 2010).
Determining the optimal timing and progression of mobility and factors influencing the
ability to mobilize affect the safe, functional recovery of critically ill adults (Winkleman
et al., 2012). Early mobilization restores function, and passive movement is appropriate
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when a patient’s physiologic assessment identifies limitations to active involvement in
mobility (Stockley et al., 2012). Functional and physiologic capacity mobility
assessments vary and include the use of exclusion criteria, family reports of previous
mobility levels, and the use of a variety of balance and strength assessments to
determine a patient’s readiness for mobilization (McWilliams et al., 2015). Despite
evidence supporting early mobility benefits to a patient’s recovery, timing, frequency,
and application of mobility vary, affecting a patient’s recovery.
Approach
The John Hopkins Evidence-based Practice model (JHNEBP) was the
developmental framework for this systematic review. The JHNEBP model is an effective
problem-solving approach to clinical decision-making using healthcare evidence (Dang
& Dearholt, 2017). Accordingly, the generation of research evidence that is effective,
feasible, appropriate, and meaningful to specific populations helps identify and address
patient’s health care needs (Dang & Dearholt, 2017.). The JHNEBP approach ensures
research findings and best practices in evidence-informed patient care (Dang &
Dearholt, 2017). The JHNEBP model is in congruence with holistic nursing care
delivery and balances scientific and humanistic characteristics of health and its
importance (Dang & Dearholt, 2017). The JHNEBP model integrates the best scientific
evidence with the best patient and practitioner evidence, considers internal and external
influences on practice, and encourages clinical reasoning in the application of evidence
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to care of patients and populations (White et al., 2016). The model also ensures research
findings and best practices in evidence-informed care, including clinical assessment
measures, guidelines, protocols, or tools, which are solutions for translating research
into practice (Dang & Dearholt, 2017).
The organization and beginning analysis of the DNP project literature review
involved the creation of a synthesis matrix. The synthesis matrix provided an overview
of the current research and quality improvement projects relevant to the selected topic. A
synthesis matrix facilitated the examination of multiple articles and how they relate to
themes in the research or quality improvement (Clark & Buckley, 2017). Synthesized
information supported the integration of evidence-based physiologic assessment
measures into mobility readiness practice.
A logic model was used to interpret the information obtained on readiness
assessments for mobility. The logic model promoted system thinking by highlighting
relationships of mobility readiness details to the whole process of patient mobility along
with congruencies and inconsistencies (Anderson et al., 2011). The model was used to
scope the review, define and conduct the review, and facilitate the review relevant to
practice (Anderson et al., 2011). The model facilitated the synthesis of current
knowledge on physiologic assessment measures for mobility readiness and early
mobility management
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Identifying the scope of the review included the use of databases and search
engines to find outcomes and research; databases included the Cochrane Database for
Systematic Reviews and the Joanna Briggs Institute EBP database. Available evidence
searches engines to find evidence included PubMed, CINAHL Plus, Medline, and
ProQuest Health & Medical Collection. Key search terms and combinations of these
terms for further searches included activity, mobilization, functional capacity,
physiologic stability, rehabilitation, critical care, ICU, recovery, exercise, and
movement. The study considered peer-reviewed primary sources from 2010-2020 for
inclusion in the doctoral project prospectus and systematic review.
Connecting current evidence to the practice questions requires a detailed review
of sources to determine applicability (Walden University, 2017b). After searching and
evaluating evidence, an additional search ensured all points of view from available
peerreviewed sources were included that apply to the DNP project questions. The search
was exhaustive by using various search terms and phrase combinations that cover the
practice-focused questions and the target population. Plans included methods to identify
the integrity of evidence, including approaches to outliers, missing information, and
statistical analysis procedures used in the doctoral project to address the practicefocused
questions. Analysis and synthesis included identifying gaps that exist in the current
literature and the strengths and weaknesses of existing literature. Established standards
were applied to appraise study quality, to assemble all relevant sources, and to identify
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the basis of knowledge (Walden, 2017b). Clinical practice improvement
recommendations for patient mobility decisions came from the interpretation and
synthesis of the evidence.
Resources needed to complete the doctoral project included time and the support
of the writing center, library, and my DNP supervisory committee chair. Additionally,
the use of the DNP capstone resources and the DNP project mentoring course provided
the support needed to obtain data and resources needed to complete the DNP project.
Planning for protected daily time for my DNP project facilitated the completion of my
systematic review DNP scholarly project.
Significance
Nursing Practice
This DNP project holds significance to the field of critical care and nursing
practice, as it may help establish and motivate the local site to adopt evidence-based
measures for physiologic assessment to determine the mobility readiness of critically ill
patients. This DNP project also addresses the problem of the lack of and use of consistent,
evidence-based measures to assess and determine mobility readiness for critically ill
patients that would support a nurse-driven mobility guideline or tool. In the project site,
this issue has affected patient safety, patient outcomes, the patient’s length of stay, and
hospital costs. Nursing practice is universally affected. The project may help identify
physiologic assessment measures that can guide clinical practice, nursing care, empower
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decisions based on evidence, improve patient outcomes, decrease the negative outcomes
from immobility, and decrease unnecessary health care costs.
A review of published scholarly articles for this DNP project may help establish
physiologic assessment measures for critically ill patients’ mobilization. Also, the
literature review may help establish physiologic assessment measures for mobilization of
critically ill patients at the local practicum site. An example of an organization’s attempts
to address physiologic assessment includes a pilot in a surgical/trauma ICU using Stiller’s
safety mobilization guidelines for ICU clinicians and the Borg Rate of Perceived Exertion
scale (Zomorodi et al., 2012). A multidisciplinary team developed a mobilization protocol
comprised of activity events twice a day till discharge, documenting heart rate, blood
pressure, and oxygen saturation at baseline, 5 minutes, and 15 minutes after mobility
(Zomorodi et al., 2012). The flowchart and decision tree matched the outcomes assessed
by physical therapy, and the pilot concluded the severity of illness affects mobility
progression and participation contributed to patients’ length of stay, healthcare cost, and
ventilator-free days (Zomorodi et al. 2012). The pilot demonstrated there were significant
physiologic changes associated with immobility and critical illness to consider when
mobilizing critically ill patients (Zomorodi et al., 2012). The establishment of a guideline
containing evidence-based measures for physiologic patient assessment for readiness for
mobilization may allow nurses at the local site to make informed decisions and advocate
for their patients. Additionally, a guideline may provide optimal patient care management
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that will improve patient outcomes and decrease the occurrence of complications from
immobility and unsafe mobility activities. Accordingly, this may lead to decreased length
of stay in the hospital and ICU and increased nursing autonomy, as nurses may feel their
assessments and interventions surrounding mobility are positively impacting patient care
and outcomes.
Stakeholders
In the ICU, critically ill patients admitted conditions caused by immobility are
disabling and limit mobility. Nurses provide care to these patients that include the
management of mobilization to limit the effects of immobility and achieve optimum
patient outcomes. The challenges of early progressive mobility of critically ill patients
include the assessment of physiologic stability and readiness for mobility activities, of
which there is a lack of a gold standard to guide clinical practice.
The results of this DNP project may affect multiple stakeholders by addressing the
lack of evidence-based physiologic mobility assessment measures to determine mobility
readiness and nurse-driven practice implementation of these measures. Stakeholders
include nurses, physical therapists, occupational therapists, respiratory therapists, nursing
assistants, nurse practitioners, physician assistants, and physicians who provide care to
critically ill patients. Additional members of the healthcare team that may be affected
include nurse educators, unit and professional governance council committees, the
mobility wellness bundle committee, organization practice boards, and nursing and
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administrative management. Stakeholders also include the patient, their caregivers, and
family. Including them in the experience of care and individualized plan of care
development can improve care delivery as well as allow for collaboration with the
healthcare team. The nursing staff may gain new insight, assessment skills, and practice
knowledge in the management of patient mobility, activities associated with mobility,
and patient care. Patient impact includes decreased complications from immobility and
deconditioning. The systematic literature review provided the local organization with the
potential to improve patient outcomes, decrease costs and complications associated with
immobility, and reduce critical care and hospital length of stay.
Contribution of the Doctoral Project
The project contributes to nursing practice by enhancing knowledge and skill and
by providing effective physiologic assessment measures for mobility readiness of
critically ill patients prior to, during, and after mobility. The outcomes of this review may
also improve patient safety and outcomes, reducing ICU and hospital stay. The American
Association of Colleges of Nursing (2006) indicates the essentials of the DNP are to
design, implement, and evaluate therapeutic interventions based on nursing science
(p.16). The systematic literature review of physiologic assessment measures for early
mobility readiness and management of adult patients in critical care encompasses the
DNP Essentials I, II, III, VI, VIII. It allowed me to analyze, collaborate with
intraprofessional and interprofessional teams during the integration of evidence-based
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measures into practice. My DNP project synthesized the literature to provide
recommendations. It can guide, mentor, and support nurses to achieve excellence in
nursing during collaborations with the healthcare team about patient-specific mobility
measures for optimum outcomes (AACN, 2006). Additionally, the cost-effectiveness of
this practice initiative accounts for risk, safety, and improvement of health care outcomes,
including the decreased cost associated with adverse outcomes from immobility and
increased length of stay in the ICU and hospital (AACN, 2006).
Transferability
Evidence-based practice (EBP) is the integration of clinical expertise, patient
values, and needs, and the best evidence into the decision-making process for patient care
(White et al., 2016). The gap between recommended EBP and what is implemented can
lead to poor outcomes; therefore, the ability to integrate evidence into practice is key in
ensuring quality health care practice (White et al., 2016). EBP supports clinical decision
making because it offers solutions to improve health care quality and provide
costeffective care (Tucker, 2017). Physiologic assessment measures for mobility
readiness of adult patients in critical care may improve the safety and management of
critically ill patients mobilizing in ICUs with similar practice problems. The findings of
the systematic review can be shared with other critical care units locally within the health
care organization and system, as well as locally within the state with other ICUs. The
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DNP project provides an evidence-based practice evaluation for knowledge transfer for
nursing and other disciplines throughout all hospitals with ICUs in the state of the project
site.
Social Change Implication
The DNP project can create positive social change within the project site by
encouraging nurses to improve clinical practice through evidence-based practice
education and implementation. Evidence-based practice based on current research
improves patient outcomes and decreases health care costs. Adopting and supporting
nurse-driven measures for physiologic assessment for mobility readiness can enhance
nurse autonomy, as the measures identified empower nurses to collaborate with practical,
safe decision making in the mobilization of critically ill patients in the ICU. A systematic
literature review can also improve the safety and patient outcomes at the local practicum
site. The physiologic assessment measures may improve patient care and outcomes
related to mobility at the site, and measures can be potentially used globally in the
mobilization of critically ill patients in ICUs. Incorporating new evidence-based measures
will facilitate change in the decision-making process surrounding the mobilization of
critically ill patients in the ICU. Nurse-drive assessment measures for mobility
management improve nurse autonomy and satisfaction, improve patient safety, decrease
mechanical ventilation, and hospital and ICU length of stay (Corcoran et al., 2017).
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Accordingly, nurses can use assessment measures to determine mobility readiness guided
by evidence.
Summary
Immobility and unsafe mobility practices can lead to poor outcomes in patient
care practice. Effective physiologic assessment measures and management of
mobilization is essential for improving ineffective mobilization practices in the ICU.
Because of unsafe and poor patient outcomes that result from ineffective physiologic and
mobility assessment measures for critically ill patients, there is a need for evidence-based
guidelines to facilitate effective mobilization activities and decrease the incidence of
immobility that facilitate the best results for patients. Also, evidence-based guidelines
provides nurses with measures they can use when making clinical decisions in the care of
critically ill patients to decrease the negative effects of immobility. Evidence suggests the
use of a nurse-driven protocol to guide decisions with patient readiness criteria for
mobilization, the step-wise progression of mobility, and behavioral safety for out-of-bed
progressive mobilization is effective leading to sustained improvement in patients’ level
of mobility (Klein et al., 2018). Also, a nurse-driven early progressive mobility protocol
can sustain improvement in length of unit and hospital stay, depression, anxiety, and
hostility levels (Klein et al., 2018). With a summary of the evidence-based physiologic
assessment measures and methods to determine a critically ill patient’s readiness for
mobilization, intensive care nurses may possess the latest best practice measures.
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Evidence-based best practice knowledge on early mobility management may assist nurses
in managing patient mobilization activities based on current evidence. Nurses may no
longer rely just on personal judgment and experience when managing decisions
surrounding mobilization activities of critically ill patients. The systematic literature
review facilitates the use of evidence-based best practice measures in clinical practice
surrounding critically ill patient physiologic assessment to determine mobilization
readiness that improves patient safety.
Section 2: Background and Context
Introduction
Nursing care incorporating evidence-based practice will positively impact
patients, outcomes, and social change. Evidence-based practice is an innovative approach
to problem-solving in the care of patients, and the health care delivery system’s
complexity challenge nurses and other disciplines to identify and use evidence to guide
practice (White et al., 2016). Management of critically ill patients’ progressive mobility is
a complex process affected by many variables. The practice problem at the practicum
site was the current practice of mobility management comes from patient orders without
the adoption of an evidence-based physiologic assessment guide to support collaboration
between health care team members. Clinical practice may also vary based on the
individual nurse and disciplines caring for the patient. Evidence on early progressive
mobility demonstrated sustained improvement in patients’ level of mobility, length of
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ICU and hospital stay, depression, anxiety, functional status, and survivability (Klein et
al., 2018). However, mobilization therapy does not consistently address the physiologic
readiness of a patient during the prescription of activity regimens (Eakin et al., 2015).
Understanding the assessment of physiologic stability is needed to implement and sustain
safe mobility in critically ill patients successfully.
This doctoral project included three focused practice questions:
4. What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
5. What is the effect of using physiologic assessment measures on
determining patient readiness for safe mobility?
6. What is the effect of using physiologic assessment measures on the
incidence and safety of patient mobility events?
In critically ill adults 18 years and older, does the intervention of physiologic assessment
measures for mobilization provide safe and effective patient physiologic assessment
measures for readiness for mobilization therapy? The intent of this DNP project, a
systematic review of the literature, examined and summarized evidence-based practice
measure guidelines that can improve the nursing practice and interdisciplinary
collaboration of early progressive mobility of critically ill patients.
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Concepts, Models, and Theories
The concept of EPB in nursing is the basis of this DNP project. EPB in this
project includes the nurse applying knowledge to find a solution for a problem by
critically analyzing and applying current evidence to achieve a better understanding of
clinical decision making regarding critically ill patients’ mobilization in the ICU (Terry,
2018). The practicum site does not currently have an evidence-based physiologic
assessment measures guideline or protocol to determine critically ill patients’ readiness
for mobility, only an assessment for possible mobility level. Another concept included in
the systematic review is practice-based evidence, the knowledge generated from practice
as well as from research, which includes the importance of the environment in
determining practice recommendations (McEwen & Wills, 2014).
The JHNEBP model was the developmental framework for this systematic
literature review. The JHNEBP model is an effective problem-solving approach to
clinical decision-making using healthcare evidence in a systematic literature review
(Dang & Dearholt, 2017). Accordingly, the generation of research evidence that is
feasible, appropriate, and meaningful to specific populations helps identify and address a
patient’s health care needs (Dang & Dearholt, 2017). The model also ensures research
findings and best practices in evidence-informed care, including clinical assessment
measures, guidelines, protocols, or tools, which are solutions for translating research into
practice (Dang & Dearholt, 2017). The model incorporates the use of available evidence
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as a core component within the domains of professional nursing: nursing practice,
education, and research (Gawlinski & Rutledge, 2008). It is an appropriate model for
understanding the different forms of knowledge, and the guidelines for the model reflect
the “PET” process: practice question, evidence, and translation (Gawlinski & Rutledge,
2008). Evidence comes from the search and review of literature, literature is rated, and
recommendations for changes in processes of care are identified (Gawlinski & Rutledge,
2008). The JHNEBP model is in congruence with holistic nursing care delivery and
balances scientific and humanistic characteristics of health and its importance (Dang &
Dearholt, 2017). JHNEBP model goals include but are not limited to the use of evidence
to promote optimal outcomes, support rational decisions that reduce inappropriate
deviation, create a culture of critical thinking, and grow an environment where the
evidence supports clinical and administrative decisions (White et al., 2016). JHNEBP
model was developed by nurses to support EBP integration.
My DNP project included transitions theory, a middle range and situation-specific
theory. Meleis developed the theory encompassing the transition experience (Im, 2014).
The theory’s purpose is to describe, explain, and predict an individual’s experiences in
various types of transition (Im, 2014). The theory assumes all nursing phenomena involve
a type of transition (Im, 2014). Transitions theory includes understanding the nature of
and responses to change, facilitating the experience and responding to its different
phases, and prompting dynamic balance in health before, during, and at the end of a
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change event (Im, 2014). Transitions theory assumes nursing should play a central role in
facilitating smooth and successful transitions for those experiencing change (Im, 2014).
Transitions Theory includes the intervention made to facilitate transitions and promote
health and mastery of health-illness consequences (Im, 2014). Transitions Theory also
includes understanding the transition experience and that transitions may exacerbate
responses impacting health (Im, 2014).
Theory can guide and link practice to evidence. The theory knowledge gap exists
when the body of knowledge is unknown, accessible, or used as it should be in practice
(McEwen & Wills, 2014). Nursing practice can validate the theory, and the theory can be
a guide for making informed decisions that are grounded by practice (McEwen & Wills,
2014). In today’s challenging health care environments, nurses must continually seek to
evaluate, inform, and improve their practice by the integration of appropriate best
evidence (White et al., 2016). Evidence-based practice includes the integration of the best
evidence, clinical expertise, and patient preferences for clinical decision making (White
et al., 2016). The goal of this DNP project was to reduce clinical practice variation or
lack of physiologic assessment for evaluation of mobilization readiness of critically ill
patients.
Related Synthesis
The evidence-based model facilitates the application of evidence into clinical
practice and achieving best practice (Melnyk & Fineout-Overholt, 2015). The model
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applications include clinical practice, quality improvement, and education aspects of
nursing, and the model’s goal is to ensure the latest evidence and best practices quickly
and appropriately integrate into care (Melnyk & Fineout-Overholt, 2015). Assessing the
need for change or identifying a clinical practice gap includes an evaluation of the
existing evidence, synthesis, and integration of evidence into practice (Melnyk,
FineoutOverholt, 2015). The JHNEBP model was used to implement a daily ambulation
checklist for specified mobilization and venous thromboembolism (VTE) orders for high
to moderate risk patients (Anthony et al., 2017). Patients who experience less
mobilization and prolonged immobility experience less optimal outcomes (Anthony,
Bernard, & Butler, 2017). Surgery patients are at risk for VTE, and patients tend to limit
mobilization due to pain that may predispose them to venous stasis (Anthony et al.,
2017).
Transitions theory outcomes and potential for nursing therapeutics include the
patterns of response of the patient, which is fundamental to nursing (McEwen & Wills,
2014). Nursing therapeutics encompasses the assessment of readiness, preparation for the
transition, and role supplementation, the use of education and practice to facilitate
healthillness concerns (McEwen & Wills, 2014). The concept of situation-specific
transition theory on the transition to adult day health services, included the development
of inhibitors that included a mismatch between the elder’s functional ability and interests
and the activities available impacting mobility goals (Im, 2014). Additionally, the
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situation-specific transitions theory was used as a framework to guide interventions
including mobility for people with heart failure and determine the effect of heart failure
education on knowledge and readmission (Im, 2014). The situation-specific, transitions
theory was appropriate for this systematic review of physiologic assessment measures for
mobility readiness of adult patients in critical care.
Clarification of Terms
The following terms provide clarity to this DNP project:
Mobilization: An interdisciplinary, goal-directed therapy used to facilitate
movement and improve outcomes that expends energy and includes physical and
psychological domains as well as various activities (Amidei, 2012-b).
Movement: A type of activity that is a functional pattern that allows individuals to
control their environment (Amidei, 2012-b). The capacity for movement is composed of
purposefulness, awareness of self, and continuity (Amidei, 2012-b).
Physiologic stability: A dynamic state, including the variability of physiological
parameters and their ability to regulate maintaining balance after exposure to a disruptive
element (Lebel, Alderson, & Aita, 2014).
Evidence-based nursing: A term that is used interchangeably with evidence-based
practice (White, Dudley-Brown, & Terhaar, 2016).
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Evidence-based practice (EBP): “A paradigm and lifelong problem-solving
approach that involves the conscientious use of the best available evidence, with clinical
expertise and patient values and preferences to improve patient outcomes” (Melnyk &
Fineout-Overholt, 2015, p. 604).
Relevance to Nursing Practice
History of the Broader Problem in Nursing Practice
Evidence-based practice is fundamental to decision-making in clinical practice.
Organizations developing and supporting initiatives to promote the advancement of
evidence-based practice include Sigma Theta Tau International, the American
Association of Critical-Care Nurses, the Institute of Medicine, and the Magnet
Recognition Program of the American Nurses Credentialing Center. Because of the gap
between new knowledge and implementation of that knowledge to improve patient care
the American Association of Critical-Care Nurses provides resources for clinicians
including practice alerts and a hierarchal rating system for levels of evidence for nurses
to determine the strength of research studies, assess findings, and evaluate the evidence
for integration into best practice (Peterson et al., 2014). By the year 2020, 90% of clinical
decisions will come from accurate, timely, and up-to-date clinical information reflecting
the best available evidence (Institute of Medicine, 2009).
A systematic literature review of physiologic assessment measures for mobility
readiness of adult patients in critical care may change nurse-driven mobilization practices
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locally, which could lead to a state-level change. Integrating the current science and best
evidence on physiologic assessment measures can reduce the unpredictable outcomes of
mobilization practices related to physiologic stability, patient functional capacity, and
patient safety (Adler & Malone, 2012). Acquiring evidence-based physiologic assessment
measures to determine mobility readiness for critically ill adult patients can facilitate safe
clinical decisions around patient mobility level, readiness, and frequency. Evidencebased
practice is an essential nursing competency (IOM, 2010). Integrating evidencebased
practice continues to be the challenge.
The Society of Critical Care Medicine published the ABCDEF, Bundle E,
addressing the physical effects of immobility critically ill patients face and strategies for
implementation of early mobility programs in any ICU (SCCM, n.d.). Bundle E provides
tools for comprehensive management of critically ill patients’ mobility, including a
mobility pathway with exclusion criteria for physiologically unstable patient types
(SCCM, n.d.). However, physiologic assessment measures are not present in the pathway
for patient mobility. Evidence identifies a lack of expert consensus and recommendations
on physiologic safety criteria for active mobilization (Hodgson et al., 2014).
Evidencebased physiologic assessment measures are overlooked by health care staff
when making mobility decisions.
Currently, the process to determine readiness for mobilization of critically ill
patients is specific to the organization, provider practice, physical therapist, or nurse.
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Standardized evaluation of a patient’s mobility throughout hospitalization is necessary to
determine progression or regression and to ensure avoidance of further physical
debilitation (Anderson, Sparbel, Barr, Doerschug, & Corbridge, 2018). Using an
evidence-based protocol coupled with up-front staff education leads to staff
empowerment, a sense of security, confidence, and ownership of the practice which
sustains adherence to and practice of the program (Anderson et al., 2018). At the
University of Michigan, a standardized mobility protocol incorporated safe patient
handling and mobility pre-assessment guidelines, mobility standards, equipment
guidelines, and documentation tools to get patients moving (Dickinson, Taylor, & Anton,
2018). The protocol adjusted for all patient populations by modifying the inclusion and
exclusion criteria, and the activities are grounded in evidence to prevent complications,
promote mobilization, and prevent patient and staff harm (Dickerson et al., 2018). A
multidisciplinary team developed and implemented a mobility order set with an
embedded algorithm to guide the nursing assessment of mobility potential in ICU and
Intermediate Care settings at a large community hospital (Drolet et al., 2013). The
protocol assessments empowered the nurse to consult physical therapy or occupational
therapy for patient mobilization (Drolet et al., 2013). The nurse-driven assessments
resulted in an increased rate of patient ambulation in the first 72 hours of a hospital stay
(Drolet et al., 2013). Many studies recommended further studies of nurse-drive
mobilization management of critically ill patients
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Current Nursing Practice for Mobilization of Critically Ill Patients
The current state of nursing practice and assessment measures for readiness for
mobilization includes a provider request or order and the nurse’s or respiratory therapist’s
clinical experience and observation of patient’s during activity. There is inconsistent
evidence to guide the ICU staff with clinical problems related to the patient’s functional
capacity, tolerance, and dynamic stability. There is a need for nursing practice
improvement in physiologic assessment measures to guide safe patient mobility practice,
which could guide nurses in the multidisciplinary collaborative decision-making process
involved in patient mobility management and associated patient care. Physiologic
stability and functional capacity should be incorporated in the decision to mobilize a
patient and in determining the appropriate mobility level (Amidei, 2012; Eakin et al.,
2015). Determining the progression of mobility and factors influencing the ability to
mobilize affect the safe, functional recovery of adults (Winkleman et al., 2012). Cultures
that support patient mobility continue to have variations in assessment, intensity, and
frequency of patient mobility (Corcoran et al., 2017). The recommendation is an early
mobility bundle containing physiologic assessment measures for mobility on every
patient every day to lessen immobility complications and decrease variability in care
(SCCM, n.d.). Implementing physiologic assessment measures that incorporate
evidencebased practice is an effective approach in helping nurses and other professions
with decision-making on mobility readiness and level (SCCM, n.d.). Management of
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mobility is complex and requires a consistent approach to application and timing to
maximize mobility benefits in a patient’s recovery.
Previous Strategies
Evidence shows critically ill patients are at risk for muscle weakness that often
results from the treatment the health care team is implementing to save a patient’s life
and the associated immobility. Immobility frequently results in reduced venous blood
flow in the pockets of venous valves, promoting inflammation and hypercoagulability
and risk for venous thrombosis (Engers et al., 2014). Mobility measures are
fundamentally important areas of critical care practice, and the adult clinical practice
guidelines from the Society of Critical Care Medicine, Bundle E, addresses early
mobility and exercise (SCCM, n.d.). The Bundle E element identifies strategies for
successful implementation of early mobility and prevention of physical deficits
associated with immobility (SCCM, n.d.). There are a variety of approaches used to
avoid patient immobility and muscle weakness based on physician preference, the
resources available, and the assessment of providers, nursing staff, and physical therapy.
Guidelines for mobility and assessment are beneficial in critically ill adult patient care
delivery and outcomes.
ICU patients lose approximately 2% of muscle mass every 24 hours (Doherty &
Steen, 2010). As a result, the patient experiences a significant reduction in skeletal
muscle force, indicating the assessment of physiologic and functional capacity is an
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important step before mobilizing (Doherty & Steen, 2010). Determining the optimal
timing and progression of mobility and factors influencing the ability to mobilize affect
the safe, functional recovery of critically ill adults (Winkleman et al., 2012). Early
mobilization restores function, and passive movement is appropriate when a patient’s
physiologic assessment identifies limitations to active involvement in mobility
(Stockley, Morrison, Rooney, & Hughes, 2012). Functional and physiologic capacity
mobility assessments vary and include the use of exclusion criteria, family reports of
previous mobility levels, and the use of a variety of balance and strength assessments to
determine a patient’s readiness for mobilization (McWilliams et al., 2015). Despite
evidence supporting early mobility benefits to the patient’s recovery, timing, frequency,
and application of mobility vary, affecting a patient’s recovery. A nurse-driven guideline
or protocol that facilitates comprehensive physiologic assessment to determine mobility
readiness is needed to address the gap in determining patient readiness and safety.
Local Background and Context
Summary of Local Evidence
The practicum site for this project serves as a large academic teaching facility in
an urban area on the west coast. It consists of multiple critical care units on two
campuses. Due to the varied opportunities for experiences in critical care, educational
advancement, and translation of evidence into practice nursing and health care staff from
the United States and other countries seek opportunities to be part of the health care
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team. Despite evidence-based practice and utilization of the latest evidence available to
provide patient care quality, consistent, evidence-based patient mobility practice,
including physiologic readiness assessment, remains an issue, and needs improvement.
An identified need is a consistent nurse-driven physiologic assessment to determine
patients’ readiness for mobility and mobility management. There is also a pressing need
to adapt nurse-driven physiologic assessment guidelines to determine mobility readiness
and management to support patient safety and the use of the latest available best
practices while enhancing nursing practice.
Institution Context
The practicum site provides health care services to adult, pediatric, and neonates
with acute and chronic conditions. The vision of the practicum site is to be the number
one health care provider on the west coast, providing quality evidence-based, innovative
care to patients, families, and the community. The practicum site believes in patient
advocacy, and evidence-based care focused on quality outcomes and patient and staff
safety. The unit for this DNP project’s intent is a 24-bed adult critical care unit. Safe
early mobility is essential for 100% of the critically ill adult patients admitted to the unit
to help facilitate the management of their underlying condition and minimize muscle
weakness and promote quality outcomes.
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State/Federal Context
The Evidence-based Practice Center Programs of the Agency for Healthcare
Research and Quality explore clinical issues focus on improving healthcare quality,
safety, efficiency, and effectiveness by synthesizing evidence and facilitating the
translation of evidence-based research findings (AHRQ, 2020). In 2019 two programs
exist on the west coast near my practicum site. Information from AHRQ’s research is
available to support informed healthcare decisions, improve the quality of healthcare
services, and to provide technical assistance to facilitate quality improvement tools
(AHRQ, 2020). Each state’s nurse practice act helps ensure the safe delivery of nursing
care. The safety and delivery of nursing care will improve by complying with the State
Board of Nursing Practice Act and using evidence-based practice.
Role of the DNP Student
Student Professional Context
I practice as an advanced practice nurse and nursing leader in an adult critical care
unit at a large academic teaching facility. My role includes but is not limited to
assessing, mentoring, collaborating, and providing leadership to promote the delivery of
quality care to adult critical care patients. My role provides me with the opportunity to
promote the physiologic assessment of patients to determine mobility readiness that
promotes the health and wellbeing of patients and improved patient outcomes while
supporting safe patient mobility. Promoting evidence-based practice and change to
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improve quality patient care is a key role of a leader and an advanced practice nurse
(AACN, 2006). The project took place at a large academic teaching facility on the west
coast. The population served at this site includes critically ill adult patients with various
diseases requiring care in an intensive care unit, conditions related to medical
complications and surgery. The practicum site and DNP project have no relationship to
my employment.
Student’s Role in the Doctoral Project
My goal and focus during this DNP project were to investigate the current best
practices in literature for early mobility readiness assessments to facilitate the safe
mobility of critically ill patients. Additionally, what are the best evidence-based
practices available for the practicum’s site use that may improve mobility readiness
assessment, nursing confidence in collaboration with healthcare team on mobility
management, and safe mobility practices. Based on the evidence and information
reviewed, the summary of the evidence and recommendations may help enhance and
improve nursing patient mobility practice and assessment at the practicum site.
Collaboration and stakeholder buy-in are goals of this DNP project as well as facilitating
change that will improve patient care quality concerning patient mobility outcomes.
Student Motivation
As a leader and advanced practice nurse, I seek to used advanced communication
skills and collaboration to foster evidence-based practice change, which improves patient
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care quality and also mentors and inspires others to be change agents valuing best
practice improvements. As both a clinical nurse specialist and leader, my role includes
utilizing evidence-based practice managing the care of complex and vulnerable
populations while educating and supporting interprofessional staff. My passion for
physiologic assessment needs to determine a patient’s early mobility comes from a need
expressed by my peers, colleagues, and my practice for a standard that maintains patient
safety during mobility management. This need instilled a desire to seek what current
evidence is known about the problem to help identify best practices for mobility
management for adult critically ill populations.
Potential Biases
Melnyk and Fineout-Overholt (2015) indicate bias is possible at any point during
a study, and positive results are more likely to be published than studies with negative or
inconclusive results. Bias prevents objective consideration reinforcing the need to be
aware of possible sources of bias. Potential bias for this DNP project is for this student to
note and consider stakeholder opinions and values about early mobility management.
Summary
Nurses care for patients with competence and diligence to provide excellent care
advocacy for patients. An evidence-based practice model facilitated the literature review
of physiologic assessment measures to determine patient mobility readiness and safe
early patient mobility management. The DNP project may result in the adoption of a
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nurse-driven guideline for nurses to guide their assessment and practice around early
patient mobility. The following section will discuss and include the of evidence used to
guide the synthesis of the systematic literature review. The analysis and synthesis of
evidence for this DNP project will also be addressed in this section.
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Section 3: Collection and Analysis of Evidence
Introduction
Early mobility management in the critically ill adult population is challenging
because multiple assessments and methods determine the severity of illness, care
requirements, and the efficacy of mobility treatments. The objective of this DNP project
was to investigate and synthesize evidence that can be used as a recommendation to
adopt a standardized mobility readiness assessment as part of early mobility
management in the ICU. During this project, I reviewed and identified evidence-based
physiologic assessments and approaches for early mobility management of critically ill
adults and the nurse’s role with regards to mobility management. The nursing staff at the
site were often overwhelmed when making decisions about whether patients are ready
for mobility or if they can be safely participating in the activity. Patients and families
depend on nurses to provide evidence-based care focused on quality outcomes healing
one patient at a time. This DNP project assists nurses in providing the safest care to
patients surrounding early mobility while collaborating with the healthcare team. In this
section, I provided the sources of evidence and an overview of the methodology used in
evidence searches, such as the process of selecting and exclusion criteria, as well as
analysis and synthesis of the system used to organize and record the evidence obtained.
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Practice-Focused Questions
The current practice of mobility management at the practice site comes from
patient orders without the adoption of an evidence-based physiologic assessment to guide
to patient mobility management. Patients may be negatively affected by the lack of
evidence-based mobility readiness measures. The practice-focused questions for this
doctoral project include:
4. What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
5. What is the effect of using physiologic assessment measures on determining
patient readiness for safe mobility?
6. What is the effect of using physiologic assessment measures on the incidence and
safety of patient mobility events?
Population: Critically ill Adults 18 years and older
Intervention: Systematic review of the literature for Physiologic Assessment Measures
for Mobilization Readiness
Comparison: The normal routine for Mobility Assessment
Outcome: In critically ill adults 18 years and older, does the intervention of physiologic
assessment measures for mobilization provide safe and effective patient physiologic
assessment measures for readiness for mobilization therapy?
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The project is significant to practice, as it is expected to reduce the variation in
physiologic assessment measures to determine early mobility readiness and management
for nursing and the health care teams’ practice with recommendations provided from the
systematic literature review.
Clarifying the Purpose
The purpose of this doctoral project was to evaluate and synthesize EBP on
physiologic assessment measures to determine early mobility readiness and management
best practice to make recommendations for adoption of a nurse-driven early mobility
management guideline in adult critical care. The approach aligned with the
practicefocused questions, as the evidence that was collected provided information that
supports a recommendation for EPB guidelines in the clinical nursing practice for
physiologic assessment measures to determine mobility readiness and management in
the critical care unit. The evidence-based data can provide a standard, already validated
measures for a nurse-driven early mobility physiologic assessment to determine mobility
readiness and management. As a result, this review can be implemented and used as the
best practice in early mobility management.
Sources of Evidence
The purpose of this DNP project included evaluating and synthesizing the best
available evidence relevant to nurse assessment for physiologic readiness for patient
early mobility and mobility management for recommendations to improve the existing
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nursing and health care team practice surrounding the care of critically ill adult patients.
The source of evidence used to address the practice-focused questions was current
literature. A review of the literature indicated that physiologic assessment to determine
early mobility readiness and management is a worldwide challenge in healthcare. The
systematic review of literature included textbooks, both primary and secondary sources
of peer-reviewed journal articles and published guidelines from CINHAL, PubMed,
Cochrane Library, Joanna Briggs Institute, and Medline. I used Walden Library and
Google scholar to identify resources in these databases. Available evidence addressing
the context of the systematic review includes the ICU Liberation, ABCDEF bundle E on
early mobility and exercise. Bundle E focuses on the physical deficits that ICU survivors
face and strategies for implementation of early mobility programs in any ICU (SCCM,
n.d.). Resources and reports from clinical specialty organizations, such as the American
Association of Critical Care Nurses, the Society of Critical Medicine, the Agency for
Healthcare Research and Quality, and the Institute for Healthcare Improvement, were
also reviewed for relevant information. Nurses, physical therapists, respiratory
therapists, and providers provided additional resource information. The evidence
included qualitative, quantitative, and mixed methods studies.
Relationship of Evidence to the Purpose
The purpose of this DNP project was to evaluate and synthesize the best available
evidence to recommend a nurse-drive mobility guideline and assessment. The evidence
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gathered from the literature provided the information needed to guide the
recommendation of the assessment and guideline. Multiple strategies assess mobility
readiness and help manage the early mobility of critically ill adults. An essential
literature search was exhausted to seek validation for the best practice concerning early
mobility readiness assessment measures and management.
Evidence to Address the Practice-Focused Questions
The collection and analysis of evidence facilitates the approach to decisionmaking
in evidence-based nursing practice. The articles selected came from a strategy search.
Keywords included early mobility, early ambulation, early mobilization, early
rehabilitation, assessment tools, assessment methods, assessing, guidelines, protocols,
practice guidelines, bundle, physiologic assessment, nurse-drive early mobility
management, ICU patient activity, hemodynamic stability, and evidence-based
guidelines for early mobility in critical care, early mobility patient interventions and
assessments, the effects of physiologic assessment measures on early patient mobility,
and physiologic assessment measures supporting safe patient mobility. Synthesizing all
evidence gathered will be crucial to obtaining information needed to answer the
practice-focused questions. The search procedure resulted in a total of 37 articles used
for this systematic review. The search procedure began by using CINAHL, and the
search keyword used was early mobility or early ambulation or early mobilization or
early rehabilitation.
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Databases and Search Engines
The Peer-reviewed articles were accessed from on-line databases, such
as
CINAHL, Google Scholar, Walden Library, Joanna Briggs Institute, Medline, Cochrane
Database, and PubMed. Also, official websites such as the Society of Critical Care
Medicine, the American Association of Critical Care Nurses, the Agency for Healthcare
Research and Quality, and the Institute for Healthcare Improvement were assessed for
additional resources and evidence.
Key Search Terms and Combinations of Search Terms
Additional search terms included keywords such as critically ill patients’ mobility
and activity, hemodynamic stability mobility assessment, ICU Liberation, ICU patient
mobility management, nurse-driven mobility bundles or guidelines in ICU, physiologic
stability assessment measures before mobility in ICU, safe patient mobility in ICU,
evidence-based guidelines for early mobility in ICU, and early mobility in adult ICUs.
The Scope of this Review
Gathering relevant sources of information from the literature search relating to
critically ill adult patients’ physiologic stability assessment measures and early mobility
management provide evidence for the recommendation for nurse-driven evidence-based
guideline. The searches considered peer-reviewed primary sources from 2010-2021 for
inclusion in the systematic review. Article selection criteria included if the author(s)
addressed early mobility management and assessment for mobility. Also, the selection
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considered articles relevant to the management of critically ill adult patients’ safe early
mobility. Articles were excluded if the articles were not relevant to early mobility
management, articles were not full-text articles, they were published before 2010, and if
they were not relevant to physiologic assessment measures or criteria to determine safe
early mobility.
Search Exhaustive and Comprehensive
The search was exhaustive, using various search terms and phrase combinations
that cover the practice-focused question and the target population. A review of abstracts
and articles’ reference lists occurred to ensure the search was exhaustive. The articles
selected were read in full to determine inclusion and exclusion based on the selection
criteria.
Institutional Review Board
The project is a systematic literature review, and the protection of human rights is
not an issue. An application for approval of the institutional review board from Walden
University was obtained to ensure that all rights are protected, 01-29-21-0758434.
Analysis and Synthesis
Systems used for Recording, Tracking, Organizing, and Analyzing the Evidence
Evidence was manually organized and documented in a Microsoft Word matrix
table. Table columns for each article include year published, author(s), title, purpose,
sample, design, and conclusions (see Appendix A). The project’s data organization
utilized the levels of evidence Melnyk hierarchy pyramid (Melnyk & Fineout-Overholt,
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2011; see Appendix B for illustration). The search procedure began by using CINAH
and Medline, and the initial search keyword used was early mobility or early ambulation
or early mobilization or early rehabilitation. The initial search resulted in a total of 3599
articles, narrowed down to 614 full text articles, narrowed down to 150 references
available, and further narrowed to 129 articles for publication years from 2010-2020.
Review of the 129 articles for relevance to the project’s practice questions, and inclusion
criteria resulted in 37 relevant articles. A PRISMA flowchart diagram will show an
illustration of the article’s selection procedure (see Appendix C).
Analysis Procedure
The analysis procedure used in this DNP project resulted in the evidence obtained
and will be categorized based on the strength of the evidence. The strongest available
evidence was selected to recommend a nurse-driven early mobility management
guideline. Data analysis will support the recommendation of a nurse-driven early
mobility management guideline, including physiologic assessment measures to
determine early mobility readiness. The JHEBP evidence level and quality guide was
used to grade the strength of reviewed evidence (Dang, et al., 2022).
Summary
A review of the current body of evidence on physiologic assessment and stability
in the mobilization of critically ill patients will answer how research and quality
improvement studies on mobilization in critical care address physiologic stability in
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decisions to mobilize patients and if there is a consistent, safe best practice. The goal of
this DNP project is to provide recommendations that can assist in addressing the lack of
nurse-driven early mobility management guidelines and physiologic assessment to
determine safe early mobility readiness of critically ill adult patients. Patient outcomes
and nursing practice in critical care units advanced by the evidence identified in this
systematic literature review. The DNP project addressing physiologic assessment
measures to determine early mobility readiness of critically ill adults and nurse-driven
safe patient early mobility management can improve safety in the healthcare
organization once implemented. The next section will include findings and
recommendations from the systematic literature review and their implications for the
practice-focused questions.
Section 4: Findings and Recommendations
Introduction
Nurses play a vital role in assessment and management of early mobility of
patients in the ICU. Early mobility management can be affected by multiple variables
including the experience level of the healthcare staff, assessment measures used to assess
mobility readiness, the level of nursing skills, as well as the patient’s physiologic and
hemodynamic response and status. The importance of EBP to the care nurse provide
includes improving the delivery of nursing care and patient outcomes. The gap between
implemented EBP and what occurs in practice can lead to poor outcomes; therefore, the
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ability to integrate evidence into practice is key in ensuring quality health care practice
(White et al., 2016).
EBP supports clinical decision making because it offers solutions to improve
health care quality and provide cost-effective care (Tucker, 2017). The absence of
evidence-based safe mobility guidelines and mobility readiness assessments affects
patient care decisions and outcomes. Guidelines have the potential to facilitate patient
care decisions, but due to inconsistent adoption in clinical practice guidelines have
limited affect and present a health system challenge (Kastner et al., 2011). Fundamental
to the practicum site to facilitate quality outcomes is evidence-based nursing practice
aligned with the latest research. Evidence-based guidelines also provide a variety of
structures that help ensure safe effective nursing care delivery. Evidence-based nursing
practice enhances knowledge sharing and collaboration across disciplines in solving
complex patient problems and decisions. Providing a summary of current research and
quality improvement on physiologic assessment guides nursing practice and other
disciplines in addressing the gap in clinical practice of critically ill patients’ readiness for
mobilization. A gap in nursing practice exists when an evidence-based readiness
assessment and practice guideline to support nursing practice in the management of early
mobility is not available. The purpose of this project was to examine and summarize the
benefits of evidence-based tools for physiologic assessment and stability in the
mobilization of critically ill patients. Synthesis of evidence relevant to physiologic
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assessment to determine mobility readiness and nurse-driven early mobility management
was completed to a improve the existing nursing practice of early mobility management
in the practicum site ICU.
The practice focused questions used to facilitate this DNP project
included:
4. What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
5. What is the effect of using physiologic assessment measures on determining
patient readiness for safe mobility?
6. What is the effect of using physiologic assessment measures on the incidence
and safety of patient mobility events?
Primary and secondary sources such as peer-reviewed evidence was used to support this
systematic literature review. Primary and secondary sources of peer-reviewed journal
articles and published guidelines were retrieved from Medline, PubMed, CNHAL,
Cochrane Library, and Joanna Briggs Institute. Available evidence used for the content of
the systematic review included the ICU Liberation, ABCDEF bundle E on early mobility
and exercise. Official websites of the Society of Critical Care Medicine, the American
Association of Critical Care Nurses, the Agency for Healthcare Research and Quality, and
the Institute for Healthcare Improvement were accessed for additional resources and
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evidence. The systematic review also included textbooks. Articles meeting the inclusion
criteria were used in the review.
The key word search terms used were early mobility, early ambulation, early
mobilization, early rehabilitation, assessment tools, assessment methods, assessing,
guidelines, protocols, practice guidelines, bundle, physiologic assessment, nurse-driven
early mobility management, ICU patient activity, hemodynamic stability, and
evidencebased guidelines for early mobility in critical care, early mobility patient
interventions and assessments, the effects of physiologic assessment measures on early
mobility, and physiologic assessment measures supporting safe patient mobility. Other
key words included in the search included critically ill patients’ mobility and activity,
hemodynamic stability mobility assessment, ICU Liberation, ICU patient mobility
management, nursedriven mobility bundles or guidelines in the ICU, physiologic stability
assessment measures before mobility in the ICU, and early mobility in adult ICUs.
Findings and Implications
The literature resulted in a total 3599 articles; 2985 were excluded due to lack of
full text; however, abstracts were reviewed for relevant information. From the screening
process, 464 articles were removed for lack of available references. The eligibility
involving the recent timeframe yielded 150 articles, which were further narrowed to a
publication timeframe 2010 to 2021. The analysis resulted in (N = 37) articles meeting
criteria for the review selection procedure (see Appendix C). The inclusion criteria for
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this systematic literature review included full-text articles addressing physiologic
assessment measures for mobility and articles relevant to early mobility guidelines and
protocols and barriers. Walden Library was contacted to explore access for full-text data.
Systematic Reviews were included in this literature review. Adler and Malone
(2012) conducted a systematic review of 15 studies on early mobilization in the ICU
using Sackett’s Levels of Evidence to rate the strength of the research of which one study
was Level 1 evidence, four were Level 2, one was Level 3, and nine were Level 4. The
studies included prospective and retrospective design of which included randomization.
The systematic review identified six criteria summarized from the literature for
terminating a PT/OT mobilization session. Termination criteria included parameters
concerning heart rate, pulse oximetry, blood pressure, respiratory rate, mechanical
ventilation, and alertness/agitation and patient symptoms (Adler & Malone, 2012).
Alaparthi et al. (2020) reviewed 56 studies in order to summarize the different aspects of
mobilization in the ICU of patients with or without mechanical ventilation. The review
identified safety measures including criteria for respiratory, cardiovascular, neurological
considerations, and others for early mobilization in the ICU. Other considerations were
identified as no unstable fractures or bony instability, not on continuous dialysis, no deep
vein thrombosis, body temperature <38.5, and no active bleeding (Alaparthi et al., 2020).
Alaparthis et al. (2020) also complied from studies red and green signals for active
mobilization of mechanically ventilated patients identifying which were for were for
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exercises in bed and which were for exercise out of bed. Hodgson et al. (2014) reviews
analyzed safety criteria for active mobilization of mechanically ventilated critically ill
adults resulting in expert consensus using a red, yellow, green coding system to
operationalize adverse event risk. Red indicated significant risk during mobilization,
yellow indicated mobilization after measuring risk versus benefit, and green mobilization
could be performed with a low risk (Hodgson et al., 2014). The review also summarizes
strategies for overcoming barriers including hemodynamic instability as a barrier with
strategy being a stepwise approach (Alaparthis et al., 2020). Costa et al. (2017) reviewed
49 studies after analysis identified four barriers to ABCDE implementation for adult
patients in the ICU: patient related (instability and safety concerns), clinician-related
(lack of knowledge and staff safety concerns), protocol-related (unclear and cumbersome
protocols), and ICU contextual barriers (interprofessional team coordination). Patient
instability and safety concerns included hemodynamics, treatment-related adverse events,
and physiologic patient issues (Costa et al., 2017). Patient safety issues considered issues
as diarrhea, fatigue, leaking wound, patient weight or size, confusion, agitation, and
imminent death (Costa et al., 2017). Costa et al. (2017) identified use of the domains as a
potential differential diagnosis for implementation of the ABCDE bundle. Dubb et al.
(2016) synthesized data from 40 studies to identify barriers to early mobilization and
strategies to overcome barriers. The most common patient related barrier was
hemodynamic instability identified in 20 (50%) studies then vascular access devices,
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tubes, and drains in 18 (45%) studies (Dubb et al., 2016). Strategies to address patient
related barriers for early mobilization included defining inclusion and exclusion criteria
for mobility, development and implementation of protocols, and interdisciplinary
collaboration (Dubb et al., 2016). Parry et al. (2017) analysis of 89 papers identified five
major themes patient physical and psychological ability to perform physical activity,
safety influences hemodynamic and respiratory physiologic stability culture and team
influences, motivation and beliefs about physical activity from patients, family, and
health care providers, and environmental influences (Parry et al., 2017). Development of
physiological stability guidelines for rehabilitation helped enable patient safety and
mobility (Parry et al., 2017). Reviews recommended protocols and a structured approach
or assessment to physiologic barriers to mobility using inclusion and exclusion criteria
based on patient assessment.
The remaining studies address the benefits of early mobility on patient outcomes
and patient mobility readiness measures. A non-randomized experimental pilot using a
mobility readiness protocol had eleven patients who passed and thirty-five patients who
failed the protocol for hemodynamic parameters including twenty-four with heart rate
above 120 beats per minute, seventeen with PEEP above 10cm H2O, and seventeen with
a PAO2 to FIO2 ratio smaller than 250 mmHg (Comradie et al., 2017). The readiness
protocol was found to be too strict when used to identify patients who could tolerate an
upright position using mean arterial pressure and oxygen consumption via venous oxygen
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saturation (Comradie et al., 2017). Cooper et al. (2021) study of 105 patients in a
medical intensive care out of 191 orally intubated were eligible for out of bed activities
using criteria based on hemodynamic stability found mobility practice still nonexistent.
All mobility readiness criteria must be met prior to out of bed activities including RASS
score, mean arterial pressure, FIO2, Spo2, systolic blood pressure, no titration of
inotropic medications, and PEEP (Cooper et al., 2021). Colwell et al. (2018) used a
severity of illness scale from one to four to determine mobility readiness, achieved
mobilization in more than 50% of the patients, and mobility complications included
transient desaturation, tachypnea, and emesis. Staff reported the most significant mobility
implementation barrier was the perception of physiologic instability and the additional
staff need for mobility activities (Colwell et al., 2018). Drolet et al. (2013) study included
eall patients were screened for mobility readiness and exclusion criteria to determine
mobility readiness was incorporated on order sets with defined criteria to prevent patient
desaturation and excessive work of breathing.
Safe patient handling is elemental to many study guidelines and protocol when
determining readiness and activities. Dickinson et al. (2018) study of integrating a
mobility program and safe patient handling included patients being evaluated for
inclusion in the mobility protocol and exclusion criteria are used to determine the need to
withhold mobility. Mobility program assessment questions guide staff on mobility phase
and safe patient handling equipment use (Dickinson et al., 2018). Eakin et al. (2015)
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described overcoming safety and mobility barriers including hemodynamic instability,
rising vasopressor requirements, accidental removal of an endotracheal tube, and line loss
using a model that includes engaging, educating, executing, and evaluating. Engel et al.
(2013) from a retrospective analysis of data indicated mobility and treatment starts by
identifying if there are exclusion criteria present and if yes assess ability to tolerate and
participate in mobility activities and if no assessment criteria determine mobility level.
Hickmann e al. (2016) an observational study on mechanically ventilated patients and
non-mechanically ventilated used a mobility protocol with levels zero to four taking into
account RASS, Glascow, and muscular strength and mobility provided at least once in
81% of all patients within 24 hours of ICU admission. Limiting factors for the study
included instability for 709 patients during bed to chair mobilization with severe
physiological in 42, hemodynamic in 21, respiratory in 5 and neurological in 16
(Hickmann et al., 2016). Hodgson et al. (2014) a prospective observational study on an
ICU mobility scale from existing studies and the John Hopkins scale adding more levels
of mobilization and the levels of assistance required found the maximum level of
mobility not achieved by the cohort and measures to determine stability and readiness
were no included. John Hopkins Early Mobility Toolkit Your Work Plan for Translating
Evidence into Practice (2020) includes a medical screening algorithm to evaluate patients
for mobility beginning with the ability to open eyes to verbal stimulation and assessment
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for mobility to occur within 24 hours of admission including neurologic, respiratory, and
cardiovascular elements.
Klein et al. (2018) a prospective longitudinal study includes an early progressive
mobility protocol to guide nursing decisions with patient readiness criteria for identified
stepwise mobility progression including four progressive mobility milestones from 16
mobility levels. Krupp et al. (2019) an exploratory descriptive study looked at factors
nurses in the ICU consider when making decisions about patient mobility and concluded
mobility programs should begin as soon as the patient demonstrates physiologic stability
and observations of patient’s strength, mental status, and physiologic response to activity
influence maintaining or progressing mobility. An additional prospective study with a
nonexperimental design used a contrasted-group approach, inter-rater assessments, and
expert agreement approach to assess the Banner Mobility Assessment Tool (BMAT) for
Nurses in use provided evidence the tool is valid in assessing a patient’s mobility status
(Boynton et al., 2014). When consulted physical therapists guide the mobility plan of
care and progress completing mobility and gait assessments creating a disconnect
between actionable items for nursing and the desire to increase mobility (Boynton et al.,
2014). Lin et al. (2018) a prospective observational study of an early mobilization
protocol identified discontinuation of mobilization criteria was also a criterion for
readiness including hemodynamic and respiratory parameters as symptomatic heart rate,
blood pressure, arrhythmias, oxygen saturation, respiratory rate and mechanical ventilator
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asynchrony. Respiratory, cardiac, and consciousness parameters were identified for
advancing the protocol and the incidence of adverse events for all sessions was 2.2% out
of 587 (Lin et al., 2018).
Mobility goals should be included for patients eligible for activities. Messer et al.
(2015) a correlational descriptive study identified exclusion mobility readiness criteria
including unstable hemodynamic status, two or more vasopressors, neuromuscular
blockade, physician order for bedrest, and end of life. Dangling was the only specific
activity after nursing education that increased despite a goal of all patients who met
inclusion criteria receive a level of intervention besides turning (Messer et al., 2015).
Milano et al. (2014) used a decision tree flow chart after a physician gave medical
clearance to start mobility progression by a nurse or physical therapist using care boards
to document why, how it is done, and what the patient needs to do. Perme et al. (2014)
describes a mobility score assessment tool including potential mobility barriers as bed
mobility, transfers, gait, endurance, and functional status with high scores indicating few
mobility barriers and decreased assistance. Patients on low levels of vasopressors were
five times as likely to be mobilized and those on moderate doses were twice as likely to
be mobilized (Perme et al., 2014). Rebel et al. (2019), in their retrospective cohort study,
found patients were mobilized on one-third of vasoactive days found in 195 episodes of
mobilization patients were more likely to experience an adverse event with a low mean
arterial pressure, higher SpO2 and higher FiO2. The Society of Critical Care Medicine,
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ICU Liberation Bundle E (2013) identifies maximal activity includes hemodynamic
stability, an awake patient, and a patient that was walking before admission and absolute
contraindication to is hemodynamic instability defined as a patient on escalating doses or
multiple vasopressors. Sommers et al. (2016 a prospective observational reliability and
validity study indicated the assessment of patients in the ICU is complicated by
pulmonary and hemodynamic conditions needing medications and invasive equipment
with changing medical situations and the ability to perform mobility activities changes
within an hour due to fatigue and exertion. Whelan et al. (2018) a quasi-experimental
study used ten domains to measure physical function using the Chelsea critical care
physical assessment (CPAx) tool in the ICU graded zero to five to identify problems and
address. The CPAx tool is an outcome measure that responds to change designed to
assess physical ability, respiratory function, cough, bed mobility, supine to sitting on the
edge of the bed, dynamic sitting, sit to stand, standing balance, transferring from bed to
chair, and stepping and grip strength (Whelan et al., 2018). Zomorodi et al. (2012)
completed a pilot study included a mobility decision tree flow chart beginning with is
patient hemodynamically stable and if no mobility is not indicated and if yes evaluate if
vital signs stable in bed with rolling for bed linens changes and hygiene then begin
activity. Stiller’s safety for mobilization guidelines beginning with level one with six
total activity events and during mobility activities nurse’s role included monitoring blood
pressure, heart rate, oxygen saturation, and lines and tube safety (Zomorodi et al., 2012).
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Evidence-based programs for mobility support quality outcomes. The Agency for
Healthcare Research and Quality for Advancing Excellence in Healthcare Safety Program
for Mechanically Ventilated Patients, Nurse Driven Early Mobility Protocol (2019)
contains an ICU mobility screen with exclusion criteria and mobility to begin when the
patient meets criteria including follows the keys to prevent excessive work of breathing
and desaturation. Balas et al. (2012) indicates parameters used to assess patients’
readiness for mobility include neurologic, respiratory, circulatory, and central line
contraindications and patients not eligible or have activity halted for an adverse event are
reassessed every day and thus eligible begin activity. Boyton et al. (2014) looked at
clinical practice guidelines for mobility without determination criteria for patient
readiness and noted staff injuries decreased after implementation and increased nurse use
of mobility guidelines in patient activity. Clinical practice guideline for mobility along
with a mobility champion providing knowledge of the impact of immobility can support a
seven progressive step mobility plan for patients (Bruce & Forry, 2018). Campbell et al.
(2015) included contraindications for initiating and continuing mobility along with
detailed steps to prepare for mobility and offered evidence that high fidelity simulation
builds confidence in early mobility collaborations around patients that can occur during
mobility events.
Barriers, patient assessments, and patient conditions limit mobility activities.
Costa et al. (2017) identified ABCDE barriers including patient instability and safety
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concerns, clinician related including staff safety concerns, lack of knowledge, protocol
related, and ICU contextual barriers. Patient related issues include hemodynamics,
treatment related adverse events, and physiologic patient issues (Costa et al., 2017).
Costa et al. (2017) Identified barriers, grouped into four domains as a differential
diagnosis checklist to assess barriers to ABCDE implementation. Engel et al. (2013)
three medical center’s quality improvement mobility projects identified patient
assessment for exclusion criteria and if patient able to properly attend to tasks and
inclusion if patient verbal or manual stimulation with an identified RASS and further
considerations include patient remains alert, demonstrates trunk control, and vital signs
are acceptable. Klein et al. (2018) a quasi-experimental a quality improvement project
used an inpatient algorithm combining the John Hopkins Highest Level of Mobility Scale
and the Activity Measure for Post-Acute Inpatient Mobility Short Form to guide the
nursing team on setting mobility goals. The Activity Measure for Post-Acute Inpatient
Mobility Short form six questions quantify functional limitations based on direct
observation or clinical judgement of needed from another during activities as turning,
sitting on the edge of the bed, transfer from bed to chair, standing from chair, walking in
the room, and climbing three to five steps (Klein et al., 2018). McWilliams et al. (2015)
identified mobility for ventilated patients should include sitting on side of bed when
appropriate within the first five days allows assessment of sitting balance, exercise
capacity and physiological stability with six exclusion criteria and five restrictions to
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edge sitting. Before beginning activity, the protocol assessed for RASS score and/or
presence of contraindications to determine use of passive or active mobility measures
(McWilliams et al., 2015). Schallom et al. (2020) a staggered quality improvement
project using the American Association of Critical Care early mobility protocol begins
with step one screening for safety and evaluating patients every 12 hours for myocardial
and oxygenation stability, vasopressor use, vascular access, engaging to voice, and
neurological/ortho/wound stability findings included increased mobility levels. The four
mobility levels included goals at each level and measurements during phase one of the
project included CAM-ICU twice daily and the highest and lowest RASS score in
24hours (Schallom et al., 2020). Hemodynamic instability is one of the most common
perceived patient-related barriers limiting the practice of early mobilization (Alaprrthi et
al., 2020). Physiologic assessment to determine mobility readiness is a clinical risk
assessment focusing on improving quality and safety by identifying circumstances that
put patients at risk (Asefzadeh et al., 2013). Conradie et al. (2017) a nonrandomized
experimental pilot evaluated the feasibility of a protocol using hemodynamic parameters,
mean arterial pressure, and central venous oxygen saturation of eleven patients in the
baseline line position and then again at 0.3 and 10 minutes in a therapeutic upright
position found the protocol was to strict. One hundred and thirty-eight patients were
screened with 10 excluded for logistical reasons, 82 patients excluded based on exclusion
criteria, and 35 failed the protocol (Conradie et al., 2017). Reasons for failing the
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protocol included a heart rate above 120 beats per minute (n = 24), PEEP above
10cmH2O (n-17), and PaO2/FiO2 ratio smaller than 250mmHg (n = 17) (Conradie et al.,
2017).
Limitations/Potential Impact on Findings
Most of the studies resulted in improvement in patient’s outcomes with the
exception of a study where 35 patients failed the protocol and the most prevalent reason
was a heart rate above 120 beats per minute (n=24), a PEEP above 10cm H20 (n=17), and
a PAO2/FiO2 ratio smaller than 250 mmHg (n=17) (Comadie et al., 2017). Krupp et al.
(2019) also found variations in nursing practice including hesitancy to be the first to
mobilize a patient and most critically ill patients did not have a mobility goal, and
decisions to mobilize were based on a nurse’s decision instead of an established standard
of care along with nurse education about mobility does not increase the frequency of
patient mobility. Messer et al. (2015) study identified after education of MSICU nurses
the 39% of the 75 potential mobility events resulted in some type of mobility increased to
only 60% of the 85 potential and the goal of all patients who met inclusion criteria
receive some level of intervention besides turning was not met. Moraes et al. (2019)
found resistance to change until the proposed concept is consistent and reproducible in
low sample size and effect size. Zomorodi et al. (2012) a pilot study with a sample size
of three limited the interpretation of the results even though the study helped identify
efficacy of the protocol.
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Implication for Social Change
This systematic literature review supports the need for available evidence-based
nurse driven readiness assessment and guideline for nurses to collaborate with the
healthcare team in the management of safe early patient mobility. An adaption of a
mobility readiness assessment and evidence-based early mobility practice guideline will
result in the enhancement of nursing practice supporting quality patient outcomes. Nurses
will be able to monitor, assess, and measure the effects of interventions in the patient’s
care guided by evidence (White et al., 2016). This systematic literature review addresses
the gap between mobility readiness assessments and early mobility practice which will
ultimately improve the safety and out comes at the local clinical practicum site. This will
impact positive social change and nursing practice.
Recommendations
After analyzing and synthesizing the data collected in this systematic literature
review for the project it was concluded the project will have an influence on the nursing
practice at the project site. The recommendations concluded from this systematic
literature review revealed the need for additional studies on comprehensive mobility
readiness measures and management to be conducted using the adult critically ill patient
population. Further studies will help validate the implication of mobility readiness
assessments and safe early mobility management in the care of critically ill adult
population.
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Plan to Extend Beyond the DNP Project
The DNP project will be continued post the doctoral phase in collaboration with
the health care team and local IRB office to operationalize early mobility readiness
assessment and a nurse-driven guideline for early mobility for critically ill adult patients.
Furthering the project will require time and collaboration with key stakeholders. Next
steps will include piloting the project and evaluating the effectiveness of the project prior
to full implementation estimating six months to a year from pilot to full implementation
and continued follow thereafter.
Strengths and Limitations of the Doctoral Project
Knowledge gained throughout the project process is a strength of the doctoral
process. A large source of evidence and data with positive outcomes was found in the
literature in the critical ill adult population on early mobility and mobility readiness
including barriers. There is less evidence in the literature regarding the impact of
mobility readiness assessments impact on early mobility management in the adult
critically ill patient population. Benefits of the project include sharing of information with
stakeholders and frontline nursing staff as well as the leadership team within the project
site and critical care nursing associations. The project summary can be used to help
nursing leadership and healthcare staff with decision making on mobility initiatives in
improving clinical practice and patient care. Limitations of the project include the lack of
research studies on mobility readiness assessments impact on patient outcomes and
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delays in mobility in the critically ill patient population. This project benefit is validated
in the adult critically ill patient ICUs beyond the project site ICU.
Recommendations for Future Projects
This review identified the need for more studies on the impact of mobility
readiness assessment on critically ill patient outcomes with mobility guidelines. The
analysis and synthesis of the project found several studies demonstrated the lack of
evidence in early mobility management patient assessment for readiness to mobilize. The
results of the review concluded the adoption of an evidence-based practice mobility
guideline including readiness assessment improves positive patients’ outcomes and
nursing practice. Further research is needed in mobility readiness criteria since this
review produced lack of comprehensive guidelines in the adult critically ill population in
the ICU and studies comparing comprehensive guidelines.
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Section 5: Dissemination Plan
EBP is essential in nursing practice and researching incidence and validity of
early mobility management can help identify plans to effectively disseminate new
knowledge and information. Quality patient outcomes are dependent on translating new
knowledge into practice. Early mobility readiness assessments included in early mobility
guidelines is challenging due to limited published literature and the lack of consistent
nursing practice concerning early mobility. The purpose of this project was to evaluate
and synthesize evidence on mobility readiness assessments and nurse-driven early
mobility management, which could lead to a recommendation that would improve early
mobility management in the ICU. The findings of this project were intended to inform
nursing and healthcare leadership and provide recommendations for adopting EBP for
management of early mobility and mobility readiness assessment. The synthesis of this
project’s results can be disseminated to the practicum site leaders through the literature
review project.
Audiences for Dissemination
The nursing staff and healthcare team at the practicum site are the primary
audience for this project dissemination. Stakeholders involved in this project include the
Vice President of Nursing, the Director of Nursing, and the practicum site mentor. An oral
PowerPoint presentation will be used to disseminate the project findings and
recommendations to the intended nursing staff and leadership. Findings from the project
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may promote and support early mobility management and other changes in nursing
practice for the practicum site ICU. Collaboration and sharing knowledge learned from
the findings of this project with other ICU units includes a future poster presentation and
submission of an abstract to several critical care journals of interest.
Analysis of Self
My experience in the DNP program started with a need to grow and continue
lifelong learning postmasters, and a need to continue on a journey for self-improvement
and as a champion of EBP. Sharing and promoting EBP is a passion which ultimately
improves nursing practice and patient outcomes. Critical thinking and problem solving is
grounded in EBP. Collaboration with the healthcare team and nursing colleagues helped
identify my DNP project focus as I heard areas of concern and practice needs around
patient readiness assessment and mobility management. I have gained great appreciation
for EBP from my previous experience as a clinical nurse specialist and realize
evidencebased practice is not part of many nurses’ clinical practice. My DNP program
experiences have reinforced the importance of EBP throughout. My doctoral program
journey has provided growth for me professionally and personally.
My professional role in nursing is an advanced practice nurse and leader of an
ICU and an Intermediate Care Unit. Over the years of my career, I have worked as a staff
nurse in both ICU and PACU, a clinical nurse specialist in Critical Care, and as a nurse
leader. Each role has shaped my career and prepared me for where I am in nursing today
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as a professional and nurse leader. My goal through this program was to analyze existing
EBP concerning mobility management and patient readiness assessments for mobility to
adapt an evidence-based mobility management practice guideline that may assist in
decreasing variations in practice for adult critically ill patients. Resistance to change is an
ongoing issue in clinical practice and a challenge I anticipated because adopting EBP has
barriers despite improving patient outcomes. During DNP practicum experiences and
courses, I have learned and been exposed to strategies to address resistance to change.
My leadership experience has provided many opportunities to successfully implement
EBP.
Summary
Safe early mobility management is challenging yet essential component of care
for the adult critically ill patient population within the ICU. Patient outcomes and
complications depend on decreasing immobility and the deconditioning associated with
immobility in the ICU. During this project, I conducted a systematic literature review to
examine and summarize evidence that can be used to recommend a nurse-driven
guideline including readiness assessment for early mobility of critically ill adults in the
ICU. This systematic literature review can provide nurses with a tool useful in the
collaboration with the healthcare team to efficiently manage early patient mobility.
Research should be conducted to confirm these findings as well as to determine the
relationship between using evidence-based nurse driven assessment for mobility
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readiness, early mobility guidelines, and patient outcomes. As the recommendations of
the project findings are provided to the practicum site, it rests with the practicum site to
implement the project.
Mobility is a necessary element of care provided to critically ill adults. Safe
patient mobility helps to ensure a patient does not experience complications due to
immobility. Patient mortality increases with complications. Patient safety and clinical risk
management is an element of clinical governance and includes identifying the
circumstances and opportunities that put patients at risk of harm and acting to prevent or
control risk (Asefzadeh et al., 2013). Early progressive mobilization of critically ill
patients is feasible, safe, and results in benefits including functional outcomes, and
reduced intensive care unit (ICU) and hospital length of stay (Hodgson et al., 2014).
However, weakness begins with serious illness, and effects from immobility and
weakness are associated with prolonged mechanical ventilation, ICU length of stay, and
1-year mortality (Latronico et al., 2017). Physical activity may mitigate weakness and
muscle damage from critical illness, but critically ill patients may have limits to their
activity tolerance (Amidei, 2012a). Despite knowledge of the harmful effects of
immobility on multiple body systems, the ICU is a challenging and difficult environment
where many barriers exist to mobilizing critically ill patients (Adler & Malone, 2012).
At the practicum site for which this Doctor of Nursing Practice (DNP) project was
completed, critically ill patients’ mobility management orders would come from a
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collaboration between the healthcare team on daily rounds based on the priority placed on
mobility, a process which led to inconsistent practice and patient outcomes.
Attending to the mobility of critically ill patients is challenging. The tenuous
dynamic status of critically ill patients and their physiological derangements can result in
adverse hemodynamic responses to activity and mobility (Adler & Malone, 2012). It is
not uncommon for deconditioned critically ill patients with limited physiologic reserve to
respond to activity and exertional stress with changes in hemodynamic status. Patient
changes include activity intolerance as fainting, changes in blood pressure and heart rate,
and inability to support their body weight (Amidei, 2012a). As such, this project sought to
identify evidence-based practices addressing enhanced and safe mobility in critically ill
patients.
Physiologic Stability and Functional Capacity
The physiologic stability and functional capacity of critically ill patients impact
mobility readiness and level. Nursing strives to incorporate levels of safe mobility in care
based on multiple assessments including physiologic concerns (Amidel, 2012a).
Professionals in nursing and health care endeavor to decrease the length of stay in the
ICU and hospital, increase positive patient outcomes, and decrease costs associated with
care. Guidelines have the potential to facilitate patient care decisions and the
implementation of evidence-based practice concerning safe patient mobility, but due to
inconsistent adoption in clinical practice guidelines have limited impact and present a
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health system challenge (Kastner et al., 2011). Having an evidence-based patient
guideline or tool for physiologic assessment measures for mobility readiness in critical
care at the practicum site may support collaborative efforts of critical care nurses and the
healthcare team to provide quality care and safe, effective mobility measures.
Problem Statement
Local Nursing Practice Problem
The current practice of mobility management comes from patient orders without
the adoption of an evidence-based physiologic assessment guide to support safe
mobility. Patient mobility management is affected by many variables, including patient
physiologic stability, alertness, and strength, and the experience and skill level of staff
caring for the patient. The current local nursing practice problem is that mobility
assessment and management differ based on the healthcare team members caring for
patients and the ICUs where patients receive care. The project site has assessment tools
for nurses to address some aspects of mobility management; however, comprehensive
nursing guidelines, including physiologic assessment, are not currently in use. The
nursing staff feel pressured to ambulate critically ill patients and have difficulty in
balancing the patient’s need to ambulate versus the benefit and safety of ambulation in
the presence of hemodynamic intolerance. The need to address safe mobility and
physiologic assessment of patients before ambulation at the clinical site is evident due to
the negative impact of immobility on patient outcomes. The purpose of this systematic
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review is to look at the current practice of physiologic assessment measures and then
utilize the findings to influence safe patient mobility in the ICU.
Local Relevance
Safe prescription of patient mobility includes comprehensive preassessment and
diagnostic information evaluation to improve outcomes and meet patient mobility goals
(Amidei, 2012b). However, mobilization therapy does not consistently address the
physiologic readiness of a patient when prescribing activity regimens (Eakin et al.,
2015). Hence, it is important to understand critical factors as physiologic stability to
implement and sustain safe mobility in critically ill patients successfully.
Multiple assessments and methods determine the severity of illness, care
requirements, and the efficacy of mobility treatments. Nursing strives to incorporate
appropriate levels of mobility in care based on multiple assessments and exclusions for
physiologic concerns (Amidei, 2012b). Physiologic stability may change during
mobility, and unsafe patient mobilization results in adverse patient outcomes that
increase patient recovery time. There are inherent complications related to physiologic
stability, patient safety, and functional outcomes associated with the mobilization of
critical care patients (Adler & Malone, 2012). For safe mobilization to occur in the ICU,
with minimal risk of adverse events, assessment of patient physiologic stability should
occur before mobilization (Hodgson et al., 2014). Assessment of the right time and
readiness for mobilization includes a review of a patient’s physiologic and functional
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capacity (Eakin et al., 2015). Physiologic stability and functional capacity of critically
ill patients also help determine mobility readiness and appropriate mobility levels
(Amidei, 2012b).
Purpose Statement
Incongruence exists in the literature and practice about when to use mobilization,
who should perform mobilization, and to what extent to apply mobilization. The purpose
of this systematic literature review is to examine and summarize the benefits of
evidencebased practice tools for physiologic assessment and stability in the mobilization
of critically ill patients. Also, to evaluate tools that are published and can improve the
mobilization of critically ill patients by nursing and other disciplines. A review of the
current body of evidence on physiologic assessment and stability in the mobilization of
critically ill patients will answer how research and quality improvement studies on the
mobilization of critically ill patients address physiologic stability in decisions to mobilize
patients and if there is a consistent, safe best practice. Additionally, this project may
contribute to the enhancement of better patient outcomes by identifying optimal critical
care patient populations that would benefit from physiologic assessment for mobility
readiness.
Gap in Practice
Evidence-based practice is the standard nurses use to provide effective clinical
care. The gap in practice is that the ICU does not have a consistent, evidence-based
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approach to assess or determine a patient’s readiness for mobilization, despite the benefits
of safety and quality outcomes associated with evidence-based practice. Based on current
practice, it is apparent that a clinical practice gap exists in determining a critically ill
patient’s readiness and safety for mobilization activities. This DNP project may provide
nurses and other disciplines with physiologic assessment measures to determine critically
ill patients’ mobilization readiness. A nurse-driven mobility readiness assessment
included in mobility management will support the provision of safe, efficient care and
assessment in the management of critically ill patient mobility.
Practice-Focused Questions
The purpose of this systematic literature review is to examine and summarize the
benefits of evidence-based practice tools for physiologic assessment and stability in the
mobilization of critically ill patients. The three questions were:
• What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
• What is the effect of using physiologic assessment measures on determining
patient readiness for safe mobility?
• What is the effect of using physiologic assessment measures on the incidence
and safety of patient mobility events?
The following parameters guided the focus in answering the practice-focused questions:
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• Population: Critically ill Adults 18 years and older
• Intervention: Systematic review of the literature for Physiologic Assessment
Measures for Mobilization Readiness
• Comparison: The normal routine for Mobility Assessment
• Outcome: In critically ill adults 18 years and older, does the intervention of
physiologic assessment measures for mobilization provide safe and effective
patient physiologic assessment measures for readiness for mobilization
therapy?
The systematic literature review evaluated whether adapting and implementing an
evidence-based practice assessment tool or guideline has been found to enhance nursing
practice related to mobilization of critically ill patients. The design of this systematic
review included the synthesis of the literature review research for systematic reviews,
quantitative studies, qualitative studies, and pilot studies.
Addressing the Gap in Clinical Practice
Currently, the nursing practice of critically ill patient mobilization relies on
provider order, or clinical judgment and experience. Providing a summary of current
research and quality improvement on physiologic assessment can guide nursing practice
and other disciplines in addressing the gap in clinical practice of critically ill patients’
readiness for mobilization. Also, findings may guide nursing practice, improve patient
outcomes and safety, decrease unnecessary costs, and support nurses in making
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assessments and decisions based on evidence. Findings from the systematic literature
review may encourage nurse participation in evidence-based clinical practice by
demonstrating how nurse-driven measures can positively impact patients at the unit,
organization, and system level. The optimal timing and progression of mobility and
factors influenced the ability to mobilize affect positive patient outcomes (Winkleman et
al., 2012). The systematic review may provide additional benefits to the critically ill adult
populations in other organizations’ nursing staff and other disciplines through
summarizing research on evidence-based physiologic assessments for mobility readiness
of critically ill patients.
Nature of the Doctoral Project
The nature of this DNP project was to provide a systematic review of
evidencebased research patient guidelines or tools for physiologic assessment measures
for mobility readiness in critical care. The project goal was to provide a guide for critical
care nurses in safe mobility assessments and decisions in the ICU. This DNP project can
lead to positive social change in nursing practice by identifying physiologic assessment
measures that support patients’ readiness for mobility measures and safety during
mobility activities. The review of safe early mobility management also identifies
physiologic assessment measures to determine early mobility readiness and management
effectiveness, which can influence the care and mobility of critically ill adult patients.
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Accordingly, this project can improve nursing practice, decrease the adverse effects of
patient immobility while promoting better outcomes, and create positive social change.
Sources of Evidence
Evidence-based mobility practice increases patient safety, improves clinical
outcomes, reduces healthcare-related costs, and decreases variations in patient outcomes
and care (SCCM, n.d.). The project focus included collecting current evidence on
physiologic assessment measures for patient mobility readiness in ICUs that support safe
patient handling and decrease adverse events. Sources included textbooks, critical care,
and nursing journals, and peer-reviewed journals presenting articles on patient mobility,
including the Journal of Critical Care, Intensive and Critical Care Nursing, Physical
Medicine & Rehabilitation Journal, Critical Care Research and Practice, and the
Journal of Safe Patient Handling & Movement. Using Walden Library resources,
peerreviewed articles also came from online databases like Medline, Cochrane, PubMed,
CINAHL, and Google Scholar. Official websites accessed included the Society for
Critical Care Medicine, the American Association of Critical Care Nurses, the Agency
for Healthcare Research and Quality, and the Institute for Healthcare Improvement.
Nurses, physical therapists, respiratory therapists, and providers provided additional
resource information including seminal work from 2016-2020.
The decision for patient mobility avoids immobility and includes patient
assessments from admission to discharge. Immobility may affect a patient’s state of
health, and impaired health affects a patient’s physiologic and functional capacity
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limiting the ability to mobilize (Amidei, 2012). A patient’s participation in mobility
depends on resources to support ambulation, changes in sedation to enable patient
participation, and patient assessments to determine the level of activity and ability to
mobilize (Eakin et al., 2015). Conditions caused by immobility are as disabling as the
patient’s admitted condition and mobility limits these conditions. Assessing the efficacy
of early mobility of patients with and without mechanical ventilation is predicated on
establishing a culture of mobility in the ICU (Corcoran et al., 2017). However, cultures
that support patient mobility continue to have variations in assessment, intensity, and
frequency of patient mobility (Corcoran et al., 2017). An early mobility bundle,
including physiologic patient readiness assessment tools for mobility on every patient
every day, lessens immobility complications and decreases variations in care (SCCM,
n.d.). Individualized mobility assessments are essential for safe patient mobilization.
The patient’s functional and physiologic status improves with mobility and
declines with immobility. ICU patients lose approximately 2% of muscle mass every 24
hours (Doherty & Steen, 2010). As a result, the patient experiences a significant
reduction in skeletal muscle force, indicating the assessment of physiologic and
functional capacity is an important step before mobilizing (Doherty & Steen, 2010).
Determining the optimal timing and progression of mobility and factors influencing the
ability to mobilize affect the safe, functional recovery of critically ill adults (Winkleman
et al., 2012). Early mobilization restores function, and passive movement is appropriate
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when a patient’s physiologic assessment identifies limitations to active involvement in
mobility (Stockley et al., 2012). Functional and physiologic capacity mobility
assessments vary and include the use of exclusion criteria, family reports of previous
mobility levels, and the use of a variety of balance and strength assessments to
determine a patient’s readiness for mobilization (McWilliams et al., 2015). Despite
evidence supporting early mobility benefits to a patient’s recovery, timing, frequency,
and application of mobility vary, affecting a patient’s recovery.
Approach
The John Hopkins Evidence-based Practice model (JHNEBP) was the
developmental framework for this systematic review. The JHNEBP model is an effective
problem-solving approach to clinical decision-making using healthcare evidence (Dang
& Dearholt, 2017). Accordingly, the generation of research evidence that is effective,
feasible, appropriate, and meaningful to specific populations helps identify and address
patient’s health care needs (Dang & Dearholt, 2017.). The JHNEBP approach ensures
research findings and best practices in evidence-informed patient care (Dang &
Dearholt, 2017). The JHNEBP model is in congruence with holistic nursing care
delivery and balances scientific and humanistic characteristics of health and its
importance (Dang & Dearholt, 2017). The JHNEBP model integrates the best scientific
evidence with the best patient and practitioner evidence, considers internal and external
influences on practice, and encourages clinical reasoning in the application of evidence
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to care of patients and populations (White et al., 2016). The model also ensures research
findings and best practices in evidence-informed care, including clinical assessment
measures, guidelines, protocols, or tools, which are solutions for translating research
into practice (Dang & Dearholt, 2017).
The organization and beginning analysis of the DNP project literature review
involved the creation of a synthesis matrix. The synthesis matrix provided an overview
of the current research and quality improvement projects relevant to the selected topic. A
synthesis matrix facilitated the examination of multiple articles and how they relate to
themes in the research or quality improvement (Clark & Buckley, 2017). Synthesized
information supported the integration of evidence-based physiologic assessment
measures into mobility readiness practice.
A logic model was used to interpret the information obtained on readiness
assessments for mobility. The logic model promoted system thinking by highlighting
relationships of mobility readiness details to the whole process of patient mobility along
with congruencies and inconsistencies (Anderson et al., 2011). The model was used to
scope the review, define and conduct the review, and facilitate the review relevant to
practice (Anderson et al., 2011). The model facilitated the synthesis of current
knowledge on physiologic assessment measures for mobility readiness and early
mobility management
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Identifying the scope of the review included the use of databases and search
engines to find outcomes and research; databases included the Cochrane Database for
Systematic Reviews and the Joanna Briggs Institute EBP database. Available evidence
searches engines to find evidence included PubMed, CINAHL Plus, Medline, and
ProQuest Health & Medical Collection. Key search terms and combinations of these
terms for further searches included activity, mobilization, functional capacity,
physiologic stability, rehabilitation, critical care, ICU, recovery, exercise, and
movement. The study considered peer-reviewed primary sources from 2010-2020 for
inclusion in the doctoral project prospectus and systematic review.
Connecting current evidence to the practice questions requires a detailed review
of sources to determine applicability (Walden University, 2017b). After searching and
evaluating evidence, an additional search ensured all points of view from available
peerreviewed sources were included that apply to the DNP project questions. The search
was exhaustive by using various search terms and phrase combinations that cover the
practice-focused questions and the target population. Plans included methods to identify
the integrity of evidence, including approaches to outliers, missing information, and
statistical analysis procedures used in the doctoral project to address the practicefocused
questions. Analysis and synthesis included identifying gaps that exist in the current
literature and the strengths and weaknesses of existing literature. Established standards
were applied to appraise study quality, to assemble all relevant sources, and to identify
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the basis of knowledge (Walden, 2017b). Clinical practice improvement
recommendations for patient mobility decisions came from the interpretation and
synthesis of the evidence.
Resources needed to complete the doctoral project included time and the support
of the writing center, library, and my DNP supervisory committee chair. Additionally,
the use of the DNP capstone resources and the DNP project mentoring course provided
the support needed to obtain data and resources needed to complete the DNP project.
Planning for protected daily time for my DNP project facilitated the completion of my
systematic review DNP scholarly project.
Significance
Nursing Practice
This DNP project holds significance to the field of critical care and nursing
practice, as it may help establish and motivate the local site to adopt evidence-based
measures for physiologic assessment to determine the mobility readiness of critically ill
patients. This DNP project also addresses the problem of the lack of and use of consistent,
evidence-based measures to assess and determine mobility readiness for critically ill
patients that would support a nurse-driven mobility guideline or tool. In the project site,
this issue has affected patient safety, patient outcomes, the patient’s length of stay, and
hospital costs. Nursing practice is universally affected. The project may help identify
physiologic assessment measures that can guide clinical practice, nursing care, empower
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decisions based on evidence, improve patient outcomes, decrease the negative outcomes
from immobility, and decrease unnecessary health care costs.
A review of published scholarly articles for this DNP project may help establish
physiologic assessment measures for critically ill patients’ mobilization. Also, the
literature review may help establish physiologic assessment measures for mobilization of
critically ill patients at the local practicum site. An example of an organization’s attempts
to address physiologic assessment includes a pilot in a surgical/trauma ICU using Stiller’s
safety mobilization guidelines for ICU clinicians and the Borg Rate of Perceived Exertion
scale (Zomorodi et al., 2012). A multidisciplinary team developed a mobilization protocol
comprised of activity events twice a day till discharge, documenting heart rate, blood
pressure, and oxygen saturation at baseline, 5 minutes, and 15 minutes after mobility
(Zomorodi et al., 2012). The flowchart and decision tree matched the outcomes assessed
by physical therapy, and the pilot concluded the severity of illness affects mobility
progression and participation contributed to patients’ length of stay, healthcare cost, and
ventilator-free days (Zomorodi et al. 2012). The pilot demonstrated there were significant
physiologic changes associated with immobility and critical illness to consider when
mobilizing critically ill patients (Zomorodi et al., 2012). The establishment of a guideline
containing evidence-based measures for physiologic patient assessment for readiness for
mobilization may allow nurses at the local site to make informed decisions and advocate
for their patients. Additionally, a guideline may provide optimal patient care management
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that will improve patient outcomes and decrease the occurrence of complications from
immobility and unsafe mobility activities. Accordingly, this may lead to decreased length
of stay in the hospital and ICU and increased nursing autonomy, as nurses may feel their
assessments and interventions surrounding mobility are positively impacting patient care
and outcomes.
Stakeholders
In the ICU, critically ill patients admitted conditions caused by immobility are
disabling and limit mobility. Nurses provide care to these patients that include the
management of mobilization to limit the effects of immobility and achieve optimum
patient outcomes. The challenges of early progressive mobility of critically ill patients
include the assessment of physiologic stability and readiness for mobility activities, of
which there is a lack of a gold standard to guide clinical practice.
The results of this DNP project may affect multiple stakeholders by addressing the
lack of evidence-based physiologic mobility assessment measures to determine mobility
readiness and nurse-driven practice implementation of these measures. Stakeholders
include nurses, physical therapists, occupational therapists, respiratory therapists, nursing
assistants, nurse practitioners, physician assistants, and physicians who provide care to
critically ill patients. Additional members of the healthcare team that may be affected
include nurse educators, unit and professional governance council committees, the
mobility wellness bundle committee, organization practice boards, and nursing and
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administrative management. Stakeholders also include the patient, their caregivers, and
family. Including them in the experience of care and individualized plan of care
development can improve care delivery as well as allow for collaboration with the
healthcare team. The nursing staff may gain new insight, assessment skills, and practice
knowledge in the management of patient mobility, activities associated with mobility,
and patient care. Patient impact includes decreased complications from immobility and
deconditioning. The systematic literature review provided the local organization with the
potential to improve patient outcomes, decrease costs and complications associated with
immobility, and reduce critical care and hospital length of stay.
Contribution of the Doctoral Project
The project contributes to nursing practice by enhancing knowledge and skill and
by providing effective physiologic assessment measures for mobility readiness of
critically ill patients prior to, during, and after mobility. The outcomes of this review may
also improve patient safety and outcomes, reducing ICU and hospital stay. The American
Association of Colleges of Nursing (2006) indicates the essentials of the DNP are to
design, implement, and evaluate therapeutic interventions based on nursing science
(p.16). The systematic literature review of physiologic assessment measures for early
mobility readiness and management of adult patients in critical care encompasses the
DNP Essentials I, II, III, VI, VIII. It allowed me to analyze, collaborate with
intraprofessional and interprofessional teams during the integration of evidence-based
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measures into practice. My DNP project synthesized the literature to provide
recommendations. It can guide, mentor, and support nurses to achieve excellence in
nursing during collaborations with the healthcare team about patient-specific mobility
measures for optimum outcomes (AACN, 2006). Additionally, the cost-effectiveness of
this practice initiative accounts for risk, safety, and improvement of health care outcomes,
including the decreased cost associated with adverse outcomes from immobility and
increased length of stay in the ICU and hospital (AACN, 2006).
Transferability
Evidence-based practice (EBP) is the integration of clinical expertise, patient
values, and needs, and the best evidence into the decision-making process for patient care
(White et al., 2016). The gap between recommended EBP and what is implemented can
lead to poor outcomes; therefore, the ability to integrate evidence into practice is key in
ensuring quality health care practice (White et al., 2016). EBP supports clinical decision
making because it offers solutions to improve health care quality and provide
costeffective care (Tucker, 2017). Physiologic assessment measures for mobility
readiness of adult patients in critical care may improve the safety and management of
critically ill patients mobilizing in ICUs with similar practice problems. The findings of
the systematic review can be shared with other critical care units locally within the health
care organization and system, as well as locally within the state with other ICUs. The
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DNP project provides an evidence-based practice evaluation for knowledge transfer for
nursing and other disciplines throughout all hospitals with ICUs in the state of the project
site.
Social Change Implication
The DNP project can create positive social change within the project site by
encouraging nurses to improve clinical practice through evidence-based practice
education and implementation. Evidence-based practice based on current research
improves patient outcomes and decreases health care costs. Adopting and supporting
nurse-driven measures for physiologic assessment for mobility readiness can enhance
nurse autonomy, as the measures identified empower nurses to collaborate with practical,
safe decision making in the mobilization of critically ill patients in the ICU. A systematic
literature review can also improve the safety and patient outcomes at the local practicum
site. The physiologic assessment measures may improve patient care and outcomes
related to mobility at the site, and measures can be potentially used globally in the
mobilization of critically ill patients in ICUs. Incorporating new evidence-based measures
will facilitate change in the decision-making process surrounding the mobilization of
critically ill patients in the ICU. Nurse-drive assessment measures for mobility
management improve nurse autonomy and satisfaction, improve patient safety, decrease
mechanical ventilation, and hospital and ICU length of stay (Corcoran et al., 2017).
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Accordingly, nurses can use assessment measures to determine mobility readiness guided
by evidence.
Summary
Immobility and unsafe mobility practices can lead to poor outcomes in patient
care practice. Effective physiologic assessment measures and management of
mobilization is essential for improving ineffective mobilization practices in the ICU.
Because of unsafe and poor patient outcomes that result from ineffective physiologic and
mobility assessment measures for critically ill patients, there is a need for evidence-based
guidelines to facilitate effective mobilization activities and decrease the incidence of
immobility that facilitate the best results for patients. Also, evidence-based guidelines
provides nurses with measures they can use when making clinical decisions in the care of
critically ill patients to decrease the negative effects of immobility. Evidence suggests the
use of a nurse-driven protocol to guide decisions with patient readiness criteria for
mobilization, the step-wise progression of mobility, and behavioral safety for out-of-bed
progressive mobilization is effective leading to sustained improvement in patients’ level
of mobility (Klein et al., 2018). Also, a nurse-driven early progressive mobility protocol
can sustain improvement in length of unit and hospital stay, depression, anxiety, and
hostility levels (Klein et al., 2018). With a summary of the evidence-based physiologic
assessment measures and methods to determine a critically ill patient’s readiness for
mobilization, intensive care nurses may possess the latest best practice measures.
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Evidence-based best practice knowledge on early mobility management may assist nurses
in managing patient mobilization activities based on current evidence. Nurses may no
longer rely just on personal judgment and experience when managing decisions
surrounding mobilization activities of critically ill patients. The systematic literature
review facilitates the use of evidence-based best practice measures in clinical practice
surrounding critically ill patient physiologic assessment to determine mobilization
readiness that improves patient safety.
Section 2: Background and Context
Introduction
Nursing care incorporating evidence-based practice will positively impact
patients, outcomes, and social change. Evidence-based practice is an innovative approach
to problem-solving in the care of patients, and the health care delivery system’s
complexity challenge nurses and other disciplines to identify and use evidence to guide
practice (White et al., 2016). Management of critically ill patients’ progressive mobility is
a complex process affected by many variables. The practice problem at the practicum
site was the current practice of mobility management comes from patient orders without
the adoption of an evidence-based physiologic assessment guide to support collaboration
between health care team members. Clinical practice may also vary based on the
individual nurse and disciplines caring for the patient. Evidence on early progressive
mobility demonstrated sustained improvement in patients’ level of mobility, length of
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ICU and hospital stay, depression, anxiety, functional status, and survivability (Klein et
al., 2018). However, mobilization therapy does not consistently address the physiologic
readiness of a patient during the prescription of activity regimens (Eakin et al., 2015).
Understanding the assessment of physiologic stability is needed to implement and sustain
safe mobility in critically ill patients successfully.
This doctoral project included three focused practice questions:
7. What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
8. What is the effect of using physiologic assessment measures on
determining patient readiness for safe mobility?
9. What is the effect of using physiologic assessment measures on the
incidence and safety of patient mobility events?
In critically ill adults 18 years and older, does the intervention of physiologic assessment
measures for mobilization provide safe and effective patient physiologic assessment
measures for readiness for mobilization therapy? The intent of this DNP project, a
systematic review of the literature, examined and summarized evidence-based practice
measure guidelines that can improve the nursing practice and interdisciplinary
collaboration of early progressive mobility of critically ill patients.
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Concepts, Models, and Theories
The concept of EPB in nursing is the basis of this DNP project. EPB in this
project includes the nurse applying knowledge to find a solution for a problem by
critically analyzing and applying current evidence to achieve a better understanding of
clinical decision making regarding critically ill patients’ mobilization in the ICU (Terry,
2018). The practicum site does not currently have an evidence-based physiologic
assessment measures guideline or protocol to determine critically ill patients’ readiness
for mobility, only an assessment for possible mobility level. Another concept included in
the systematic review is practice-based evidence, the knowledge generated from practice
as well as from research, which includes the importance of the environment in
determining practice recommendations (McEwen & Wills, 2014).
The JHNEBP model was the developmental framework for this systematic
literature review. The JHNEBP model is an effective problem-solving approach to
clinical decision-making using healthcare evidence in a systematic literature review
(Dang & Dearholt, 2017). Accordingly, the generation of research evidence that is
feasible, appropriate, and meaningful to specific populations helps identify and address a
patient’s health care needs (Dang & Dearholt, 2017). The model also ensures research
findings and best practices in evidence-informed care, including clinical assessment
measures, guidelines, protocols, or tools, which are solutions for translating research into
practice (Dang & Dearholt, 2017). The model incorporates the use of available evidence
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as a core component within the domains of professional nursing: nursing practice,
education, and research (Gawlinski & Rutledge, 2008). It is an appropriate model for
understanding the different forms of knowledge, and the guidelines for the model reflect
the “PET” process: practice question, evidence, and translation (Gawlinski & Rutledge,
2008). Evidence comes from the search and review of literature, literature is rated, and
recommendations for changes in processes of care are identified (Gawlinski & Rutledge,
2008). The JHNEBP model is in congruence with holistic nursing care delivery and
balances scientific and humanistic characteristics of health and its importance (Dang &
Dearholt, 2017). JHNEBP model goals include but are not limited to the use of evidence
to promote optimal outcomes, support rational decisions that reduce inappropriate
deviation, create a culture of critical thinking, and grow an environment where the
evidence supports clinical and administrative decisions (White et al., 2016). JHNEBP
model was developed by nurses to support EBP integration.
My DNP project included transitions theory, a middle range and situation-specific
theory. Meleis developed the theory encompassing the transition experience (Im, 2014).
The theory’s purpose is to describe, explain, and predict an individual’s experiences in
various types of transition (Im, 2014). The theory assumes all nursing phenomena involve
a type of transition (Im, 2014). Transitions theory includes understanding the nature of
and responses to change, facilitating the experience and responding to its different
phases, and prompting dynamic balance in health before, during, and at the end of a
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change event (Im, 2014). Transitions theory assumes nursing should play a central role in
facilitating smooth and successful transitions for those experiencing change (Im, 2014).
Transitions Theory includes the intervention made to facilitate transitions and promote
health and mastery of health-illness consequences (Im, 2014). Transitions Theory also
includes understanding the transition experience and that transitions may exacerbate
responses impacting health (Im, 2014).
Theory can guide and link practice to evidence. The theory knowledge gap exists
when the body of knowledge is unknown, accessible, or used as it should be in practice
(McEwen & Wills, 2014). Nursing practice can validate the theory, and the theory can be
a guide for making informed decisions that are grounded by practice (McEwen & Wills,
2014). In today’s challenging health care environments, nurses must continually seek to
evaluate, inform, and improve their practice by the integration of appropriate best
evidence (White et al., 2016). Evidence-based practice includes the integration of the best
evidence, clinical expertise, and patient preferences for clinical decision making (White
et al., 2016). The goal of this DNP project was to reduce clinical practice variation or
lack of physiologic assessment for evaluation of mobilization readiness of critically ill
patients.
Related Synthesis
The evidence-based model facilitates the application of evidence into clinical
practice and achieving best practice (Melnyk & Fineout-Overholt, 2015). The model
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applications include clinical practice, quality improvement, and education aspects of
nursing, and the model’s goal is to ensure the latest evidence and best practices quickly
and appropriately integrate into care (Melnyk & Fineout-Overholt, 2015). Assessing the
need for change or identifying a clinical practice gap includes an evaluation of the
existing evidence, synthesis, and integration of evidence into practice (Melnyk,
FineoutOverholt, 2015). The JHNEBP model was used to implement a daily ambulation
checklist for specified mobilization and venous thromboembolism (VTE) orders for high
to moderate risk patients (Anthony et al., 2017). Patients who experience less
mobilization and prolonged immobility experience less optimal outcomes (Anthony,
Bernard, & Butler, 2017). Surgery patients are at risk for VTE, and patients tend to limit
mobilization due to pain that may predispose them to venous stasis (Anthony et al.,
2017).
Transitions theory outcomes and potential for nursing therapeutics include the
patterns of response of the patient, which is fundamental to nursing (McEwen & Wills,
2014). Nursing therapeutics encompasses the assessment of readiness, preparation for the
transition, and role supplementation, the use of education and practice to facilitate
healthillness concerns (McEwen & Wills, 2014). The concept of situation-specific
transition theory on the transition to adult day health services, included the development
of inhibitors that included a mismatch between the elder’s functional ability and interests
and the activities available impacting mobility goals (Im, 2014). Additionally, the
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situation-specific transitions theory was used as a framework to guide interventions
including mobility for people with heart failure and determine the effect of heart failure
education on knowledge and readmission (Im, 2014). The situation-specific, transitions
theory was appropriate for this systematic review of physiologic assessment measures for
mobility readiness of adult patients in critical care.
Clarification of Terms
The following terms provide clarity to this DNP project:
Mobilization: An interdisciplinary, goal-directed therapy used to facilitate
movement and improve outcomes that expends energy and includes physical and
psychological domains as well as various activities (Amidei, 2012-b).
Movement: A type of activity that is a functional pattern that allows individuals to
control their environment (Amidei, 2012-b). The capacity for movement is composed of
purposefulness, awareness of self, and continuity (Amidei, 2012-b).
Physiologic stability: A dynamic state, including the variability of physiological
parameters and their ability to regulate maintaining balance after exposure to a disruptive
element (Lebel, Alderson, & Aita, 2014).
Evidence-based nursing: A term that is used interchangeably with evidence-based
practice (White, Dudley-Brown, & Terhaar, 2016).
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Evidence-based practice (EBP): “A paradigm and lifelong problem-solving
approach that involves the conscientious use of the best available evidence, with clinical
expertise and patient values and preferences to improve patient outcomes” (Melnyk &
Fineout-Overholt, 2015, p. 604).
Relevance to Nursing Practice
History of the Broader Problem in Nursing Practice
Evidence-based practice is fundamental to decision-making in clinical practice.
Organizations developing and supporting initiatives to promote the advancement of
evidence-based practice include Sigma Theta Tau International, the American
Association of Critical-Care Nurses, the Institute of Medicine, and the Magnet
Recognition Program of the American Nurses Credentialing Center. Because of the gap
between new knowledge and implementation of that knowledge to improve patient care
the American Association of Critical-Care Nurses provides resources for clinicians
including practice alerts and a hierarchal rating system for levels of evidence for nurses
to determine the strength of research studies, assess findings, and evaluate the evidence
for integration into best practice (Peterson et al., 2014). By the year 2020, 90% of clinical
decisions will come from accurate, timely, and up-to-date clinical information reflecting
the best available evidence (Institute of Medicine, 2009).
A systematic literature review of physiologic assessment measures for mobility
readiness of adult patients in critical care may change nurse-driven mobilization practices
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locally, which could lead to a state-level change. Integrating the current science and best
evidence on physiologic assessment measures can reduce the unpredictable outcomes of
mobilization practices related to physiologic stability, patient functional capacity, and
patient safety (Adler & Malone, 2012). Acquiring evidence-based physiologic assessment
measures to determine mobility readiness for critically ill adult patients can facilitate safe
clinical decisions around patient mobility level, readiness, and frequency. Evidencebased
practice is an essential nursing competency (IOM, 2010). Integrating evidencebased
practice continues to be the challenge.
The Society of Critical Care Medicine published the ABCDEF, Bundle E,
addressing the physical effects of immobility critically ill patients face and strategies for
implementation of early mobility programs in any ICU (SCCM, n.d.). Bundle E provides
tools for comprehensive management of critically ill patients’ mobility, including a
mobility pathway with exclusion criteria for physiologically unstable patient types
(SCCM, n.d.). However, physiologic assessment measures are not present in the pathway
for patient mobility. Evidence identifies a lack of expert consensus and recommendations
on physiologic safety criteria for active mobilization (Hodgson et al., 2014).
Evidencebased physiologic assessment measures are overlooked by health care staff
when making mobility decisions.
Currently, the process to determine readiness for mobilization of critically ill
patients is specific to the organization, provider practice, physical therapist, or nurse.
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Standardized evaluation of a patient’s mobility throughout hospitalization is necessary to
determine progression or regression and to ensure avoidance of further physical
debilitation (Anderson, Sparbel, Barr, Doerschug, & Corbridge, 2018). Using an
evidence-based protocol coupled with up-front staff education leads to staff
empowerment, a sense of security, confidence, and ownership of the practice which
sustains adherence to and practice of the program (Anderson et al., 2018). At the
University of Michigan, a standardized mobility protocol incorporated safe patient
handling and mobility pre-assessment guidelines, mobility standards, equipment
guidelines, and documentation tools to get patients moving (Dickinson, Taylor, & Anton,
2018). The protocol adjusted for all patient populations by modifying the inclusion and
exclusion criteria, and the activities are grounded in evidence to prevent complications,
promote mobilization, and prevent patient and staff harm (Dickerson et al., 2018). A
multidisciplinary team developed and implemented a mobility order set with an
embedded algorithm to guide the nursing assessment of mobility potential in ICU and
Intermediate Care settings at a large community hospital (Drolet et al., 2013). The
protocol assessments empowered the nurse to consult physical therapy or occupational
therapy for patient mobilization (Drolet et al., 2013). The nurse-driven assessments
resulted in an increased rate of patient ambulation in the first 72 hours of a hospital stay
(Drolet et al., 2013). Many studies recommended further studies of nurse-drive
mobilization management of critically ill patients
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Current Nursing Practice for Mobilization of Critically Ill Patients
The current state of nursing practice and assessment measures for readiness for
mobilization includes a provider request or order and the nurse’s or respiratory therapist’s
clinical experience and observation of patient’s during activity. There is inconsistent
evidence to guide the ICU staff with clinical problems related to the patient’s functional
capacity, tolerance, and dynamic stability. There is a need for nursing practice
improvement in physiologic assessment measures to guide safe patient mobility practice,
which could guide nurses in the multidisciplinary collaborative decision-making process
involved in patient mobility management and associated patient care. Physiologic
stability and functional capacity should be incorporated in the decision to mobilize a
patient and in determining the appropriate mobility level (Amidei, 2012; Eakin et al.,
2015). Determining the progression of mobility and factors influencing the ability to
mobilize affect the safe, functional recovery of adults (Winkleman et al., 2012). Cultures
that support patient mobility continue to have variations in assessment, intensity, and
frequency of patient mobility (Corcoran et al., 2017). The recommendation is an early
mobility bundle containing physiologic assessment measures for mobility on every
patient every day to lessen immobility complications and decrease variability in care
(SCCM, n.d.). Implementing physiologic assessment measures that incorporate
evidencebased practice is an effective approach in helping nurses and other professions
with decision-making on mobility readiness and level (SCCM, n.d.). Management of
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mobility is complex and requires a consistent approach to application and timing to
maximize mobility benefits in a patient’s recovery.
Previous Strategies
Evidence shows critically ill patients are at risk for muscle weakness that often
results from the treatment the health care team is implementing to save a patient’s life
and the associated immobility. Immobility frequently results in reduced venous blood
flow in the pockets of venous valves, promoting inflammation and hypercoagulability
and risk for venous thrombosis (Engers et al., 2014). Mobility measures are
fundamentally important areas of critical care practice, and the adult clinical practice
guidelines from the Society of Critical Care Medicine, Bundle E, addresses early
mobility and exercise (SCCM, n.d.). The Bundle E element identifies strategies for
successful implementation of early mobility and prevention of physical deficits
associated with immobility (SCCM, n.d.). There are a variety of approaches used to
avoid patient immobility and muscle weakness based on physician preference, the
resources available, and the assessment of providers, nursing staff, and physical therapy.
Guidelines for mobility and assessment are beneficial in critically ill adult patient care
delivery and outcomes.
ICU patients lose approximately 2% of muscle mass every 24 hours (Doherty &
Steen, 2010). As a result, the patient experiences a significant reduction in skeletal
muscle force, indicating the assessment of physiologic and functional capacity is an
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important step before mobilizing (Doherty & Steen, 2010). Determining the optimal
timing and progression of mobility and factors influencing the ability to mobilize affect
the safe, functional recovery of critically ill adults (Winkleman et al., 2012). Early
mobilization restores function, and passive movement is appropriate when a patient’s
physiologic assessment identifies limitations to active involvement in mobility
(Stockley, Morrison, Rooney, & Hughes, 2012). Functional and physiologic capacity
mobility assessments vary and include the use of exclusion criteria, family reports of
previous mobility levels, and the use of a variety of balance and strength assessments to
determine a patient’s readiness for mobilization (McWilliams et al., 2015). Despite
evidence supporting early mobility benefits to the patient’s recovery, timing, frequency,
and application of mobility vary, affecting a patient’s recovery. A nurse-driven guideline
or protocol that facilitates comprehensive physiologic assessment to determine mobility
readiness is needed to address the gap in determining patient readiness and safety.
Local Background and Context
Summary of Local Evidence
The practicum site for this project serves as a large academic teaching facility in
an urban area on the west coast. It consists of multiple critical care units on two
campuses. Due to the varied opportunities for experiences in critical care, educational
advancement, and translation of evidence into practice nursing and health care staff from
the United States and other countries seek opportunities to be part of the health care
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team. Despite evidence-based practice and utilization of the latest evidence available to
provide patient care quality, consistent, evidence-based patient mobility practice,
including physiologic readiness assessment, remains an issue, and needs improvement.
An identified need is a consistent nurse-driven physiologic assessment to determine
patients’ readiness for mobility and mobility management. There is also a pressing need
to adapt nurse-driven physiologic assessment guidelines to determine mobility readiness
and management to support patient safety and the use of the latest available best
practices while enhancing nursing practice.
Institution Context
The practicum site provides health care services to adult, pediatric, and neonates
with acute and chronic conditions. The vision of the practicum site is to be the number
one health care provider on the west coast, providing quality evidence-based, innovative
care to patients, families, and the community. The practicum site believes in patient
advocacy, and evidence-based care focused on quality outcomes and patient and staff
safety. The unit for this DNP project’s intent is a 24-bed adult critical care unit. Safe
early mobility is essential for 100% of the critically ill adult patients admitted to the unit
to help facilitate the management of their underlying condition and minimize muscle
weakness and promote quality outcomes.
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State/Federal Context
The Evidence-based Practice Center Programs of the Agency for Healthcare
Research and Quality explore clinical issues focus on improving healthcare quality,
safety, efficiency, and effectiveness by synthesizing evidence and facilitating the
translation of evidence-based research findings (AHRQ, 2020). In 2019 two programs
exist on the west coast near my practicum site. Information from AHRQ’s research is
available to support informed healthcare decisions, improve the quality of healthcare
services, and to provide technical assistance to facilitate quality improvement tools
(AHRQ, 2020). Each state’s nurse practice act helps ensure the safe delivery of nursing
care. The safety and delivery of nursing care will improve by complying with the State
Board of Nursing Practice Act and using evidence-based practice.
Role of the DNP Student
Student Professional Context
I practice as an advanced practice nurse and nursing leader in an adult critical care
unit at a large academic teaching facility. My role includes but is not limited to
assessing, mentoring, collaborating, and providing leadership to promote the delivery of
quality care to adult critical care patients. My role provides me with the opportunity to
promote the physiologic assessment of patients to determine mobility readiness that
promotes the health and wellbeing of patients and improved patient outcomes while
supporting safe patient mobility. Promoting evidence-based practice and change to
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improve quality patient care is a key role of a leader and an advanced practice nurse
(AACN, 2006). The project took place at a large academic teaching facility on the west
coast. The population served at this site includes critically ill adult patients with various
diseases requiring care in an intensive care unit, conditions related to medical
complications and surgery. The practicum site and DNP project have no relationship to
my employment.
Student’s Role in the Doctoral Project
My goal and focus during this DNP project were to investigate the current best
practices in literature for early mobility readiness assessments to facilitate the safe
mobility of critically ill patients. Additionally, what are the best evidence-based
practices available for the practicum’s site use that may improve mobility readiness
assessment, nursing confidence in collaboration with healthcare team on mobility
management, and safe mobility practices. Based on the evidence and information
reviewed, the summary of the evidence and recommendations may help enhance and
improve nursing patient mobility practice and assessment at the practicum site.
Collaboration and stakeholder buy-in are goals of this DNP project as well as facilitating
change that will improve patient care quality concerning patient mobility outcomes.
Student Motivation
As a leader and advanced practice nurse, I seek to used advanced communication
skills and collaboration to foster evidence-based practice change, which improves patient
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care quality and also mentors and inspires others to be change agents valuing best
practice improvements. As both a clinical nurse specialist and leader, my role includes
utilizing evidence-based practice managing the care of complex and vulnerable
populations while educating and supporting interprofessional staff. My passion for
physiologic assessment needs to determine a patient’s early mobility comes from a need
expressed by my peers, colleagues, and my practice for a standard that maintains patient
safety during mobility management. This need instilled a desire to seek what current
evidence is known about the problem to help identify best practices for mobility
management for adult critically ill populations.
Potential Biases
Melnyk and Fineout-Overholt (2015) indicate bias is possible at any point during
a study, and positive results are more likely to be published than studies with negative or
inconclusive results. Bias prevents objective consideration reinforcing the need to be
aware of possible sources of bias. Potential bias for this DNP project is for this student to
note and consider stakeholder opinions and values about early mobility management.
Summary
Nurses care for patients with competence and diligence to provide excellent care
advocacy for patients. An evidence-based practice model facilitated the literature review
of physiologic assessment measures to determine patient mobility readiness and safe
early patient mobility management. The DNP project may result in the adoption of a
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nurse-driven guideline for nurses to guide their assessment and practice around early
patient mobility. The following section will discuss and include the of evidence used to
guide the synthesis of the systematic literature review. The analysis and synthesis of
evidence for this DNP project will also be addressed in this section.
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Section 3: Collection and Analysis of Evidence
Introduction
Early mobility management in the critically ill adult population is challenging
because multiple assessments and methods determine the severity of illness, care
requirements, and the efficacy of mobility treatments. The objective of this DNP project
was to investigate and synthesize evidence that can be used as a recommendation to
adopt a standardized mobility readiness assessment as part of early mobility
management in the ICU. During this project, I reviewed and identified evidence-based
physiologic assessments and approaches for early mobility management of critically ill
adults and the nurse’s role with regards to mobility management. The nursing staff at the
site were often overwhelmed when making decisions about whether patients are ready
for mobility or if they can be safely participating in the activity. Patients and families
depend on nurses to provide evidence-based care focused on quality outcomes healing
one patient at a time. This DNP project assists nurses in providing the safest care to
patients surrounding early mobility while collaborating with the healthcare team. In this
section, I provided the sources of evidence and an overview of the methodology used in
evidence searches, such as the process of selecting and exclusion criteria, as well as
analysis and synthesis of the system used to organize and record the evidence obtained.
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Practice-Focused Questions
The current practice of mobility management at the practice site comes from
patient orders without the adoption of an evidence-based physiologic assessment to guide
to patient mobility management. Patients may be negatively affected by the lack of
evidence-based mobility readiness measures. The practice-focused questions for this
doctoral project include:
7. What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
8. What is the effect of using physiologic assessment measures on determining
patient readiness for safe mobility?
9. What is the effect of using physiologic assessment measures on the incidence and
safety of patient mobility events?
Population: Critically ill Adults 18 years and older
Intervention: Systematic review of the literature for Physiologic Assessment Measures
for Mobilization Readiness
Comparison: The normal routine for Mobility Assessment
Outcome: In critically ill adults 18 years and older, does the intervention of physiologic
assessment measures for mobilization provide safe and effective patient physiologic
assessment measures for readiness for mobilization therapy?
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The project is significant to practice, as it is expected to reduce the variation in
physiologic assessment measures to determine early mobility readiness and management
for nursing and the health care teams’ practice with recommendations provided from the
systematic literature review.
Clarifying the Purpose
The purpose of this doctoral project was to evaluate and synthesize EBP on
physiologic assessment measures to determine early mobility readiness and management
best practice to make recommendations for adoption of a nurse-driven early mobility
management guideline in adult critical care. The approach aligned with the
practicefocused questions, as the evidence that was collected provided information that
supports a recommendation for EPB guidelines in the clinical nursing practice for
physiologic assessment measures to determine mobility readiness and management in
the critical care unit. The evidence-based data can provide a standard, already validated
measures for a nurse-driven early mobility physiologic assessment to determine mobility
readiness and management. As a result, this review can be implemented and used as the
best practice in early mobility management.
Sources of Evidence
The purpose of this DNP project included evaluating and synthesizing the best
available evidence relevant to nurse assessment for physiologic readiness for patient
early mobility and mobility management for recommendations to improve the existing
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nursing and health care team practice surrounding the care of critically ill adult patients.
The source of evidence used to address the practice-focused questions was current
literature. A review of the literature indicated that physiologic assessment to determine
early mobility readiness and management is a worldwide challenge in healthcare. The
systematic review of literature included textbooks, both primary and secondary sources
of peer-reviewed journal articles and published guidelines from CINHAL, PubMed,
Cochrane Library, Joanna Briggs Institute, and Medline. I used Walden Library and
Google scholar to identify resources in these databases. Available evidence addressing
the context of the systematic review includes the ICU Liberation, ABCDEF bundle E on
early mobility and exercise. Bundle E focuses on the physical deficits that ICU survivors
face and strategies for implementation of early mobility programs in any ICU (SCCM,
n.d.). Resources and reports from clinical specialty organizations, such as the American
Association of Critical Care Nurses, the Society of Critical Medicine, the Agency for
Healthcare Research and Quality, and the Institute for Healthcare Improvement, were
also reviewed for relevant information. Nurses, physical therapists, respiratory
therapists, and providers provided additional resource information. The evidence
included qualitative, quantitative, and mixed methods studies.
Relationship of Evidence to the Purpose
The purpose of this DNP project was to evaluate and synthesize the best available
evidence to recommend a nurse-drive mobility guideline and assessment. The evidence
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gathered from the literature provided the information needed to guide the
recommendation of the assessment and guideline. Multiple strategies assess mobility
readiness and help manage the early mobility of critically ill adults. An essential
literature search was exhausted to seek validation for the best practice concerning early
mobility readiness assessment measures and management.
Evidence to Address the Practice-Focused Questions
The collection and analysis of evidence facilitates the approach to decisionmaking
in evidence-based nursing practice. The articles selected came from a strategy search.
Keywords included early mobility, early ambulation, early mobilization, early
rehabilitation, assessment tools, assessment methods, assessing, guidelines, protocols,
practice guidelines, bundle, physiologic assessment, nurse-drive early mobility
management, ICU patient activity, hemodynamic stability, and evidence-based
guidelines for early mobility in critical care, early mobility patient interventions and
assessments, the effects of physiologic assessment measures on early patient mobility,
and physiologic assessment measures supporting safe patient mobility. Synthesizing all
evidence gathered will be crucial to obtaining information needed to answer the
practice-focused questions. The search procedure resulted in a total of 37 articles used
for this systematic review. The search procedure began by using CINAHL, and the
search keyword used was early mobility or early ambulation or early mobilization or
early rehabilitation.
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Databases and Search Engines
The Peer-reviewed articles were accessed from on-line databases, such
as
CINAHL, Google Scholar, Walden Library, Joanna Briggs Institute, Medline, Cochrane
Database, and PubMed. Also, official websites such as the Society of Critical Care
Medicine, the American Association of Critical Care Nurses, the Agency for Healthcare
Research and Quality, and the Institute for Healthcare Improvement were assessed for
additional resources and evidence.
Key Search Terms and Combinations of Search Terms
Additional search terms included keywords such as critically ill patients’ mobility
and activity, hemodynamic stability mobility assessment, ICU Liberation, ICU patient
mobility management, nurse-driven mobility bundles or guidelines in ICU, physiologic
stability assessment measures before mobility in ICU, safe patient mobility in ICU,
evidence-based guidelines for early mobility in ICU, and early mobility in adult ICUs.
The Scope of this Review
Gathering relevant sources of information from the literature search relating to
critically ill adult patients’ physiologic stability assessment measures and early mobility
management provide evidence for the recommendation for nurse-driven evidence-based
guideline. The searches considered peer-reviewed primary sources from 2010-2021 for
inclusion in the systematic review. Article selection criteria included if the author(s)
addressed early mobility management and assessment for mobility. Also, the selection
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considered articles relevant to the management of critically ill adult patients’ safe early
mobility. Articles were excluded if the articles were not relevant to early mobility
management, articles were not full-text articles, they were published before 2010, and if
they were not relevant to physiologic assessment measures or criteria to determine safe
early mobility.
Search Exhaustive and Comprehensive
The search was exhaustive, using various search terms and phrase combinations
that cover the practice-focused question and the target population. A review of abstracts
and articles’ reference lists occurred to ensure the search was exhaustive. The articles
selected were read in full to determine inclusion and exclusion based on the selection
criteria.
Institutional Review Board
The project is a systematic literature review, and the protection of human rights is
not an issue. An application for approval of the institutional review board from Walden
University was obtained to ensure that all rights are protected, 01-29-21-0758434.
Analysis and Synthesis
Systems used for Recording, Tracking, Organizing, and Analyzing the Evidence
Evidence was manually organized and documented in a Microsoft Word matrix
table. Table columns for each article include year published, author(s), title, purpose,
sample, design, and conclusions (see Appendix A). The project’s data organization
utilized the levels of evidence Melnyk hierarchy pyramid (Melnyk & Fineout-Overholt,
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2011; see Appendix B for illustration). The search procedure began by using CINAH
and Medline, and the initial search keyword used was early mobility or early ambulation
or early mobilization or early rehabilitation. The initial search resulted in a total of 3599
articles, narrowed down to 614 full text articles, narrowed down to 150 references
available, and further narrowed to 129 articles for publication years from 2010-2020.
Review of the 129 articles for relevance to the project’s practice questions, and inclusion
criteria resulted in 37 relevant articles. A PRISMA flowchart diagram will show an
illustration of the article’s selection procedure (see Appendix C).
Analysis Procedure
The analysis procedure used in this DNP project resulted in the evidence obtained
and will be categorized based on the strength of the evidence. The strongest available
evidence was selected to recommend a nurse-driven early mobility management
guideline. Data analysis will support the recommendation of a nurse-driven early
mobility management guideline, including physiologic assessment measures to
determine early mobility readiness. The JHEBP evidence level and quality guide was
used to grade the strength of reviewed evidence (Dang, et al., 2022).
Summary
A review of the current body of evidence on physiologic assessment and stability
in the mobilization of critically ill patients will answer how research and quality
improvement studies on mobilization in critical care address physiologic stability in
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decisions to mobilize patients and if there is a consistent, safe best practice. The goal of
this DNP project is to provide recommendations that can assist in addressing the lack of
nurse-driven early mobility management guidelines and physiologic assessment to
determine safe early mobility readiness of critically ill adult patients. Patient outcomes
and nursing practice in critical care units advanced by the evidence identified in this
systematic literature review. The DNP project addressing physiologic assessment
measures to determine early mobility readiness of critically ill adults and nurse-driven
safe patient early mobility management can improve safety in the healthcare
organization once implemented. The next section will include findings and
recommendations from the systematic literature review and their implications for the
practice-focused questions.
Section 4: Findings and Recommendations
Introduction
Nurses play a vital role in assessment and management of early mobility of
patients in the ICU. Early mobility management can be affected by multiple variables
including the experience level of the healthcare staff, assessment measures used to assess
mobility readiness, the level of nursing skills, as well as the patient’s physiologic and
hemodynamic response and status. The importance of EBP to the care nurse provide
includes improving the delivery of nursing care and patient outcomes. The gap between
implemented EBP and what occurs in practice can lead to poor outcomes; therefore, the
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ability to integrate evidence into practice is key in ensuring quality health care practice
(White et al., 2016).
EBP supports clinical decision making because it offers solutions to improve
health care quality and provide cost-effective care (Tucker, 2017). The absence of
evidence-based safe mobility guidelines and mobility readiness assessments affects
patient care decisions and outcomes. Guidelines have the potential to facilitate patient
care decisions, but due to inconsistent adoption in clinical practice guidelines have
limited affect and present a health system challenge (Kastner et al., 2011). Fundamental
to the practicum site to facilitate quality outcomes is evidence-based nursing practice
aligned with the latest research. Evidence-based guidelines also provide a variety of
structures that help ensure safe effective nursing care delivery. Evidence-based nursing
practice enhances knowledge sharing and collaboration across disciplines in solving
complex patient problems and decisions. Providing a summary of current research and
quality improvement on physiologic assessment guides nursing practice and other
disciplines in addressing the gap in clinical practice of critically ill patients’ readiness for
mobilization. A gap in nursing practice exists when an evidence-based readiness
assessment and practice guideline to support nursing practice in the management of early
mobility is not available. The purpose of this project was to examine and summarize the
benefits of evidence-based tools for physiologic assessment and stability in the
mobilization of critically ill patients. Synthesis of evidence relevant to physiologic
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assessment to determine mobility readiness and nurse-driven early mobility management
was completed to a improve the existing nursing practice of early mobility management
in the practicum site ICU.
The practice focused questions used to facilitate this DNP project
included:
7. What mobility patient interventions or assessments are initiated based on
physiologic assessment measures in comparison to the normal routine for
mobility assessment?
8. What is the effect of using physiologic assessment measures on determining
patient readiness for safe mobility?
9. What is the effect of using physiologic assessment measures on the incidence
and safety of patient mobility events?
Primary and secondary sources such as peer-reviewed evidence was used to support this
systematic literature review. Primary and secondary sources of peer-reviewed journal
articles and published guidelines were retrieved from Medline, PubMed, CNHAL,
Cochrane Library, and Joanna Briggs Institute. Available evidence used for the content of
the systematic review included the ICU Liberation, ABCDEF bundle E on early mobility
and exercise. Official websites of the Society of Critical Care Medicine, the American
Association of Critical Care Nurses, the Agency for Healthcare Research and Quality, and
the Institute for Healthcare Improvement were accessed for additional resources and
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evidence. The systematic review also included textbooks. Articles meeting the inclusion
criteria were used in the review.
The key word search terms used were early mobility, early ambulation, early
mobilization, early rehabilitation, assessment tools, assessment methods, assessing,
guidelines, protocols, practice guidelines, bundle, physiologic assessment, nurse-driven
early mobility management, ICU patient activity, hemodynamic stability, and
evidencebased guidelines for early mobility in critical care, early mobility patient
interventions and assessments, the effects of physiologic assessment measures on early
mobility, and physiologic assessment measures supporting safe patient mobility. Other
key words included in the search included critically ill patients’ mobility and activity,
hemodynamic stability mobility assessment, ICU Liberation, ICU patient mobility
management, nursedriven mobility bundles or guidelines in the ICU, physiologic stability
assessment measures before mobility in the ICU, and early mobility in adult ICUs.
Findings and Implications
The literature resulted in a total 3599 articles; 2985 were excluded due to lack of
full text; however, abstracts were reviewed for relevant information. From the screening
process, 464 articles were removed for lack of available references. The eligibility
involving the recent timeframe yielded 150 articles, which were further narrowed to a
publication timeframe 2010 to 2021. The analysis resulted in (N = 37) articles meeting
criteria for the review selection procedure (see Appendix C). The inclusion criteria for
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this systematic literature review included full-text articles addressing physiologic
assessment measures for mobility and articles relevant to early mobility guidelines and
protocols and barriers. Walden Library was contacted to explore access for full-text data.
Systematic Reviews were included in this literature review. Adler and Malone
(2012) conducted a systematic review of 15 studies on early mobilization in the ICU
using Sackett’s Levels of Evidence to rate the strength of the research of which one study
was Level 1 evidence, four were Level 2, one was Level 3, and nine were Level 4. The
studies included prospective and retrospective design of which included randomization.
The systematic review identified six criteria summarized from the literature for
terminating a PT/OT mobilization session. Termination criteria included parameters
concerning heart rate, pulse oximetry, blood pressure, respiratory rate, mechanical
ventilation, and alertness/agitation and patient symptoms (Adler & Malone, 2012).
Alaparthi et al. (2020) reviewed 56 studies in order to summarize the different aspects of
mobilization in the ICU of patients with or without mechanical ventilation. The review
identified safety measures including criteria for respiratory, cardiovascular, neurological
considerations, and others for early mobilization in the ICU. Other considerations were
identified as no unstable fractures or bony instability, not on continuous dialysis, no deep
vein thrombosis, body temperature <38.5, and no active bleeding (Alaparthi et al., 2020).
Alaparthis et al. (2020) also complied from studies red and green signals for active
mobilization of mechanically ventilated patients identifying which were for were for
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exercises in bed and which were for exercise out of bed. Hodgson et al. (2014) reviews
analyzed safety criteria for active mobilization of mechanically ventilated critically ill
adults resulting in expert consensus using a red, yellow, green coding system to
operationalize adverse event risk. Red indicated significant risk during mobilization,
yellow indicated mobilization after measuring risk versus benefit, and green mobilization
could be performed with a low risk (Hodgson et al., 2014). The review also summarizes
strategies for overcoming barriers including hemodynamic instability as a barrier with
strategy being a stepwise approach (Alaparthis et al., 2020). Costa et al. (2017) reviewed
49 studies after analysis identified four barriers to ABCDE implementation for adult
patients in the ICU: patient related (instability and safety concerns), clinician-related
(lack of knowledge and staff safety concerns), protocol-related (unclear and cumbersome
protocols), and ICU contextual barriers (interprofessional team coordination). Patient
instability and safety concerns included hemodynamics, treatment-related adverse events,
and physiologic patient issues (Costa et al., 2017). Patient safety issues considered issues
as diarrhea, fatigue, leaking wound, patient weight or size, confusion, agitation, and
imminent death (Costa et al., 2017). Costa et al. (2017) identified use of the domains as a
potential differential diagnosis for implementation of the ABCDE bundle. Dubb et al.
(2016) synthesized data from 40 studies to identify barriers to early mobilization and
strategies to overcome barriers. The most common patient related barrier was
hemodynamic instability identified in 20 (50%) studies then vascular access devices,
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tubes, and drains in 18 (45%) studies (Dubb et al., 2016). Strategies to address patient
related barriers for early mobilization included defining inclusion and exclusion criteria
for mobility, development and implementation of protocols, and interdisciplinary
collaboration (Dubb et al., 2016). Parry et al. (2017) analysis of 89 papers identified five
major themes patient physical and psychological ability to perform physical activity,
safety influences hemodynamic and respiratory physiologic stability culture and team
influences, motivation and beliefs about physical activity from patients, family, and
health care providers, and environmental influences (Parry et al., 2017). Development of
physiological stability guidelines for rehabilitation helped enable patient safety and
mobility (Parry et al., 2017). Reviews recommended protocols and a structured approach
or assessment to physiologic barriers to mobility using inclusion and exclusion criteria
based on patient assessment.
The remaining studies address the benefits of early mobility on patient outcomes
and patient mobility readiness measures. A non-randomized experimental pilot using a
mobility readiness protocol had eleven patients who passed and thirty-five patients who
failed the protocol for hemodynamic parameters including twenty-four with heart rate
above 120 beats per minute, seventeen with PEEP above 10cm H2O, and seventeen with
a PAO2 to FIO2 ratio smaller than 250 mmHg (Comradie et al., 2017). The readiness
protocol was found to be too strict when used to identify patients who could tolerate an
upright position using mean arterial pressure and oxygen consumption via venous oxygen
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saturation (Comradie et al., 2017). Cooper et al. (2021) study of 105 patients in a
medical intensive care out of 191 orally intubated were eligible for out of bed activities
using criteria based on hemodynamic stability found mobility practice still nonexistent.
All mobility readiness criteria must be met prior to out of bed activities including RASS
score, mean arterial pressure, FIO2, Spo2, systolic blood pressure, no titration of
inotropic medications, and PEEP (Cooper et al., 2021). Colwell et al. (2018) used a
severity of illness scale from one to four to determine mobility readiness, achieved
mobilization in more than 50% of the patients, and mobility complications included
transient desaturation, tachypnea, and emesis. Staff reported the most significant mobility
implementation barrier was the perception of physiologic instability and the additional
staff need for mobility activities (Colwell et al., 2018). Drolet et al. (2013) study included
eall patients were screened for mobility readiness and exclusion criteria to determine
mobility readiness was incorporated on order sets with defined criteria to prevent patient
desaturation and excessive work of breathing.
Safe patient handling is elemental to many study guidelines and protocol when
determining readiness and activities. Dickinson et al. (2018) study of integrating a
mobility program and safe patient handling included patients being evaluated for
inclusion in the mobility protocol and exclusion criteria are used to determine the need to
withhold mobility. Mobility program assessment questions guide staff on mobility phase
and safe patient handling equipment use (Dickinson et al., 2018). Eakin et al. (2015)
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described overcoming safety and mobility barriers including hemodynamic instability,
rising vasopressor requirements, accidental removal of an endotracheal tube, and line loss
using a model that includes engaging, educating, executing, and evaluating. Engel et al.
(2013) from a retrospective analysis of data indicated mobility and treatment starts by
identifying if there are exclusion criteria present and if yes assess ability to tolerate and
participate in mobility activities and if no assessment criteria determine mobility level.
Hickmann e al. (2016) an observational study on mechanically ventilated patients and
non-mechanically ventilated used a mobility protocol with levels zero to four taking into
account RASS, Glascow, and muscular strength and mobility provided at least once in
81% of all patients within 24 hours of ICU admission. Limiting factors for the study
included instability for 709 patients during bed to chair mobilization with severe
physiological in 42, hemodynamic in 21, respiratory in 5 and neurological in 16
(Hickmann et al., 2016). Hodgson et al. (2014) a prospective observational study on an
ICU mobility scale from existing studies and the John Hopkins scale adding more levels
of mobilization and the levels of assistance required found the maximum level of
mobility not achieved by the cohort and measures to determine stability and readiness
were no included. John Hopkins Early Mobility Toolkit Your Work Plan for Translating
Evidence into Practice (2020) includes a medical screening algorithm to evaluate patients
for mobility beginning with the ability to open eyes to verbal stimulation and assessment
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for mobility to occur within 24 hours of admission including neurologic, respiratory, and
cardiovascular elements.
Klein et al. (2018) a prospective longitudinal study includes an early progressive
mobility protocol to guide nursing decisions with patient readiness criteria for identified
stepwise mobility progression including four progressive mobility milestones from 16
mobility levels. Krupp et al. (2019) an exploratory descriptive study looked at factors
nurses in the ICU consider when making decisions about patient mobility and concluded
mobility programs should begin as soon as the patient demonstrates physiologic stability
and observations of patient’s strength, mental status, and physiologic response to activity
influence maintaining or progressing mobility. An additional prospective study with a
nonexperimental design used a contrasted-group approach, inter-rater assessments, and
expert agreement approach to assess the Banner Mobility Assessment Tool (BMAT) for
Nurses in use provided evidence the tool is valid in assessing a patient’s mobility status
(Boynton et al., 2014). When consulted physical therapists guide the mobility plan of
care and progress completing mobility and gait assessments creating a disconnect
between actionable items for nursing and the desire to increase mobility (Boynton et al.,
2014). Lin et al. (2018) a prospective observational study of an early mobilization
protocol identified discontinuation of mobilization criteria was also a criterion for
readiness including hemodynamic and respiratory parameters as symptomatic heart rate,
blood pressure, arrhythmias, oxygen saturation, respiratory rate and mechanical ventilator
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asynchrony. Respiratory, cardiac, and consciousness parameters were identified for
advancing the protocol and the incidence of adverse events for all sessions was 2.2% out
of 587 (Lin et al., 2018).
Mobility goals should be included for patients eligible for activities. Messer et al.
(2015) a correlational descriptive study identified exclusion mobility readiness criteria
including unstable hemodynamic status, two or more vasopressors, neuromuscular
blockade, physician order for bedrest, and end of life. Dangling was the only specific
activity after nursing education that increased despite a goal of all patients who met
inclusion criteria receive a level of intervention besides turning (Messer et al., 2015).
Milano et al. (2014) used a decision tree flow chart after a physician gave medical
clearance to start mobility progression by a nurse or physical therapist using care boards
to document why, how it is done, and what the patient needs to do. Perme et al. (2014)
describes a mobility score assessment tool including potential mobility barriers as bed
mobility, transfers, gait, endurance, and functional status with high scores indicating few
mobility barriers and decreased assistance. Patients on low levels of vasopressors were
five times as likely to be mobilized and those on moderate doses were twice as likely to
be mobilized (Perme et al., 2014). Rebel et al. (2019), in their retrospective cohort study,
found patients were mobilized on one-third of vasoactive days found in 195 episodes of
mobilization patients were more likely to experience an adverse event with a low mean
arterial pressure, higher SpO2 and higher FiO2. The Society of Critical Care Medicine,
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ICU Liberation Bundle E (2013) identifies maximal activity includes hemodynamic
stability, an awake patient, and a patient that was walking before admission and absolute
contraindication to is hemodynamic instability defined as a patient on escalating doses or
multiple vasopressors. Sommers et al. (2016 a prospective observational reliability and
validity study indicated the assessment of patients in the ICU is complicated by
pulmonary and hemodynamic conditions needing medications and invasive equipment
with changing medical situations and the ability to perform mobility activities changes
within an hour due to fatigue and exertion. Whelan et al. (2018) a quasi-experimental
study used ten domains to measure physical function using the Chelsea critical care
physical assessment (CPAx) tool in the ICU graded zero to five to identify problems and
address. The CPAx tool is an outcome measure that responds to change designed to
assess physical ability, respiratory function, cough, bed mobility, supine to sitting on the
edge of the bed, dynamic sitting, sit to stand, standing balance, transferring from bed to
chair, and stepping and grip strength (Whelan et al., 2018). Zomorodi et al. (2012)
completed a pilot study included a mobility decision tree flow chart beginning with is
patient hemodynamically stable and if no mobility is not indicated and if yes evaluate if
vital signs stable in bed with rolling for bed linens changes and hygiene then begin
activity. Stiller’s safety for mobilization guidelines beginning with level one with six
total activity events and during mobility activities nurse’s role included monitoring blood
pressure, heart rate, oxygen saturation, and lines and tube safety (Zomorodi et al., 2012).
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Evidence-based programs for mobility support quality outcomes. The Agency for
Healthcare Research and Quality for Advancing Excellence in Healthcare Safety Program
for Mechanically Ventilated Patients, Nurse Driven Early Mobility Protocol (2019)
contains an ICU mobility screen with exclusion criteria and mobility to begin when the
patient meets criteria including follows the keys to prevent excessive work of breathing
and desaturation. Balas et al. (2012) indicates parameters used to assess patients’
readiness for mobility include neurologic, respiratory, circulatory, and central line
contraindications and patients not eligible or have activity halted for an adverse event are
reassessed every day and thus eligible begin activity. Boyton et al. (2014) looked at
clinical practice guidelines for mobility without determination criteria for patient
readiness and noted staff injuries decreased after implementation and increased nurse use
of mobility guidelines in patient activity. Clinical practice guideline for mobility along
with a mobility champion providing knowledge of the impact of immobility can support a
seven progressive step mobility plan for patients (Bruce & Forry, 2018). Campbell et al.
(2015) included contraindications for initiating and continuing mobility along with
detailed steps to prepare for mobility and offered evidence that high fidelity simulation
builds confidence in early mobility collaborations around patients that can occur during
mobility events.
Barriers, patient assessments, and patient conditions limit mobility activities.
Costa et al. (2017) identified ABCDE barriers including patient instability and safety
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concerns, clinician related including staff safety concerns, lack of knowledge, protocol
related, and ICU contextual barriers. Patient related issues include hemodynamics,
treatment related adverse events, and physiologic patient issues (Costa et al., 2017).
Costa et al. (2017) Identified barriers, grouped into four domains as a differential
diagnosis checklist to assess barriers to ABCDE implementation. Engel et al. (2013)
three medical center’s quality improvement mobility projects identified patient
assessment for exclusion criteria and if patient able to properly attend to tasks and
inclusion if patient verbal or manual stimulation with an identified RASS and further
considerations include patient remains alert, demonstrates trunk control, and vital signs
are acceptable. Klein et al. (2018) a quasi-experimental a quality improvement project
used an inpatient algorithm combining the John Hopkins Highest Level of Mobility Scale
and the Activity Measure for Post-Acute Inpatient Mobility Short Form to guide the
nursing team on setting mobility goals. The Activity Measure for Post-Acute Inpatient
Mobility Short form six questions quantify functional limitations based on direct
observation or clinical judgement of needed from another during activities as turning,
sitting on the edge of the bed, transfer from bed to chair, standing from chair, walking in
the room, and climbing three to five steps (Klein et al., 2018). McWilliams et al. (2015)
identified mobility for ventilated patients should include sitting on side of bed when
appropriate within the first five days allows assessment of sitting balance, exercise
capacity and physiological stability with six exclusion criteria and five restrictions to
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edge sitting. Before beginning activity, the protocol assessed for RASS score and/or
presence of contraindications to determine use of passive or active mobility measures
(McWilliams et al., 2015). Schallom et al. (2020) a staggered quality improvement
project using the American Association of Critical Care early mobility protocol begins
with step one screening for safety and evaluating patients every 12 hours for myocardial
and oxygenation stability, vasopressor use, vascular access, engaging to voice, and
neurological/ortho/wound stability findings included increased mobility levels. The four
mobility levels included goals at each level and measurements during phase one of the
project included CAM-ICU twice daily and the highest and lowest RASS score in
24hours (Schallom et al., 2020). Hemodynamic instability is one of the most common
perceived patient-related barriers limiting the practice of early mobilization (Alaprrthi et
al., 2020). Physiologic assessment to determine mobility readiness is a clinical risk
assessment focusing on improving quality and safety by identifying circumstances that
put patients at risk (Asefzadeh et al., 2013). Conradie et al. (2017) a nonrandomized
experimental pilot evaluated the feasibility of a protocol using hemodynamic parameters,
mean arterial pressure, and central venous oxygen saturation of eleven patients in the
baseline line position and then again at 0.3 and 10 minutes in a therapeutic upright
position found the protocol was to strict. One hundred and thirty-eight patients were
screened with 10 excluded for logistical reasons, 82 patients excluded based on exclusion
criteria, and 35 failed the protocol (Conradie et al., 2017). Reasons for failing the
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protocol included a heart rate above 120 beats per minute (n = 24), PEEP above
10cmH2O (n-17), and PaO2/FiO2 ratio smaller than 250mmHg (n = 17) (Conradie et al.,
2017).
Limitations/Potential Impact on Findings
Most of the studies resulted in improvement in patient’s outcomes with the
exception of a study where 35 patients failed the protocol and the most prevalent reason
was a heart rate above 120 beats per minute (n=24), a PEEP above 10cm H20 (n=17), and
a PAO2/FiO2 ratio smaller than 250 mmHg (n=17) (Comadie et al., 2017). Krupp et al.
(2019) also found variations in nursing practice including hesitancy to be the first to
mobilize a patient and most critically ill patients did not have a mobility goal, and
decisions to mobilize were based on a nurse’s decision instead of an established standard
of care along with nurse education about mobility does not increase the frequency of
patient mobility. Messer et al. (2015) study identified after education of MSICU nurses
the 39% of the 75 potential mobility events resulted in some type of mobility increased to
only 60% of the 85 potential and the goal of all patients who met inclusion criteria
receive some level of intervention besides turning was not met. Moraes et al. (2019)
found resistance to change until the proposed concept is consistent and reproducible in
low sample size and effect size. Zomorodi et al. (2012) a pilot study with a sample size
of three limited the interpretation of the results even though the study helped identify
efficacy of the protocol.
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Implication for Social Change
This systematic literature review supports the need for available evidence-based
nurse driven readiness assessment and guideline for nurses to collaborate with the
healthcare team in the management of safe early patient mobility. An adaption of a
mobility readiness assessment and evidence-based early mobility practice guideline will
result in the enhancement of nursing practice supporting quality patient outcomes. Nurses
will be able to monitor, assess, and measure the effects of interventions in the patient’s
care guided by evidence (White et al., 2016). This systematic literature review addresses
the gap between mobility readiness assessments and early mobility practice which will
ultimately improve the safety and out comes at the local clinical practicum site. This will
impact positive social change and nursing practice.
Recommendations
After analyzing and synthesizing the data collected in this systematic literature
review for the project it was concluded the project will have an influence on the nursing
practice at the project site. The recommendations concluded from this systematic
literature review revealed the need for additional studies on comprehensive mobility
readiness measures and management to be conducted using the adult critically ill patient
population. Further studies will help validate the implication of mobility readiness
assessments and safe early mobility management in the care of critically ill adult
population.
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Plan to Extend Beyond the DNP Project
The DNP project will be continued post the doctoral phase in collaboration with
the health care team and local IRB office to operationalize early mobility readiness
assessment and a nurse-driven guideline for early mobility for critically ill adult patients.
Furthering the project will require time and collaboration with key stakeholders. Next
steps will include piloting the project and evaluating the effectiveness of the project prior
to full implementation estimating six months to a year from pilot to full implementation
and continued follow thereafter.
Strengths and Limitations of the Doctoral Project
Knowledge gained throughout the project process is a strength of the doctoral
process. A large source of evidence and data with positive outcomes was found in the
literature in the critical ill adult population on early mobility and mobility readiness
including barriers. There is less evidence in the literature regarding the impact of
mobility readiness assessments impact on early mobility management in the adult
critically ill patient population. Benefits of the project include sharing of information with
stakeholders and frontline nursing staff as well as the leadership team within the project
site and critical care nursing associations. The project summary can be used to help
nursing leadership and healthcare staff with decision making on mobility initiatives in
improving clinical practice and patient care. Limitations of the project include the lack of
research studies on mobility readiness assessments impact on patient outcomes and
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delays in mobility in the critically ill patient population. This project benefit is validated
in the adult critically ill patient ICUs beyond the project site ICU.
Recommendations for Future Projects
This review identified the need for more studies on the impact of mobility
readiness assessment on critically ill patient outcomes with mobility guidelines. The
analysis and synthesis of the project found several studies demonstrated the lack of
evidence in early mobility management patient assessment for readiness to mobilize. The
results of the review concluded the adoption of an evidence-based practice mobility
guideline including readiness assessment improves positive patients’ outcomes and
nursing practice. Further research is needed in mobility readiness criteria since this
review produced lack of comprehensive guidelines in the adult critically ill population in
the ICU and studies comparing comprehensive guidelines.
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Section 5: Dissemination Plan
EBP is essential in nursing practice and researching incidence and validity of
early mobility management can help identify plans to effectively disseminate new
knowledge and information. Quality patient outcomes are dependent on translating new
knowledge into practice. Early mobility readiness assessments included in early mobility
guidelines is challenging due to limited published literature and the lack of consistent
nursing practice concerning early mobility. The purpose of this project was to evaluate
and synthesize evidence on mobility readiness assessments and nurse-driven early
mobility management, which could lead to a recommendation that would improve early
mobility management in the ICU. The findings of this project were intended to inform
nursing and healthcare leadership and provide recommendations for adopting EBP for
management of early mobility and mobility readiness assessment. The synthesis of this
project’s results can be disseminated to the practicum site leaders through the literature
review project.
Audiences for Dissemination
The nursing staff and healthcare team at the practicum site are the primary
audience for this project dissemination. Stakeholders involved in this project include the
Vice President of Nursing, the Director of Nursing, and the practicum site mentor. An oral
PowerPoint presentation will be used to disseminate the project findings and
recommendations to the intended nursing staff and leadership. Findings from the project
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may promote and support early mobility management and other changes in nursing
practice for the practicum site ICU. Collaboration and sharing knowledge learned from
the findings of this project with other ICU units includes a future poster presentation and
submission of an abstract to several critical care journals of interest.
Analysis of Self
My experience in the DNP program started with a need to grow and continue
lifelong learning postmasters, and a need to continue on a journey for self-improvement
and as a champion of EBP. Sharing and promoting EBP is a passion which ultimately
improves nursing practice and patient outcomes. Critical thinking and problem solving is
grounded in EBP. Collaboration with the healthcare team and nursing colleagues helped
identify my DNP project focus as I heard areas of concern and practice needs around
patient readiness assessment and mobility management. I have gained great appreciation
for EBP from my previous experience as a clinical nurse specialist and realize
evidencebased practice is not part of many nurses’ clinical practice. My DNP program
experiences have reinforced the importance of EBP throughout. My doctoral program
journey has provided growth for me professionally and personally.
My professional role in nursing is an advanced practice nurse and leader of an
ICU and an Intermediate Care Unit. Over the years of my career, I have worked as a staff
nurse in both ICU and PACU, a clinical nurse specialist in Critical Care, and as a nurse
leader. Each role has shaped my career and prepared me for where I am in nursing today
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as a professional and nurse leader. My goal through this program was to analyze existing
EBP concerning mobility management and patient readiness assessments for mobility to
adapt an evidence-based mobility management practice guideline that may assist in
decreasing variations in practice for adult critically ill patients. Resistance to change is an
ongoing issue in clinical practice and a challenge I anticipated because adopting EBP has
barriers despite improving patient outcomes. During DNP practicum experiences and
courses, I have learned and been exposed to strategies to address resistance to change.
My leadership experience has provided many opportunities to successfully implement
EBP.
Summary
Safe early mobility management is challenging yet essential component of care
for the adult critically ill patient population within the ICU. Patient outcomes and
complications depend on decreasing immobility and the deconditioning associated with
immobility in the ICU. During this project, I conducted a systematic literature review to
examine and summarize evidence that can be used to recommend a nurse-driven
guideline including readiness assessment for early mobility of critically ill adults in the
ICU. This systematic literature review can provide nurses with a tool useful in the
collaboration with the healthcare team to efficiently manage early patient mobility.
Research should be conducted to confirm these findings as well as to determine the
relationship between using evidence-based nurse driven assessment for mobility
205
readiness, early mobility guidelines, and patient outcomes. As the recommendations of
the project findings are provided to the practicum site, it rests with the practicum site to
implement the project.
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