Intensive and Critical Care Nursing 42 (2017) 36–43

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Intensive and Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Original article

The MOVIN’ project (Mobilisation Of Ventilated Intensive care

patients at Nepean): A quality improvement project based on the
principles of knowledge translation to promote nurse-led
mobilisation of critically ill ventilated patients
Anwar Hassan ∗ , Arvind Rajamani, Fiona Fitzsimons
Intensive Care Unit, Nepean Hospital, Penrith, NSW, 2747, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Prospective quality improvement project to evaluate the impact of a training programme to
Accepted 25 April 2017 promote nurse-led mobilisation of intubated critically ill patients.
Methods: This project involved an educational programme to upskill nurses and overcome the barri-
Keywords: ers/challenges to nurse-led mobilisation. Initial strategies focused on educating and upskilling nurses to
Critical care attain competency in active mobilisation. Subsequent strategies focused on positive reinforcement to
Quality improvement project
achieve a culture shift. A pre- and post-intervention audit was used to evaluate its effectiveness.
Mobilisation
Results: A baseline audit showed that ∼9% of ventilated patients were mobilised. Several barriers were
Ventilated patient
identified. Twenty-three nurses underwent training in actively mobilising ventilated patients. This
increased their confidence levels and there was reduction in reported barriers. However, the rate of active
mobilisation remained low (9.7%). Subsequently, a programme of positive reinforcement with rewards
and visual reminders was introduced, which saw an increase in the number of nurse-led mobilisations
of both ventilated patients (from 9.7% to 34.8%; p = 0.0003), and non-ventilated patients (29.5% versus
62.9%; p = <0.0001).
Conclusion: It is safe and feasible to train nurses to perform active mobilisation of ventilated patients.
However, to promote a culture change, training and competency must be combined with a multi-pronged
approach including reminders, positive reinforcement and rewards.
Crown Copyright © 2017 Published by Elsevier Ltd. All rights reserved.

Implications for clinical practice

• Apart from training, motivational strategies play an important role in promoting nurse-led mobilisation in the intensive care unit.
• A multifaceted approach is more beneficial than any single intervention in implementing research into clinical practice.
• It is safe for skilled nurses to perform active mobilisation of intubated patients.

Introduction
Early mobilisation of critically ill patients is increasingly being
recognised for its beneficial effects on minimising neuromuscular
weakness (Kayambu et al., 2013; Li et al., 2013), shorter intensive
∗ Corresponding author.
E-mail addresses: anwarpt77@yahoo.com.au (A. Hassan),
rrarvind@hotmail.com (A. Rajamani).
care unit (ICU) and hospital length of stay with a trend toward
decreased ICU mortality (Bailey et al., 2007; Martin et al., 2005;
Morris, 2007; Morris et al., 2008; Schweickert et al., 2009; Stiller
et al., 2004). Despite this, the use of physical therapies in critically
ill patients remains under-utilised all over the world, including
in Australia and New Zealand (Hodgkin et al., 2009; The TEAM
Study Investigators, 2015; Needham et al., 2007; Rochester, 2009;
Winkelman et al., 2005). Common barriers that preclude mobili-
sation include safety concerns around accidental dislodgement of
the tracheal tube and/or catheters, risk of falls and haemodynamic
instability; patient-related issues such as obesity and suboptimal

http://dx.doi.org/10.1016/j.iccn.2017.04.011
0964-3397/Crown Copyright © 2017 Published by Elsevier Ltd. All rights reserved.
 A. Hassan et al. / Intensive and Critical Care Nursing 42 (2017) 36–43
sedation state; logistic issues such as the availability of time, ade-
quate staff to safely mobilise patients and the related expense
(Hodgson et al., 2015; Hopkins et al., 2007; Leditschke et al., 2012;
Li et al., 2013; Morris, 2007; Nydahl et al., 2014; Zanni et al.,
2010). Interestingly, Garzon-Serrano et al. (2011) reported that
barriers are perceived differently by physiotherapists and nurses,
with physiotherapists achieving a higher level of mobilisation than
nurses. The authors (Garzon-Serrano et al., 2011) attributed this to
several factors, time constraints for nurses and the need to priori-
tise care due to more diverse responsibilities than physiotherapists.
Physiotherapists, with their specific knowledge of neurologic and
musculoskeletal conditions might be more focused on how to
advance patients with mobilisation therapy. There have been rec-
ommendations calling for a “culture change” within the ICU to use
physiotherapy and early mobilisation of the critically ill patient
more routinely, based on the success of a multidisciplinary team
model (Ramona et al., 2007) and growing body of evidence. In our
twenty-two-bed tertiary general ICU, despite an audit showing a
high awareness among nursing and medical staff of its potential
benefits, only ∼9% of ventilated patients were mobilised. Although
regular passive mobilisation and pressure area care in the bed was
routinely performed, it was uncommon for nursing staff to initi-
ate active mobilisation of ventilated patients in the absence of a
physiotherapist. Apart from a paucity of time, other common bar-
riers cited by nursing staff were lack of skills and confidence in their
ability to lead a mobilisation team in the absence of the physiother-
apist. Our ICU only has two dedicated physiotherapists who were
unable to cope with the increased demands of early mobilisation
of ventilated patients.
To improve the practice of early mobilisation, we employed a
Knowledge Translation approach to train nurses to adopt active
mobilisation of the critically ill patient as a routine part of their
work. We had previously used the Knowledge Translation model
to successfully improve our prescription practice in our unit
(Rajamani et al., 2011). Knowledge Translation is particularly suited
to evaluating complex quality assurance projects, especially those
pertaining to changes in human behaviour (IIan et al., 2007; Scales
et al., 2009). The difference from a standard quality assurance
audit is in the strong emphasis on inclusiveness of the key stake-
holders, who are encouraged to actively participate in the project,
as opposed to being monitored or audited from above. This par-
ticipation is built through a process of consultative education to
identify the local practice barriers, followed by development and
implementation of solutions. Thus, the key components of this
approach are a focus on systems related to the care of individual
patients, engagement and empowerment of local interdisciplinary
teams to assume ownership of the project and the intervention,
finally promoting a collaborative culture within the local unit and
larger system. The Knowledge Translation model is similar to a
pre- and post-intervention audit, with the intervention placing a
strong emphasis on collaborative education of the personnel being
audited. Also, since the interventions are developed based on bar-
riers locally identified by the stakeholders, these may be modified
during the educational programme.
Overview of the training programme
The project was designed as a pre- and post-intervention quality
improvement project, with its main aim being to facilitate nurse-
led active mobilisation of ventilated patients. The intervention
was an educational programme which was developed dynamically
using the principles of Knowledge Translation. The 4E approach was
employed by engaging with stakeholders, to identify gaps in the
existing system, educating the stakeholders by providing of appro-
priate training, getting them to execute their training, and then
evaluate the outcome by audits and surveys (Pronovost et al., 2008).
37
In addition, feedback was provided back to the stakeholders. When
new challenges were identified during the project, an additional
step in the form of reminders and reward programme was intro-
duced at a later stage to reinforce adherence to the mobilisation
practice, since many studies have found reminders and rewards to
be effective agents of behavioural change (Cheung et al., 2011).
Since teaching and training were the major components of this
project, the Four Stages of Adult Learning Principles (Linda, 2006)
were also utilised in helping nurses progress from an “Unconscious
Unskilled” stage to a “Conscious Skilled” stage, with the additional
reminder and reward programme further assisting them in pro-
gressing to an “Unconscious Skilled” state.
Outcomes and objectives
This project focused on achieving two main outcomes: a) Safety
and feasibility of nurse-led active mobilisation of ventilated patient
and b) Increase in number of episodes of nurse-led mobilisation of
ventilated patients.
Methods
This project took place in a 22 bed medical and surgical
ICU attached to a Tertiary teaching hospital in Australia. Fol-
lowing the approval of the Nepean Blue Mountains Human
Research Ethics Committee (Approval Reference Number 12/65-
LNR/12/NEPEAN/124), this prospective quality improvement
implementation study was conducted in stages over a 2½ year
period between April 2013 and October 2015. The project involved
the following steps; initial audit of mobilisation practice, recruit-
ment of nurses, survey via questionnaire, teaching and training of
nurses, post training survey via questionnaire, audit of mobilisa-
tion practice, reminders and reward programme and final audit of
practice. The initial phase of identifying the barriers and imparting
training to the nurses took approximately one year from April 2013
until March 2014.
Sample recruitment
An invitation to participate in this implementation quality
project was given out to all the ICU registered nurses who worked
day-shifts with minimum of 12 months experience in ICU. A total
of twenty-three (8 males and 15 female) ICU nurses volunteered to
participate in the project. Participants were explained the objec-
tives of the project, the education and training programme and
competency process. Following this, a consent form was signed by
each participating nurse.
Survey
A pre and post training programme questionnaire survey was
completed by all the 23 participating nurses. In the absence of a
previously validated questionnaire, a “home-grown” questionnaire
was formulated by a senior intensivist with extensive experience in
qualitative research. The questions used a multiple choice answer
format, with an option for the responder to add free text answers.
a) Pre training survey: This questionnaire consisted of three main
questions to determine the site specific and nurse perceived
barriers to mobilisation activity. The questions focused on the
experience and confidence of the nurse with active mobilisa-
tion, of ventilated patients and their self-reported barriers and
challenges to mobilisation (Fig. 1).
b) Post Training survey: To assess the impact of the training pro-
gramme in heralding a culture shift, a post-intervention audit
to determine the number of active mobilisation episodes was
38 A. Hassan et al. / Intensive and Critical Care Nursing 42 (2017) 36–43

Quesonnaire for the mobilisaon acvies (Sit on the edge of bed, Sit
out of Bed & Walking)

Queson Response (please ck one)

Prior In the past a. Rounely i.e., every shi or every other shi
experience month, how 
with oen have you b. Occasionally e.g., once every few shis 
(specific independently c. Never i.e., I always wait for the
mobilisaon iniated (this physiotherapist 
acvity) mobilisaon d. Other (specify) 
acvity) without
the
physiotherapist?
How confident a. Extremely confident i.e., I am happy to do this
are you in your by myself without any educaon /
knowledge and demonstraon by the physiotherapist
ability to carry 
out (this b. Reasonably confident, but I do not think I can
mobilisaon do this enrely by myself (please explain what
acvity) support you want from the physiotherapist)
independently 
i.e., without the ______________________________________
guidance of the ______________________________________
physiotherapist? ______________________________________

c. Not at all confident i.e., I think I’ll need the

physiotherapist to teach me and also show
me at least once 
d. Other (specify) 
List some
barriers that a. ______________________________________
make it difficult
for you to carry b. ______________________________________
out (this
mobilisaon c. ______________________________________
acvity)
independently. d. ______________________________________

Fig. 1. Pre- Training Questionnaire.

done approximately 3 months after all the nurses attained com-
petency. The questionnaire consisted of ten items exploring the
value of the training programme, change in confidence levels
and perceived barriers after successfully completing the train-
ing, and their attitude towards initiating active mobilisation
(Fig. 2).
Education and training programme
Following the initial staff survey, an education and training pro-
gramme was developed by the senior ICU physiotherapist (first
author), incorporating current evidence based mobilisation prac-
tices and available mobilisation protocols and guidelines.
The programme used PowerPoint presentations, mobilisation
photographs and videos, research articles and bed-side teaching to
highlight the benefits of mobilisation. Several group and individual
face-to-face education sessions were delivered to the participating
nurses. A short mobilisation power point presentation and mobil-
isation video was also uploaded to all the bedside computers for
nurses to access in their own time. A mobilisation handbook was
developed, using the best available evidence, for the participat-
ing nurses. This handbook consisted of detailed information such
as patient assessment methods, indications and contraindications,
patient preparation and a step by step guide on how to under-
take the three main active mobilisation tasks which are functional
and goal directed (Hodgson et al., 2016). The mobilisation activ-
ities were; a) Sitting on the edge of the bed (SOEOB), b) Sit out
of bed (SOOB) & c) Walking 2–10 meters or more with or without
assistance.
The ICU physiotherapist then practically demonstrated the pro-
cess of safe planning and execution of each of these tasks when
leading a team to actively mobilising an intubated patient Con-
traindications and potential risks for active mobilisation were also
explained.
On completion of the education and training, each nurse was
assessed by an ICU physiotherapist (either authors AH or FF) for
competency on each of the three mobilisation activities using a
“home-grown” assessment tool (Table 1), devised by AH to assess
 A. Hassan et al. / Intensive and Critical Care Nursing 42 (2017) 36–43 39

Quesonnaire for the mobilisaon acvies (Sit on the edge of bed, Sit out of trainee physiotherapists in our ICU. The duration of each training
Bed & Walking) session was noted, which was defined as the time from the com-
Queson Response (please ck one) mencement of the preparatory work (setting up the equipment,
1.Value of Rate the value of a. Very useful □ informing the patient, calling the wardsperson for assistance etc.),
education the □
session PowerPoint/video
b.
c.
Reasonably useful
Not useful at all □
until the patient had safely completed the mobilisation activity.
education session
(please explain
d. Other (please specify) Once a nurse was deemed competent, they were encouraged to
Explanation:
why you chose a independently lead the next mobilisation task whenever there was
particular option)
Rate the value of a. Very useful □
an eligible patient. Additional training was provided if the compe-
the practical b. Reasonably useful □ tency criteria were not met.
demonstration c. Not useful at all □
session by the d. Other (please specify)
physiotherapist e. Explanation:
(please explain Audits of the number of mobilisation episodes
why you chose a
particular option)
Which of these a. The PowerPoint/video presentation □ Three separate audits were carried out independently by a
did you find b. The practical demonstration □
more valuable? third party blinded to the trainers (physiotherapists) and trainees
(please tick one)
(participating nurses): One conducted before the training (pre-
2. Post- How confident a. Extremely confident i.e., I am now happy to do
education are you in your this by myself without any education / training), the second after the training (post-training) and a final
mobilisation knowledge and
ability to lead a
demonstration by the physiotherapist
□ one after a further positive reinforcement programme (post-
team of people to b. Reasonably confident, but I think I still need reinforcement). The post-training audit of mobilisation practice
carry out this some support from the physiotherapist (please
(specific explain what support you want from the was conducted in May 2015, which found that the rate of mobilisa-
mobilisation physiotherapist) □ Not at all
activity) i.e., confident i.e., I think I’ll need the tions was unchanged (described in detail in the results section).
without the physiotherapist to teach me and also show me
physiotherapist? at least once more □ To see if an additional programme would further boost mobili-
c. Other (specify) □ sation attempts, an additional strategy of a reminder & reward
3. Future
practice (once
Would you now
routinely carry
a. Yes, I now plan to do this all every day for all
my eligible patients □ programme (positive reinforcement programme) was employed
found out (this b. Reasonably – I am happy but not totally from May to October 2015 (six months). This reinforcement pro-
competent by mobilisation convinced that I can use it routinely
physiotherapist) activity)? □ (please explain why you think you may be gramme was followed by the final audit of mobilisation practice.
unable to use it every time)

Post-intervention audit and positive reinforcement programme

c. No. I would not like to mobilise my patient
without physiotherapy support Approximately three months after the successful completion of
(please explain why)
the training programme, a clinical practice audit was performed.
Disappointingly, the number of nurse-led mobilisation of venti-
Are you a. Yes, I am sure I can teach any nurse, whether
confident to teach they are junior or senior lated patients remained at a low level (9.7%).
another nurse or b. Reasonably – I think I can teach a senior
to help him/her nurse, but the junior nurse is best left to the We surmised that the problem was a lack of conscious effort to
undertake (this physiotherapist □
specific c. No. Even though I can do this myself, I don’t incorporate and implement this newly learnt skill into the routine
mobilisation
activity) for a
feel confident to teach other nurses □ nursing activity. In view of the evidence that positive reinforcement
patient without
the presence of
programme often achieve better outcome than training alone, we
the introduce a number of strategies to positively reinforce patients
physiotherapist?
We would like to a. Did this project fulfil your educational needs
mobilisation by the trainee nurses, these include:
4. Comments
regarding the roll out this in training you to mobilise an ICU patient?
project educational □
project for all the b. If not, please tell us how this could be 1. From the cohort of 23 trained nurses, identifying a smaller num-
nurses working in improved □.
the ICU. ber of nurses to become high-profile “champion mobilisers”.
5. Prior In the past e. Rounely i.e., every shi or every other shi These nurses not only actively mobilised their own ventilated
experience with month, how □
(specific oen have you f. Occasionally e.g., once every few shis □ patients but also helped their colleagues to do so.
mobilisaon independently g. Never i.e., I always wait for the 2. Placement of laminated postcards on every computer terminal as
acvity) iniated (this physiotherapist □
mobilisaon h. Other (specify) □ photographic reminders on mobilisation (Fig. 3). These postcards
acvity) without
the were replaced every two weeks with another reminder message
physiotherapist?
displayed in bright colour.
How confident 1. Extremely confident i.e., I am happy to do this
are you in your by myself without any educaon / 3. Placement of motivational messages on staff bulletin boards, e.g.,
knowledge and
ability to carry
demonstraon by the physiotherapist
□
“Champion mobilisers keep up the good work” or “Early mobil-
out (this 2. Reasonably confident, but I do not think I can isation = better patient outcomes”.
mobilisaon do this enrely by myself (please explain what
acvity) support you want from the physiotherapist) 4. An incentive/reward programme recognized by the nursing staff
independently
i.e., without the ______________________________________
who were most actively involved in mobilising their patients as
guidance of the ______________________________________ “top mobilisers of the week/month”.
physiotherapist? ______________________________________
3. Not at all confident i.e., I think I’ll need the
physiotherapist to teach me and also show
me at least once □ Data collection
4. Other (specify) □
List some
barriers that e. ______________________________________
The main data collection was done in the form of audit of mobil-
make it difficult isation episodes and questionnaire completed by nurses. The audit
for you to carry f. ______________________________________
out (this was conducted by a staff member who was blinded to the project
mobilisaon g. ______________________________________
acvity)
objectives. The mobilisation data was retrieved from the electronic
independently. h. ______________________________________ medical records. Data was also gathered from the 46 sets (23 pre
and 23 post training) of pre and post questionnaire which consisted
Fig. 2. Post- Training Questionnaire.
of data on nurse’s confidence levels, perceived barriers and useful-
ness of the training programme. Other data collected (during the
training) included logistic aspects such as the time taken to com-
plete a designated mobilisation activity, the number of attempts
40 A. Hassan et al. / Intensive and Critical Care Nursing 42 (2017) 36–43

Fig. 3. Posters used for reminders.

Table 1
Nurse Assessment Tool (Used to assess competence of a nurse during each mobilisation episode).

Time Time of starting assessment: Yes No Comment

Time to start mobilisation:
Time of ending mobilisation:
Steps

Identifies indications and contraindications

Assesses the patient to determine their current mobility status
Plans the most suitable mobility therapy such as passive
exercises/sitting at the edge of the bed/sitting out of bed (transfer to
chair)/walking
Explains to the patient clearly about the mobility
Gathers the necessary equipment
Tidies up or sorts out patient attachments (e.g., ventilatory circuit,
central venous catheter, tubings and urinary catheter etc.)
Identifies required number of personnel
Gives clear instructions to colleagues/wardsperson
Monitors when necessary prior to mobilisation
Undertakes safety checklist prior to and during mobilisation
Monitors & gives instructions to patient during mobilisation
Terminates mobilisation when indicated
Conclusion (tick one) Can independently perform this activity without any further 䊐
supervision
Needs to repeat initial knowledge training (theory and 䊐
demonstration) and witness the practical demonstration
Needs to repeat mobilisation session under supervision, but does 䊐
not need initial knowledge training
Has the knowledge and expertise to train another nurse 䊐

taken by a nurse to reach competency in a designated mobilisation
activity, safety aspects such as accidental extubations or discon-
nections of lines and tubes and severe physiological abnormalities
attributed to the mobilisation etc. The participant completed a form
which had information on nurses on gender, number of years’ expe-
rience in nursing, and the number of years of ICU experience.
and reinforcement programme with the number of mobilisation
attempts were tested using log likelihood ratio (G2) test. The effect
of training and reinforcement programme were inspected by the
Pearson standardised residuals. Comparisons of different phases
were presented as odd ratios with and without partitioning of the
contingency table.

Data analysis Results

The occurrence of nurse-led active mobilisations was expressed
as the proportion of patients who were mobilised to the total
number of ventilated patients in the ICU. The occurrence of active
mobilisations in the pre- and post-intervention phases was com-
pared using z-test to compare two proportions.
The survey results were analysed by using tables and plotting
graphs for pre and post training phase. Mean and standard devia-
tions were calculated for nurse clinical experience and time taken
to complete a mobilisation task.
Number of mobilisation attempts were expressed in a con-
tingency table (Table 3). Associations of training programme
Twenty-three nurse recruited into the project. The mean post-
graduate nursing experience was 11 ± 9.9 years (range 2–38 years).
The mean ICU experience was 4 ± 6.9 years (range 1–28 years). In
the month prior to the project, 12 nurses had not mobilised any
patient, while 11 had mobilised one patient each with the help of
physiotherapist.
The mean time to train the nurses for the three mobilisa-
tion activities was 28.3 ± 4.3 min for sitting on the edge of the
bed (SOEOB), 33.7 ± 3.6 min for sitting out of bed (SOOB) and
39.4 ± 4.4 min for walking. For the first two tasks (SOEOB and
SOOB), all twenty-three nurses attained competency at the first
 A. Hassan et al. / Intensive and Critical Care Nursing 42 (2017) 36–43 41

Table 2 Table 4
Survey of Nurses’ Perception. Effect size of training and reinforcement on mobilisation attempts.

Perceived Barriers for mobilisation by ICU Pre-training Post-training Odds ratio [95%CI] P-value
nurses
Post-training vs pre-training 0.96 [0.32, 2.88] 0.936
Number of Number of Post-reinforcement vs post-training 4.95 [1.84, 13.3] <0.001
responses responses Post-reinforcement vs (pre- and post-training) 5.07 [2.23, 11.50] <0.001

Inadequate staff for assistance 10 7

Not skilled enough 9 3
Lack of time 6 3
(G2 statistics = 14.869, df = 2, P = 0.0002). There was a high
Unfamiliarity with mobilizing ventilated 5 0 indication that reinforcement resulted in higher number of
patients mobilisation attempts (Pearson’s standardized residuals for post-
Patient with “too many attachments” 5 0 reinforcement = 4.1). The odds ratios (OR) for the effect of training
Concerns regarding airway (Endotracheal tube, 6 1
are shown in Table 4. There was no statistical evidence that train-
tracheostomy tube)
Uncooperative patient 3 1 ing increased the occasions of mobilisation (OR = 0.96 [95%CI: 0.32,
Patients requiring investigations/interventions 1 1 2.88], P = 0.936). Instead, the odds of post-reinforcement on mobil-
Obese patient 1 1 isation attempts were 4.95 and 5.07 times the odds of training and
Lack of appropriate equipment 0 3 pre- and post-training combined (P < 0.001), respectively. In other
Confidence with independently leading an
words, on average, for every one mobilisation attempt with or with-
active mobilisation team
Highly confident with active mobilisation (out 1/23 14/23 out training there were approximately five mobilisation attempts
of 23 nurses) if reinforcements were provided.
Reasonably confident with active mobilisation 13/23 5/23
(out of 23 nurses)
Discussion
Not at all confident 5/23 0
No response 4/23 4/23
In this quality improvement project, we have been able to
implement research into practice by employing well-structured
attempt. For walking 2–10 meters, 18 of the 23 nurses gained com- education and training programme to overcome the nurse per-
petency at the first attempt, and the other five nurses attained ceived barriers in mobilising the ventilated patients. Our reminders
competency after the second attempt. and rewards strategy complemented the training programme well
The pre- and post-training survey results are summarised in in increasing in the mobilisation episodes.
Table 2 and Fig. 4. The survey was notable for a significant Changes that are known to improve patient outcomes are dif-
increase in nursing confidence in independently mobilising ven- ficult to absorb into existing practice even when it is backed by
tilated patients, which in turn was reflected in the reduction in the good evidence. As a result, several good quality evidence gets lost
overall number of barriers to mobilisation. In particular, the famil- in translation (Lenfant, 2003). Similarly, despite substantial evi-
iarity and fear of the endotracheal tube improved significantly with dence that early mobilisation is safe, effective and beneficial in
training. This reflects the effectiveness/usefulness of the teaching critically ill patients, its uptake has been extremely low. Imple-
and training programme. In both periods (pre and post training), mentation of research may encounter several barriers at different
inadequate staffing was cited as the most common barrier. levels such as organisational barriers (equipment and resources),
The final audit (post reinforcement programme) showed a sig- professional barriers (knowledge, workload and time) and individ-
nificant increase in the number of nurse-led active mobilisations ual arriers (knowledge, attitude and skills). (Shifaza et al., 2014).
from seven out of 79 ventilated patients (9.7%) to 16 out of 46 ven- Several authors have made suggestions and recommendations to
tilated patients (34.8%) before and after the strategy of positive overcome these barriers which are based on assumptions or clinical
reinforcement (p = 0.0003, using z-test to compare two propor- experience, but there is little evidence to prove the success of these
tions). Although not part of this study, it was also notable that there recommendations (Bassett et al., 2012; Castro et al., 2015; Dinglas
was a significant increase in the number of active mobilisations of et al., 2013). Several single interventions based strategies such as
non-ventilated patients − from 36 of 122 patients (29.5%) before audit and feedback or just education sessions have been shown
these measures to 56 of 89 patients (62.9%) to after these measures, to have smaller effect whereas multifaceted approach (e.g. engag-
(p = <0.0001, using z-test to compare two proportions). ing, educating, reminding and feedback) has been found to have
bigger impact in uptake of research (Boaz et al., 2011; Wensing
The association between training and attempted mobilisation; et al., 1998). Pronovost et al. (2008) used multifaceted approach
in knowledge translation and reported success in reducing cen-
The number of attempted mobilisations at pre-training, post- tral line related infection rates. The knowledge translation model
training and post-reinforcement audits are shown in Table 3. used in our project is somewhat similar to the one described by
The results showed that there was a strong association between Pronovost et al. (2008), which utilised the “four Es” approach −
training-reinforcement with the number of mobilisation attempts Engage, Educate, Execute and Evaluate.

Table 3
Effects of training and reinforcement on mobilisations frequency.

Number of ventilated patients Pre-training Post-training Post-reinforcement Total

Attempted mobilisation 7 7 16 30
(11.7)1 (11.2) (7.1)
(−1.9)2 (−1.7) (4.1)
Not attempted mobilisation 68 65 30 163
(63.3) (60.8) (38.4)
(1.9) (1.7) (−4.1)
% Attempted 9.3% 9.7% 34.8%
1
Estimated expected frequencies for testing independence.
2
Pearson standardized residuals.
42 A. Hassan et al. / Intensive and Critical Care Nursing 42 (2017) 36–43

Nursing self-reported confidence with mobilisaon

Not at all confident

9

9
Reasonably Confident
13

14
Confident
1

0 2 4 6 8 10 12 14 16

Post Pre

Fig. 4. Change in staff confidence pre- and post-training.

To our knowledge, this project is the first to evaluate the feasibil- and encouraging. Although this culture change is yet to be fully
ity of nurse-led mobilisation and the effect of a series of calibrated achieved, we believe that we are seeing strong signs towards this
interventions improves the practice of mobilisation. In this project, goal.
the staff survey in the planning phase highlighted several staff-
specific barriers which made us focus on Individual Barriers such
Limitations
as knowledge, and skills of the nursing staff. Interestingly, we found
that many of these self-reported barriers could be easily overcome
The outcomes mainly focused on the feasibility and logistics of
by just one or two sessions of education and training. Every nurse
training. The number of episodes of active mobilisations per day
attained competency, usually after a single training session; confi-
was chosen as a marker of the culture of the ICU. Since this was
dence improved and the perception of barriers reduced. This might
a single centre project with relatively small numbers of patients
indicate that the lack of skill/training reported by nurses may relate
undergoing active mobilisation, clinical data related to patient out-
more to perception than reality.
comes such as ventilator-free days or survival were not considered
However, it was dispiriting to see that the number of nurse-led
meaningful and were not collected.
mobilisation episodes as well as the pre-training culture of wait-
The generalisability of the present findings may be limited due
ing for the physiotherapist did not change significantly. Also, our
to selection (recruitment) bias. The nurses participated in this study
expectation of seeing the cohort of newly trained senior nurses
were volunteers and were highly motivated to implement active
becoming “champion mobilisers” and pass on their skills to other
mobilisation of the ventilated patients. While the results may not
nurses did not occur. Although our physiotherapists noticed that
be applicable generally to all critical care nurses, the present study
nurses became more proactive in assisting physiotherapists, they
provides evidence that the practice nurse-initiated mobilisation of
did not initiate and lead the mobilisation. Since the initiation of
ventilated patients is achievable if suitably motivated nurses are
active mobilisation is not a traditional nursing responsibility, it was
recruited for this task.
perhaps naïve to expect a significant change in culture with just the
Also, the applicability of these strategies to other ICUs with
training of a cohort of nurses.
potentially different sets of challenges requires further evaluation
The fact that most nurses required only single session of train-
in a multicentre study.
ing to attain competence demonstrated that our initial strategy was
probably targeting the “wrong problem”, lack of skill was the lesser
issue, as opposed to a general reluctance to use these skills in the Conclusions
limited time available to them. It is well described that learning a
new skill is a slow and uncomfortable experience and after learn- This study showed that a sustained quality improvement pro-
ing a new skill, the learner is at a “conscious skilled stage” which gramme in a tertiary ICU based on the principles of Knowledge
requires a conscious effort to put new skills into daily practice Translation can be effective in promoting nurse-led mobilisation of
(Linda, 2016). The provision of constant reminders and encourage- ventilated patients. Many of the barriers quoted in the literature can
ment converts this to a “subconscious skill” (Linda, 2016). This is a be easily overcome by a few sessions of structured education and
well-known strategy in Knowledge Translation to involve stake- training programme. However, a sustained multipronged strategy
holders in the process of culture change (Cheung et al., 2011). is required to produce a more significant outcome.
This necessitated introduction of an additional strategy, where we
employed a set of positive reinforcement (reminders and reward)
Ethical statement
measures to raise the profile of mobilisation as an important daily
nursing activity. Following this, in our project, there was a surge in
This study was approved by the Nepean Blue Mountains Human
the incidence of mobilisations, not only in ventilated patients but
Research Ethics Committee. All the participating Nursing staff gave
in all patients in the ICU.
written consent to be a part of this study.
This has now resulted in a noticeable change in culture
where the nurses routinely screen their patient’s suitability for
mobilisation. Also, the preparation for mobilisation is done more Funding
meticulously and completely, making the process smoother and
more efficient. Overall the findings of this project has been positive Authors did not receive any funding to conduct this study.
 A. Hassan et al. / Intensive and Critical Care Nursing 42 (2017) 36–43
Conflict of interest
The authors have no conflict of interest to declare.
Acknowledgment
We thank Ms. Chelsea Jones for assisting in data collection and
analysis.
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