Transforming the culture: The key to hardwiring early mobility and safe patient handling

To avoid injuring their patients and themselves, healthcare providers must get in the habit of using safe patient handling and mobility (SPHM) technology. In this supplement, national experts share their perspectives and best practices on topics ranging from dealing with bariatric patients, managing slings, and assessing a patient’s mobility to transforming the culture, building the business case for an SPHM, and developing a successful SPHM program.

Download a PDF of the entire supplement here.


Early mobility in the intensive care unit (ICU) is critical to a patient’s short- and long-term recovery. Studies show early mobility programs result in more ventilator-free days, fewer skin injuries, shorter ICU and hospital stays, reduced delirium duration, and improved physical functioning.

But accomplishing early mobility requires significant coordination, commitment, and physical effort by the multidisciplinary team. How do we balance the benefits of early mobilization against the potential risk of staff or patient injury during the mobilization activity? Part of the solution to ensuring safe mobilization of critically ill patients is to view mobilization along a continuum based on patient readiness, progression based on goals, strategies to prevent complications, and assessment of activity tolerance. This view keeps safety at the forefront.

Within the ICU, barriers to early mobility may include clinicians’ knowledge deficits and fears, insufficient human and equipment resources, patients’ physiologic instability, lack of emphasis on the value and priority of mobilizing patients, and the ICU culture related to mobility. A 2014 international survey of early mobilization practices in 833 ICUs found only 27% had formal early mobility protocols, 21% had adopted mobility practices without a protocol, and 52% hadn’t incorporated early mobility into routine care practices. Barriers to implementation of mobility initiatives included competing staffing priorities, insufficient physical therapy staff, and concern about patient and caregiver injury. The study found that a standardized protocol may promote successful implementation of an early mobility program.

Importance of a culture change

Sustaining any clinical improvement initiative requires an organizational culture change. Baseline assessment of the current culture as well as early engagement of team members is the starting point. In 2012, the authors led a VHA, Inc. critical care improvement team collaborative of 13 ICUs from eight organizations to implement safe and effective early patient mobility in the ICU. Efforts focused on elements central to sustainable change. First, team members acquired key knowledge to understand why ICU mobility is important. Next, strategies for organizational, leadership, and clinical staff engagement were discussed. To promote the transition in practice and the required culture change, ICU clinicians needed guidance. An organizational development tool was designed to help teams create an effective culture change. Although it was adapted specifically to integrate with early patient mobility efforts in the ICU, this tool can be applied to other settings. (See Learning progression for patient mobility.)

Three elements are crucial to successfully implementing and sustaining an improvement initiative:


  • Team members must understand and be able articulate what’s being proposed. To help them understand, they must receive evidence-based literature and other relevant information.
  • Team members must grasp why the initiative is important to the patient, themselves, and the organization. Clinicians typically respond favorably to change when they can connect it to real impacts.
  • The leader of the initiative must define the role of each team member and discipline. Understanding team roles creates a solid platform on which the culture change builds.

Four stages of learning

To learn a skill or concept, a person progresses through four stages, according to a learning model attributed to Abraham Maslow. This model can be applied to clinicians learning about safe patient handling and mobility (SPHM).

Stage 1: Subconscious, unskilled

In this stage, team members are unaware of how little they know and don’t realize a change is necessary. Also, they may have fears and misconceptions about the change. For example, some critical care clinicians believe repositioning or mobilizing critically ill patients threatens the security of vital tubes and lines. But with the proper knowledge, training, and resources, staff can mobilize and reposition ICU patients safely without jeopardizing tubes and lines. In one study, 1,449 activity events (such as sitting up in bed, sitting in a chair, and ambulating) were performed with mechanically ventilated patients; fewer than 1% experienced adverse events. As part of the culture change, misconceptions about SPHM need to be addressed through education and coaching. Once the purpose of SPHM is defined clearly and misconceptions have been addressed, team members are ready to move on to stage 2.

Stage 2: Conscious, unskilled

In the conscious, unskilled stage, team members understand why SPHM is important but don’t know how to accomplish it. Although open to new learning, they may have fears about specific processes or actions involved in patient mobilization. For instance, they may fear certain types of mobilization activities can cause hemodynamic instability. Education and practical application experiences can help them overcome this fear. Another way educators can break through such barriers is to use a decision tree that incorporates the latest scientific knowledge to help clinicians minimize the hemodynamic impact or retrain patients to tolerate movement. (See Decision tree for mobilizing hemodynamically unstable patients.)

A critical resource used with the VHA team was a nurse-driven, evidence-based multidisciplinary progressive mobility continuum tool that addresses mobility phases and corresponding interventions. The team received education on the tool and how to apply it in practice. The tool provided a visual foundation to guide safe mobility practices, create consistency, promote team communication, and enhance processes.

Numerous studies show that education, skill building, and protocols may not be enough to create sustainable change. Using strategies to evaluate available nursing resources and systems that can produce change makes it easier for clinicians to provide the right care for the right patient at the right time while balancing these needs against caregivers’ needs for safety.

In bed and out-of-bed activities

Strategies to promote patient and caregiver safety during mobilization can be divided into two basic categories—those used when the patient is in bed and those used when the patient is out of bed. In-bed mobility encompasses repositioning activities, lateral-rotation therapy, tilt-table exercises, and bed-chair sitting. Modern critical-care beds should be capable of rotating the patient continuously, creating a tilt table through the use of a reverse Trendelenburg position and an adjustable footboard, progressing the body through the head elevation–foot down position to a chair, and ultimately assisting the patient with standing. These features reduce the risk of patient and caregiver injury and make it easier to perform mobility actions.

For in-bed repositioning from side to side and moving up, using a breathable glide sheet and specially designed foam wedges helps reduce shear and friction for the patient and help prevents injuries to caregivers because they require a pulling rather than lifting motion. In one study, implementation of this turn-and-position system reduced hospital-acquired pressure ulcers by 28% and reduced staff injuries by 58%. Lifts can be used for some in-bed mobility activities and are effective during ambulation and the transition from in-bed to out-of-bed activities.

Stage 3: Conscious, skilled

Stage 3 learning focuses on implementing the change, with attention to fine-tuning the process. Coaching, mentoring, and maintaining engagement are critical. In previous stages, much effort was expended in educating and training staff. During the transition from stage 3 to stage 4, the skills and knowledge required for the SPHM initiative must become “hardwired” or ingrained into caregivers’ subconscious. This requires deliberate, focused energy on continued engagement. However, staff energy, resource availability, and competing priorities may pose barriers to sustaining the change.

Throughout stage 3, positive feedback, motivation, and sharing of successes and challenges are important for driving continual improvement and culture change. These goals can be accomplished in various ways. Here are some examples:

  • Networking with other organizations in various stages of the practice change can be extremely useful. It allows collaborative identification and sharing of challenges, struggles, effective strategies, and success stories. This process creates synergistic energy among the team members, helping to motivate them and accelerate the change.
  • Within the VHA mobility collaborative network, teams shared reward strategies. One team gave out M&Ms® when “caught in the act” of Moving and Mobilizing patients. Such moments present crucial coaching opportunities. For example, after a mobility event, staff can huddle briefly to discuss the event and what, if any, improvements could be made to make the process more effective.

Stage 4: Subconscious, skilled

During this stage, the practice and culture changes are well on their way to becoming firmly rooted and incorporated into caregivers’ daily practice. Although the practice change is becoming the new norm, coaching and mentoring are needed to help maintain momentum. Stories learned along the journey should be used to inspire both novice and expert clinicians.

Objective evaluation of the improvement process should continue, focusing on outcome measures and identifying improvement opportunities to promote refinement. Team members are now doing things they never thought were possible—and previously believed to be unsafe. Recently, I learned of a ventilator patient at St. Luke’s Medical Center, Boise/Meridian (Idaho) who was receiving continuous renal replacement therapy (CRRT). Staff safely mobilized the patient to the chair using the hospital’s mobility protocol. In many ICUs, such a patient would be bedbound. But at St. Luke’s, early mobility is now routine practice even for these patients. Conversation about mobility occurs in daily rounds and often is a major focus of daily patient goals.

In fact, staff members are likely to comment that they no longer ask the question “Can we mobilize this patient?” Instead, they ask, “Is there a reason why we can’t mobilize the patient?” Key lessons learned to promote and maintain this cultural transformation include the importance of testing new practices on a small scale, getting regular feedback of performance and outcome data, providing sufficient education, and increasing caregivers’ will to mobilize patients by seeing the work in action.

Deliberate focus, full engagement

Incorporating new evidence into daily practice isn’t enough to sustain a culture change to emphasize early mobility and SPHM. Such a change comes only with a deliberate focus on three key questions: What are we are doing? Why are we doing it? What’s my role? Full engagement and cultural transformation can occur only when all team members can respond to these questions with full understanding.

References

Bailey PB, Thomsen GE, Bezdjian L, et al. The progression of early activity in mechanically ventilated patients is improved upon transfer within ICUs. Crit Care Med. 2005;33(12):A118.

Bakhru RN, McWilliams D, Spuhler V, Schweickert WD. C15. Central nervous system and motor impairment in critical illness: an international survey of early mobilization practices [abstract]. Am J Resp Crit Care Med. 2014;189:A3933.

Bassett RD, Vollman KM, Brandwene L, Murray T. Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): a multicentre collaborative. Intensive Crit Care Nurs. 2012;28(2):88-97.

Jackson JC, Santoro MJ, Ely TM, et al. Improving patient care through the prism of psychology: application of Maslow’s hierarchy to sedation, delirium, and early mobility in the intensive care unit. J Crit Care. 2014;29(3):438-44.

Herridge MS, Tansey CM, Matté A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011;364(14):1293-304.

Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to facilitate early mobility. Crit Care Clin. 2007;23(1):81-96.

Morris PE. Moving our critically ill patients: mobility barriers and benefits. Crit Care Clin. 2007;23(1):1-20.

Morris PE, Goad A, Thompson C, et al. Early intensive care mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-43.

Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010;91(4):536-42.

Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009; 373(9687):1874-82.

Stiller K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin. 2007;23(1):35-53.

Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med. 2008;36(4):1119-24.

Vollman KM. Interventional patient hygiene: discussion of the issues and a proposed model for implementation of the nursing care basics. Intensive Crit Care Nurs. 2013;29(5):250-5.

Vollman KM. Understanding critically ill patients hemodynamic response to mobilization: using the evidence to make it safe and feasible. Crit Care Nurs Q. 2013;36(1):17-27.

Way H. Safe patient handling initiative results in reduction in injuries and improved patient outcomes for pressure ulcer prevention. Paper presented at: Safe Patient Handling East Conference; March 27, 2014; Orlando, Florida. www.sageproducts.com/documents/pdf/education/symposia/Sacral/Heather%20Way%20SPH%20Poster%202014_22280.pdf. Accessed July 16, 2014.

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Kathleen M. Vollman is a clinical nurse specialist, educator, and consultant with Advancing Nursing, LLC in Northville, Michigan. Rick Bassett is a cardiovascular clinical nurse specialist in adult critical care at St. Luke’s Medical Center, Boise/Meridian, Idaho.

Read the next article: Standards to protect nurses from handling and mobility injuries

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