NURS 8710 Week 9 Gap Statement Example Example

Narrower Than I Expected: A Gap Statement on Early Mobilization in Ventilated Adults Where Usual Care Starts Low and Nurses Carry the Work

Student Name

College of Nursing, Walden University

NURS 8710: Doctoral Seminar I

Instructor Name

Month Day, Year

Narrower Than I Expected: A Gap Statement on Early Mobilization in Ventilated Adults Where Usual Care Starts Low and Nurses Carry the Work

What the Evidence Settles

Any honest gap statement starts with what is not a gap. The review of eleven studies settles three things well enough that a project should not try to re-establish them. First, early active mobilization of ventilated adults is feasible and, when delivered within agreed safety criteria, rarely produces serious events during sessions; several trials and a cohort study reported no or almost no adverse events (Morris et al., 2008; Schweickert et al., 2009; Hodgson et al., 2016), and expert consensus has defined the respiratory, cardiovascular and neurological criteria under which mobilization is considered safe (Hodgson et al., 2014). Second, when the alternative is little or no structured mobilization, early mobilization improves function at or before hospital discharge (Schweickert et al., 2009; Schaller et al., 2016). Third, adding more mobilization to an already active baseline has not improved longer-term outcomes, and in the largest trial it was associated with more adverse events (TEAM Study Investigators, 2022).

The Narrowing

When the search began, I expected to find almost nothing on mobilization in community hospitals, and to write a gap statement about absence. That is not what the review found. The question has been studied extensively, in large and well-conducted trials, and a systematic review has already pooled the results (Tipping et al., 2017). The gap I can honestly claim is much smaller. It is not that the question is unstudied, but that the settings in which it was studied differ from mine in ways that matter for applying the results.

Two differences stand out. Every study in the set took place in university hospitals or in research networks of experienced ICUs, several with dedicated mobility teams or therapists who delivered the intervention. And in the trials that defined usual care, usual care already included regular mobilization. My unit is a 14-bed ICU in a community hospital with one physical therapist shared across the hospital on weekdays and none on weekends, where mobilization of ventilated patients depends largely on bedside nurses. A baseline audit of 40 recent ventilated patients found that only 9 sat on the edge of the bed while ventilated, a much lower baseline than in the largest trial's usual care arm.

The Gap, Fixed Precisely

None of the included studies reports the effect of early active mobilization delivered mainly by bedside nurses, without a dedicated mobility team or daily therapist input, in an ICU where usual care for ventilated patients involves little mobilization.

Each part of that sentence was checked against the evidence table. Delivered mainly by bedside nurses: the cohort study's team included a nurse and nursing assistant, but also a physical therapist, and the trials delivered their interventions through therapists or research teams. Without a dedicated team: no included study tested mobilization in a unit without one. Where usual care involves little mobilization: the trials with low-mobilization comparison groups were the earliest, in academic centers, and they did not report who delivered usual care or how often.

The gap is a gap in transferability, not in knowledge of whether mobilization can help. The evidence suggests that in a low-baseline unit, moving from little mobilization to some should help, which is the part of the evidence most favorable to my setting. What is not known is whether a nurse-delivered approach can reliably move a low-baseline unit to the level of mobilization that produced benefit in the trials, and whether it can do so as safely as therapist-led programs did.

The gap was also checked against the safety evidence, because a nurse-led approach raises a safety question of its own. The consensus criteria were written for teams that include therapists, and they assume someone at the bedside can judge, for example, whether a rising heart rate during standing is a reason to stop. In a unit where the bedside nurse makes that judgment alone, often while responsible for a second patient, the criteria may be applied differently. None of the included studies reports how often sessions were stopped, or should have been stopped, when nurses led them. That is a second, smaller part of the same gap, and it argues for a project that counts stopped sessions and their reasons alongside the proportion of patients mobilized.

What a Project Could and Could Not Add

A DNP project cannot run a trial, and it should not try to answer whether mobilization improves six-month outcomes, which larger studies have addressed. What a project could add is evidence on implementation in the setting the trials did not reach: whether a nurse-led protocol, using published safety criteria, increases the proportion of ventilated patients who reach sitting, standing and walking, and how often mobilization is stopped for safety reasons. That would answer a practical question for units like mine, and it would build on the strongest part of the evidence rather than relitigating the weakest.

The statement also has to say what it cannot claim. A unit-level project will not show that nurse-led mobilization improves function at discharge, because it will lack a comparison group of sufficient size. It can show whether the process changes and whether it is safe, which are the preconditions for any benefit.

The project would also need a clear comparison within the unit. Because the baseline audit already exists, the simplest design compares, before and after the protocol starts, the proportion of eligible patient-days with any active mobilization, using the same definitions and the same audit method. That design has known weaknesses, discussed in the appraisal of the cohort study, but it is proportionate to a unit-level project and can be strengthened by tracking the measure monthly, so that a change can be seen to follow the protocol's start rather than a seasonal shift.

Limits of the Gap Statement

The gap is defined against eleven studies selected by the review's criteria, not against the whole literature. Implementation studies and quality improvement reports, which the criteria excluded unless they had a comparison group, may describe nurse-led mobilization in community hospitals. Before the gap is written into a project proposal, a targeted search of implementation and quality improvement literature will check whether it has already been closed.

References

Hodgson, C. L., Bailey, M., Bellomo, R., Berney, S., Buhr, H., Denehy, L., Gabbe, B., Harrold, M., Higgins, A., Iwashyna, T. J., Papworth, R., Parke, R., Patman, S., Presneill, J., Saxena, M., Skinner, E., Tipping, C., Young, P., & Webb, S. (2016). A binational multicenter pilot feasibility randomized controlled trial of early goal-directed mobilization in the ICU. Critical Care Medicine, 44(6), 1145-1152. https://doi.org/10.1097/CCM.0000000000001643

Hodgson, C. L., Stiller, K., Needham, D. M., Tipping, C. J., Harrold, M., Baldwin, C. E., Bradley, S., Berney, S., Caruana, L. R., Elliott, D., Green, M., Haines, K., Higgins, A. M., Kaukonen, K.-M., Leditschke, I. A., Nickels, M. R., Paratz, J., Patman, S., Skinner, E. H., . . . Webb, S. A. (2014). Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Critical Care, 18(6), Article 658. https://doi.org/10.1186/s13054-014-0658-y

Morris, P. E., Goad, A., Thompson, C., Taylor, K., Harry, B., Passmore, L., Ross, A., Anderson, L., Baker, S., Sanchez, M., Penley, L., Howard, A., Dixon, L., Leach, S., Small, R., Hite, R. D., & Haponik, E. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine, 36(8), 2238-2243. https://doi.org/10.1097/CCM.0b013e318180b90e

Schaller, S. J., Anstey, M., Blobner, M., Edrich, T., Grabitz, S. D., Gradwohl-Matis, I., Heim, M., Houle, T., Kurth, T., Latronico, N., Lee, J., Meyer, M. J., Peponis, T., Talmor, D., Velmahos, G. C., Waak, K., Walz, J. M., Zafonte, R., & Eikermann, M. (2016). Early, goal-directed mobilisation in the surgical intensive care unit: A randomised controlled trial. The Lancet, 388(10052), 1377-1388. https://doi.org/10.1016/S0140-6736(16)31637-3

Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., Spears, L., Miller, M., Franczyk, M., Deprizio, D., Schmidt, G. A., Bowman, A., Barr, R., McCallister, K. E., Hall, J. B., & Kress, J. P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. The Lancet, 373(9678), 1874-1882. https://doi.org/10.1016/S0140-6736(09)60658-9

TEAM Study Investigators and the ANZICS Clinical Trials Group. (2022). Early active mobilization during mechanical ventilation in the ICU. New England Journal of Medicine, 387(19), 1747-1758. https://doi.org/10.1056/NEJMoa2209083

Tipping, C. J., Harrold, M., Holland, A., Romero, L., Nisbet, T., & Hodgson, C. L. (2017). The effects of active mobilisation and rehabilitation in ICU on mortality and function: A systematic review. Intensive Care Medicine, 43(2), 171-183. https://doi.org/10.1007/s00134-016-4612-0