Magazine article American Nurse Today

Transforming the Culture: The Key to Hardwiring Early Mobility and Safe Patient Handling: Culture Change Requires Deliberate Focus, Staff Education, and Full Engagement

Magazine article American Nurse Today

Transforming the Culture: The Key to Hardwiring Early Mobility and Safe Patient Handling: Culture Change Requires Deliberate Focus, Staff Education, and Full Engagement

Article excerpt

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. …

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