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The Effect of Early Ambulation on Patient

Outcomes for Total Joint Replacement
Melissa Yager ▼ Jaynelle Stichler

The National Association of Orthopaedic Nurses published Stillwell, & Williamson, 2010). Lewin's change theory
clinical practice guidelines in 2010 to improve outcomes was used for the planning and implementation of the
with day of surgery mobilization in the total joint re- project. The theory of constructivism was used in the
placement patient (B. Morris, M. Benetti, H. Marro, & C. development and teaching of educational content.
Rosenthal, 2010). With the cost of healthcare skyrocketing
and reimbursement marginally covering costs, healthcare EVIDENCE-BASED PRACTICE THEORY
professionals must look for ways to reduce length of stay Evidence-based practice is used by nurses to provide
for elective procedures. The purpose of this change project quality care based on current evidence rather than prac-
was to provide and measure the effectiveness of an educa- tice based on tradition (Melnyk & Fineout-Overholt,
tional intervention on the benefits of day of surgery mobility
2005). Melnyk et al. (2010) describe evidence-based
practice in seven steps. The initial step is that of inquiry;
for nurses and physical therapy staff. Acquisition of caregiv-
a nurse must start by asking a clinical question. Once a
ers’ knowledge, attitudes, and practice was measured along question is developed, it should be put into a PICO
with three patient outcomes (length of stay, discharge (Population, Intervention, Comparison, Outcome) for-
destination, and day of ambulation). The findings from this mat. By using this format, the nurse is able to use the
change project resulted in improvements in structure (new question as a framework for searching the literature.
practice protocol), processes (nursing and physical therapy For this change project, the PICO question was as fol-
care processes), and patient and organization outcomes. lows:

I
In the total joint replacement population will day of
“ just had surgery! You want me to get up now?” In
surgery ambulation versus first post-operative day
2010, the National Association of Orthopaedic ambulation result in improved clinical outcomes.
Nurses published clinical practice guidelines for
the total joint patient population. The guidelines
After a search of the evidence, the nurse must criti-
indicate improved patient outcomes with day of surgery
cally appraise each study for validity, reliability, and ap-
mobilization in the total joint replacement patient.
plicability. The evidence is then integrated with expert
Although most programs, including the program at this
opinion and patient preferences. Finally, the evidence is
hospital, provide ambulation on the first postoperative
evaluated to provide the highest quality nursing prac-
day, very few programs have day of surgery mobility as
tice (Melnyk et al., 2010).
a standard of care. Day of surgery mobility has been
shown to decrease length of stay in this patient popula-
tion significantly (Morris, Benetti, Marro, Rosenthal, CHANGE THEORY
2010). With the cost of healthcare skyrocketing and re- Kurt Lewin began publishing on change theory in 1947,
imbursement marginally covering costs, healthcare investigating the factors influencing people to change
professionals must look for innovative ways to reduce (Connelly, 2011). Lewin developed a three-stage theory,
the length of stay for elective procedures. The purpose
of this change project was to report the effectiveness of
education of nursing and physical therapy staff regard- Melissa Yager, MS, RN, CNS, ONC, Clinical Nurse Specialist, Acute Care,
ing day of surgery ambulation and its effect on patient Sharp Memorial Hospital, San Diego, CA.
outcomes. Jaynelle Stichler, DNS, NEA-BC, FACHE, FAAN, Professor Emerita,
School of Nursing, San Diego State University, Professional Development
& Research Consultant, Sharp Memorial Hospital, San Diego, CA.
Theoretical Framework Melissa Yager is employed by Sharp Memorial Hospital and had received
Three theories guided the implementation of this honorarium from NAON for past works.
change project. Evidence-based practice was used to The authors and planners have disclosed no potential conflicts of inter-
frame a clinical question, search the evidence, and de- est, financial or otherwise.
sign the process changes (Melnyk, Fineout-Overholt, DOI: 10.1097/NOR.0000000000000158

© 2015 by National Association of Orthopaedic Nurses Orthopaedic Nursing • July/August 2015 • Volume 34 • Number 4 197
Copyright © 2015 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

ONJ771_LR 197 10/07/15 4:29 PM

 using the principles of unfreezing, change, and refreez- edge about the benefits of early mobilization in other
ing. This change theory has been used successfully in patient populations, the participants were able to apply
nursing practice to motivate and engage nurses in pro- prior learning to the new process that was proposed in
cess changes (Kassean & Jagoo, 2005). the change project. The educator may also further en-
The first stage, unfreezing, is used to upset the cur- gage those with higher levels of knowledge and experi-
rent culture on the unit. This step identifies a current ence by presenting the theory behind the material
problem and causes caregivers to become uncomforta- (Billings & Halstead, 2005). In this change project, the
ble with their current practice. evidence related to early mobility, improved outcomes,
Lewin calls this exploration a force field analysis, and reduction of complications was presented in the
which was subsequently used by Bozak (2003) to imple- early stages of education. The educator engaged the staff
ment bedside handoff on a nursing unit where many by asking questions about their knowledge on the sub-
barriers to the change were present. The discomfort ject and then validated their answers with a presentation
caused by the force field analysis increases motivation of the evidence. This helped the staff apply prior knowl-
to change. The force field analysis step is also used to edge directly to the new process change.
identify potential barriers that may be viewed as a threat
to the process, although others may see them as an op-
portunity for growth. The change agent can begin to Review of Literature
eliminate or minimize the barriers to change. Once the A review of the literature was conducted to identify arti-
motivation to change outweighs the barriers, the change cles that discussed the effect of early ambulation on po-
can take place. In the current project, the nursing and tential outcomes and the use of an educational interven-
physical therapy staff were exposed to the new practice tion to improve staff's acceptance of a new practice
standards that framed the “unfreezing” stage described change. The search used CINAHL, Cochrane database,
by Lewin. ProQuest, Google Scholar, and Google search engines
The second step is the change itself. During this step, and employed key words such as joint replacement, or-
the educator will develop a detailed plan to help support thopaedic, total hip replacement, total knee replace-
the staff through the change process. The plan can in- ment, arthroplasty, early ambulation, fast-track, mobili-
clude training, encouragement, and new process steps. zation, activity, length of stay, postoperative function,
The staff need to visualize and personally adopt the goal functional indicators, and discharge destination.
for the change to take place, and the educator's role is to Ultimately, the review of the literature focused on early
facilitate this process. In this change project, the educa- intervention with three outcomes, length of stay, dis-
tor led the staff in an exercise to visualize opportunities charge destination, and time of postoperative ambula-
for improved outcomes related to early ambulation. tion.
Video was used to demonstrate process steps. Then re-
turn demonstration was employed to increase the staff's POSTOPERATIVE TIME TO AMBULATION
comfort level with the new process.
One outcome examined was the length of time from a
The final step in Lewin's change theory is the freez-
patient's arrival on the unit from the recovery room
ing or refreezing step as stated in more recent litera-
until the time of first mobilization. The mobilization
ture (Kassean & Jagoo, 2005). During this step, it is
can be as little as a dangle out of bed to mobilization to
important to identify any workflow issues that may
a chair, but few studies looked at this measure of time.
result and lead to resistance. The educator must re-
Most begin to measure “time” on the first postoperative
main open to feedback and address issues to facilitate
day rather than the day of surgery. In a descriptive study
refreezing. The change is reinforced during refreezing
of (n = 100 patients), researchers found that only seven
to ensure enculturation of the practice as the norm. In
patients were unable to meet the minimum mobiliza-
this project, a number of potential barriers were an-
tion on the first postoperative day (Holm et al., 2010). In
ticipated and were addressed in the educational con-
a meta-analysis, the outcome was examined by measur-
tent. The educator asked open-ended questions of par-
ing the time to mobility on the first postoperative day
ticipants, and potential barriers were discussed within
(Khan, Ng, Gonzalez, Hale, & Turner-Stokes, 2009), but
the group. The educator empowered and encouraged
in a study by Morris et al. (2010), time was measured in
the staff to offer solutions to their peers throughout
hours rather than days. In this study, after implement-
this discussion.
ing clinical practice guidelines, the time to mobilization
was reduced from 16.8 hours to 6 hours with 79% of the
EDUCATION THEORY
patients dangling on the day of surgery.
The education portion of this change project was guided
by the theory of constructivism. This theory states that
the basic operating processes of learning are assimila- LENGTH OF STAY
tion, accommodation, and construction and the learner Length of stay is an important factor to review for hospi-
builds on experience with new knowledge (Billings & talized patients because of the cost per day in providing
Halstead, 2005). This theory explains how the educa- acute care. Several studies have shown a relationship
tional intervention builds on the nurses’ prior knowledge between early ambulation and a decreased length of
and experience. This is ideal for experienced nurses, new stay. Lawson (2009) showed a decrease in length of stay
graduates, and assistive personnel who have valuable from 2.7 days in the control group (activity once per
knowledge to connect with learning, making the content day) to 2.0 days in the experimental group with in-
meaningful and practical. By building on existing knowl- creased activity (twice per day). The National Association

198 Orthopaedic Nursing • July/August 2015 • Volume 34 • Number 4 © 2015 by National Association of Orthopaedic Nurses
Copyright © 2015 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

ONJ771_LR 198 10/07/15 4:29 PM

 of Orthopaedic Nurses published clinical practice guide- the United States. The patient care unit has an ortho-
lines for early mobilization after surgery, which were paedics specialty and is staffed by a combination of
used by Morris et al. (2010) to guide their study reducing experienced nurses and new graduate nurses. Approval
length of stay from 4.3 days to 2.8 days by implementing from the hospital institutional review board was ob-
day of surgery ambulation/dangle by nursing. tained before the pretest and educational intervention
A meta-analysis reviewed 202 studies related to post- was initiated. A three-step intervention was used: (1)
operative activity programs with total joint replacement the nursing and physical therapy staff were educated
patients. Of the 202 studies, eight studies met criteria to about the benefits of early postoperative mobilization
be included in the report (Khan et al., 2009). The analy- for patients as documented in the literature; (2) a pre-
sis reviewed several outcomes, including a reduction in test/posttest was used to measure the change in knowl-
hospital stay, fewer postoperative complications, and edge, attitudes, and practice of the staff related to this
reduced hospital costs using standardized multidiscipli- educational intervention; and (3) a new standardized
nary patient mobilization in the hospital. practice of early ambulation of patients was imple-
Some hospitals have developed “fast-track” programs mented. After the institutional review board approval
for hip and knee surgery that includes standardized pre- from San Diego State University for retrospective data
operative education and postoperative activity. Kehlet review, subsequent review of existing hospital data de-
and Wilmore (2008) conducted a meta-analysis that termined the differences in patient outcomes (length
looked at fast-track surgical programs. The studies of stay, discharge destination, and day of ambulation)
showed that the length of stay was reduced to an average before and after the implementation of the new stand-
of 3–4 days with a fast-track program in place for total ard practice.
joint replacement patients, resulting in a significant re-
duction in hospital-related costs. Another study reported EDUCATIONAL INTERVENTION FOR NURSING AND PHYSICAL
that after implementation of a fast-track program in- THERAPY STAFF
cluding early ambulation within 24 hours of surgery for Multidisciplinary staff education took place with the
total knee and hip arthroplasty, the length of stay was nursing and physical therapy staff over a 2-week period
reduced to 2.7 days for total knee and 2.5 days for the during work time. The education included a review of
total hip population (Andersen, Gaarn-Larsen, the literature to help staff recognize a need for change
Kristensen, & Otte, 2009). (Bozak, 2003). Following this review, the educator con-
ducted a threats and opportunity discussion, similar to
DISCHARGE DESTINATION a force field analysis, which helped identify barriers and
Readiness to discharge home is an important considera- move staff to be motivated to change (Kassean & Jagoo,
tion following total joint surgery. In a meta-analysis, 2005). Following the force field analysis, the education
functional milestones were measured using the focused on implementation of a new process for postop-
Functional Independence Measure to assess postopera- erative ambulation. Last, a demonstration and return
tive mobility (Khan et al., 2009). Clinical pathways, in- demonstration concluded the class. Acquisition of
cluding early ambulation, led to a more rapid attain- knowledge was measured using a six-item pretest and
ment of functional milestones and quality of life. posttest with 3 multiple-choice and 3 items using a
Functional Independence Measure measures the level Likert-like scale with a 4-choice response set. The pre-
of independence in a number of activities of daily living, test was the same as the posttest.
including ambulation, transfers, and the ability to bathe During the initial stage of the process change, feed-
and dress oneself. Functional milestones are one crite- back was encouraged so unanticipated barriers could be
rion used to determine the need for skilled nursing fol- addressed. The clinical nurse specialist rounded daily
lowing acute discharge. After implementation of a fast- with staff and patients to ensure that the process was
track program, another study found that patients were adopted.
discharged home much earlier than with traditional
programs (Andersen et al., 2009). In another study, pa-
tients reported an increase in their preparedness to care Data Analysis and Results
for self (m = 3.9 to m = 4.1 on a 5-point Likert scale) Knowledge, attitudes, and practice were measured
after implementation of day of surgery mobilization using a pretest and posttest. Three patient outcomes
(Morris et al., 2010). (length of stay, discharge destination, and day of ambu-
The review of literature indicates that implementa- lation) were measured using existing hospital data. Data
tion of a standardized approach to early ambulation can from all total hip replacement and total knee replace-
decrease the time from surgery to mobilization and de- ment patients were included.
crease hospital length of stay, complications, and subse-
quent hospital costs. Using early ambulation as an inter- PRETEST, POSTTEST
vention may prepare patients to care for themselves at
The multiple-choice questions on the pre- and posttest
home with a higher level of independent functioning.
were coded as correct = 1 or incorrect = 0. The pretest
and posttest were analyzed using SPSS version 19 (IBM,
New York). A total mean score was calculated for each
Methodology test. A paired t test was used to determine differences in
The hospital involved in the change project was lo- the mean scores between the pre- and posttests, and
cated in an urban setting of the Southwest region of there was a statistically significant difference on the

© 2015 by National Association of Orthopaedic Nurses Orthopaedic Nursing • July/August 2015 • Volume 34 • Number 4 199
Copyright © 2015 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

ONJ771_LR 199 10/07/15 4:29 PM

 attitude scale (t = −2.762, df = 49, p = .008). No sig- because of symptoms of hypotension, nausea, or inade-
nificant difference was found (p = .42) in the pre- and quate time for the nursing staff to complete the task.
posttest knowledge scale. Further practice change may be needed to address the
lack of nursing time.
PATIENT OUTCOMES
Data were reviewed prior to the staff education and for Implications for Orthopaedic
a year after the education. Length of hospital stay was
measured in days and showed slight improvement from
Nursing
3.43 days to 3.36 days 1 year after implementation. An Nurses learn in schools that early ambulation prevents nu-
improvement of 17% was seen for patients discharged merous complications in postoperative patients. Nursing
home; the predata showed that 68.6% of patients were has been satisfied that the standard of practice for most
“discharged home,” whereas the postdata showed that total joint programs is to start ambulation on the first
85.6% “discharged home” Discharge destination was postoperative day. The findings from this change project
measured as either “home” or “skilled nursing facility.” support ambulation on the day of surgery results in im-
Early ambulation was measured as patient ambulation proved patient outcomes, reduced length of stay, and re-
or dangle at bedside by physical therapy or nursing on duced hospital costs. Overall, this evidence-based change
the day of surgery, postoperative day 1 or postoperative project resulted in improvements in structure (new prac-
day 2 with the new goal of ambulation or dangling at the tice protocol), processes (nursing and physical therapy
bedside on the day of surgery. Day of surgery ambula- care processes), and patient and organization outcomes.
tion increased from 10% of patients to 94% of patients
after the education and practice change demonstrating
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200 Orthopaedic Nursing • July/August 2015 • Volume 34 • Number 4 © 2015 by National Association of Orthopaedic Nurses
Copyright © 2015 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

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