Interventions in the Mobility Domain: An Organizational Perspective

The devastating impact of immobility is clear.1,2 In addition to the human toll physical immobility takes, the consequences of failing to intervene in this domain of care are far reaching. While this issue focuses on increasing mobility with critical care patients, the impact of decreased mobility is clearly evident in all the populations we serve and, as such, became an identified priority for attention. As with all other "critical priorities" for attention, the organizational challenge becomes how we successfully integrate this work into nursing practice in an effective and sustainable way.

Nurses in today's workplace confront change on an almost constant basis. A common concern expressed is the continual "bombardment' of practice changes, changing information, and sometimes "flavor of the month" initiatives that are perceived to be "handed down" from leadership. While many of the nurse-sensitive patient outcomes we all seek to improve (ie, the reduction of pressure ulcers and falls, increased restraint use, etc) are important, even these when viewed as serial and additive changes lend themselves to overload.

This litany of changes need to be effectively led and managed so that the priority practices that most critically impact patient care and outcomes do not get overshadowed by a barrage of continuing requests. The question then becomes, how, from an organizational and leadership perspective, do we assist and support nurses and other frontline staff in focusing on a specific practice change, such as increasing mobility, while continuing to meet multiple demands on a daily basis?

Creating meaningful work...

To move this work forward, nursing at the University of Michigan needed to prioritize and integrate this focus on mobility into work that was meaningful to patients, families, and nurses. We also understood that change is best created and executed in a collaborative process-in this case, nursing leadership, practicing nurses, and patient partners. Our first steps toward this journey occurred in 2010 when we brought more than 100 nurses in all roles, nursing faculty and students, patient and family members, and partners and interprofessional colleagues, together to cocreate a new model of nursing practice. Using a large-scale change model developed by Dannemiller Tyson Associates,3 we cocreated a model of nursing care that places the patient and family members as the drivers of their care with the goal of increasing self-care efficacy and a focus on 7 important domains of practice. Mobility and activity became one of the critical domains of interest.

Integrating practices to improve care...

As we collectively reviewed our performance on pressure ulcer prevention and restraint use and falls, we were confronted with clear opportunities to improve our care. Rather than continue to conceptualize these as separate, serial indicators, we used the mobility domain of our model as the organizing construct for action. Using this principle of integration, we hypothesized that as we concentrated on increasing the patient's mobility, even in the intensive care environment, we would increase blood flow and circulation, increase cognitive function, decrease the loss of muscle mass and therefore decrease the risk of falling, decrease the use of restraints, and prevent pressure ulcers. Integrating these individual nurse-sensitive indicators into the overall goal of increased mobility became our collective focus.

Challenging the status quo...

With this, practice areas were challenged to identify what they might do to increase mobility in the patient populations they served. In doing so, many historically held beliefs about the adverse impact of moving patients, particularly in intensive care settings, were challenged. These articles clearly describe the variety of ways nurses began to assess and creatively intervene with critically ill patients with burn injury, patients on ventilators, neurological patients, and many others.

Safety as an organizing principle...

Comprehensive assessment and patient safety became the first principle of care, but instead of fearing that mobility might harm the patient, the need to think about how increased activity might actually improve patient outcomes became the collective goal. While some of our data on the impact of mobility on patient outcomes have not yet revealed significantly positive outcomes, adverse impacts have not been experienced and the momentum to increase ambulation and mobility across all our care settings remains a core nursing practice as we continue to evaluate its impact.

Partnership for success...

The second key principle that is apparent in this journal issue is that the work we are doing depends upon a team. It is clear that not only the partnership between disciplines, such as nursing and physical therapy, is important but also the partnership with our patients and family members becomes a critical principle for success. All underscore the value of working together to innovate care.

In the end, there is hope...

The tangible results of increased mobility continue to be studied, and the work we are doing to decrease muscle loss, improve physiologic functioning, and prevent adverse outcomes remains an important goal, but there is something else. One day on rounds, I had the privilege of witnessing our team of nurses and physical therapists work with a patient who was in our critical care unit take her first steps after being placed on a ventilator. I watched as 3 nurses and a physical therapist worked gently with the patient to manage all her intravenous catheters, ventilator tubes, etc, and help her sit up and then stand. She was able to take only a few small steps but the look on her face was priceless-I saw pride. Her husband was sitting in a chair a few feet away witnessing the event, and he became almost overwhelmed with emotion, because for him, as he explained, this was the first indication that his wife "was going to make it." This was the first sign of her strength after seeing her look helpless as she lay in bed, and this for him, was hope.

I left that encounter reflecting on the intangible aspect of mobility-helping someone become mobile and start to move even a limb gives a person strength; helping someone walk again gives a person back his or her independence; increasing mobility means giving a person and his or her loved ones hope of recovery. Strength, independence, and hope are the hallmarks of our practice. In a similar fashion, we hope that this issue of Critical Care Nursing Quarterly creates a hopeful spark to integrate mobility practices into the nursing care in your organization.

-Margaret M. Calarco, PhD, RN

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