NR 559 Week 7 Evidence-Based Unit Recommendation Example

Unit Level Recommendation: Patient Care Technicians Walk Every Patient Aged 65 or Older Who Walked Before Admission, Twice on Day Shift and Once on Evenings, Recorded on the Mobility Ladder

Student Name

College of Nursing, Chamberlain University

NR 559: Research Methods and Evidence-Based Practice for Professional Nursing Practice

Instructor Name

Month Day, Year

Unit Level Recommendation: Patient Care Technicians Walk Every Patient Aged 65 or Older Who Walked Before Admission, Twice on Day Shift and Once on Evenings, Recorded on the Mobility Ladder

The Recommendation

Patient care technicians on our medical unit will help every patient aged 65 or older who was walking on their own, using an aid or not, during the fortnight before admission to walk in the hallway twice on day shift and once on evening shift, unless the nurse documents a medical reason not to, and will record the highest level reached each shift on the Johns Hopkins mobility ladder.

The Version the Studies Actually Tested

A label such as "early mobility program" can describe anything from a sign above a bed to a staffed service. The recommendation is based on the version tested in the randomized trial critiqued in this course. In that trial, older patients in the mobility group were assisted with walking up to twice daily by study staff, with a behavioral strategy to encourage mobility, and kept their life-space mobility a month after going home, while the comparison group's fell (Brown et al., 2016). The recommendation keeps the core elements: assisted walking, at least twice daily, with encouragement. It changes the deliverer from research staff to technicians, which is the version a unit can sustain, and adds an evening walk to reach patients who were sleeping or in tests during the day.

The unit project reviewed in the design comparison showed that a mobility program delivered by regular staff on general medicine units was feasible and associated with increased mobility and shorter length of stay (Hoyer et al., 2016), which supports delivery by existing roles.

Patients Here Against Patients There

The trial enrolled cognitively intact older veterans, almost all men, with a median stay of three days. Our older patients are more often women, more often have dementia and stay longer. The recommendation includes women without hesitation, since there is no reason to expect walking to harm them. It includes patients with mild cognitive impairment who can follow simple directions and walk with supervision, which goes beyond the trial, because the qualitative evidence suggests these patients are the most likely to be left in bed and because the observational evidence associates low mobility with decline across older inpatients generally (Brown et al., 2004). It excludes patients with delirium who cannot follow directions, since their safety needs are different, and they will be the subject of a separate review. The departures from the trial are stated so that results can be interpreted honestly.

Why Technicians, and What Comes Off Their List

The qualitative study reviewed in this course found that patients, nurses and physicians each saw walking as someone else's job (Brown et al., 2007), and walking tends to be dropped first under heavy workload (Kalisch, 2006). Assigning it to a named role on each shift addresses both. Technicians already help patients to the bathroom and with transfers, so walking fits their work.

To make room, two tasks will move. Hourly rounding checks on patients who are walking will be combined with the walk itself, and technicians will stop routine blood glucose checks for patients on diet-controlled diabetes, which the unit's nurse practice council has agreed can be done by nurses at medication times. The manager estimates this frees about 45 minutes per technician per shift, enough for about eight walks.

What the Nurse Does

At the start of each shift, the nurse identifies eligible patients and documents any medical reason to hold walking, such as new chest pain or a hemoglobin below the unit's threshold. The nurse also reviews intravenous lines and catheters each day and asks whether they can be removed or capped, since equipment was a barrier in the qualitative study. Orders will specify hallway walks with help three times a day rather than "ambulate as tolerated."

Safety

Walking patients who were previously kept in bed raises a fair concern about falls. The recommendation manages it by requiring a gait belt for any patient at moderate or high fall risk, by having the technician walk beside the patient rather than behind, and by stopping the walk if the patient reports dizziness or chest pain. Falls will be tracked monthly, and the nurse practice council will review any fall during a walk.

Why Not Wait for More Evidence

Some colleagues have asked why the unit should act on one trial that included almost no women and no patients with dementia. The answer is that the alternative, continuing the bed-and-alarm routine, also rests on no evidence of benefit, and observational evidence associates it with harm. The recommendation is a measured change with outcomes tracked, not a permanent commitment, and the unit's own data will show within six months whether it helps our patients. Waiting would mean continuing a practice nobody has shown to be better.

Communication

The recommendation will be introduced at the unit's staff meetings on each shift, with the evidence summary in one page, the technician task changes explained, and a question-and-answer session with the manager and the nurse practice council chair. Patients and families will receive a short card explaining that walking is part of their care and that they should expect a technician to help them walk each day.

How It Will Be Measured

The mobility ladder, recorded each shift, will show whether the recommendation is delivered: the target is that 80% of eligible patients reach level 6, walking at least 10 steps, or higher at least once a day. A telephone life-space interview by phone a month after discharge, for a sample of 30 patients before and 30 after the change will show whether patients keep their mobility. Falls, length of stay and discharge to a facility will be tracked as balancing measures. Results will be reviewed at three and six months. Evidence-based practice guidance recommends evaluating a practice change against outcomes chosen in advance (Melnyk & Fineout-Overholt, 2019).

Questions from staff will be collected before the start date and answered in writing, so that every shift receives the same information, including night staff who rarely attend meetings.

The nurse practice council will review the first month's mobility ladder data at its next meeting and adjust the technician task list if walks are not happening on evening shifts.

Staff feedback will shape that review.

References

Brown, C. J., Foley, K. T., Lowman, J. D., MacLennan, P. A., Razjouyan, J., Najafi, B., Locher, J., & Allman, R. M. (2016). Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: A randomized clinical trial. JAMA Internal Medicine, 176(7), 921-927. https://doi.org/10.1001/jamainternmed.2016.1870

Brown, C. J., Friedkin, R. J., & Inouye, S. K. (2004). Prevalence and outcomes of low mobility in hospitalized older patients. Journal of the American Geriatrics Society, 52(8), 1263-1270. https://doi.org/10.1111/j.1532-5415.2004.52354.x

Brown, C. J., Williams, B. R., Woodby, L. L., Davis, L. L., & Allman, R. M. (2007). Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians. Journal of Hospital Medicine, 2(5), 305-313. https://doi.org/10.1002/jhm.209

Hoyer, E. H., Friedman, M., Lavezza, A., Wagner-Kosmakos, K., Lewis-Cherry, R., Skolnik, J. L., Byers, S. P., Atanelov, L., Colantuoni, E., Brotman, D. J., & Needham, D. M. (2016). Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality-improvement project. Journal of Hospital Medicine, 11(5), 341-347. https://doi.org/10.1002/jhm.2546

Kalisch, B. J. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21(4), 306-313. https://doi.org/10.1097/00001786-200610000-00006

Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and healthcare: A guide to best practice (4th ed.). Wolters Kluwer.