JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Purposeful and timely nursing rounds: a best practice implementation project Juli F Daniels1
1. UCSF JBI Center for Synthesis and Implementation: an Affiliate Center of the Joanna Briggs Institute
Corresponding author: Juli F Daniels [email protected]
Key dates Commencement date: September 24, 2014 Completion date: March 23, 2015
Executive summary Background Purposeful and timely rounding is a best practice intervention to routinely meet patient care needs, ensure patient safety, decrease the occurrence of patient preventable events, and proactively address problems before they occur. The Institute for Healthcare Improvement (IHI) endorsed hourly rounding as the best way to reduce call lights and fall injuries, and increase both quality of care and patient satisfaction. Nurse knowledge regarding purposeful rounding and infrastructure supporting timeliness are essential components for consistency with this patient centred practice. Objectives The project aimed to improve patient satisfaction and safety through implementation of purposeful and timely nursing rounds. Goals for patient satisfaction scores and fall volume were set. Specific objectives were to determine current compliance with evidence-based criteria related to rounding times and protocols, improve best practice knowledge among staff nurses, and increase compliance with these criteria. Methods For the objectives of this project the Joanna Briggs Institute’s Practical Application of Clinical Evidence System and Getting Research into Practice audit tool were used. Direct observation of staff nurses on a medical surgical unit in the United States was employed to assess timeliness and utilization of a protocol when rounding. Interventions were developed in response to baseline audit results. A follow-up audit was conducted to determine compliance with the same
doi: 10.11124/jbisrir-2016-2537
Page 248
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
criteria. For the project aims, pre- and post-intervention unit-level data related to nursing-sensitive elements of patient satisfaction and safety were compared. Results Rounding frequency at specified intervals during awake and sleeping hours nearly doubled. Use of a rounding protocol increased substantially to 64% compliance from zero. Three elements of patient satisfaction had substantive rate increases but the hospital’s goals were not reached. Nurse communication and pain management scores increased modestly (5% and 11%, respectively). Responsiveness of hospital staff increased moderately (15%) with a significant sub-element increase in toileting (41%). Patient falls decreased by 50%. Conclusions Nurses have the ability to improve patient satisfaction and patient safety outcomes by utilizing nursing round interventions which serve to improve patient communication and staff responsiveness. Having a supportive infrastructure and an organized approach, encompassing all levels of staff, to meet patient needs during their hospital stay was a key factor for success. Hard-wiring of new practices related to workflow takes time as staff embrace change and understand how best practice interventions significantly improve patient outcomes. Keywords Nursing rounds; patient satisfaction; HCAHPS; patient safety; patient falls
Background The mission of many hospitals is to provide compassionate and innovative care for the whole person. Patient satisfaction and patient safety outcomes are viewed by hospital leadership as crucial determinants of success for meeting this mission. Reimbursement to the organization is also directly related to performance measures, such as patient satisfaction4 and patient safety initiatives.5 Gnida6 reported that each year, the Centers for Medicare and Medicaid Services (CMS) withhold money from hospitals, with the option to earn some of it back based on the five domains (efficiency – 25 %, HCAHPS – 25 %, clinical care process – 5%, clinical care outcomes – 25%, and safety – 20 %). The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) surveys are surveys conducted to determine the hospital’s reimbursement scores. There are 12 core measures which account for 70% of the weight while the other 30% are eight composited measures from HCAHPS.7 The eight HCAHPS measures include nursing communication, doctor communication, responsiveness of staff, pain management, communication of medications, discharge information, cleanliness and quietness of hospital environment and overall rating. Olrich, Kalman and Nigolian reported with their 2012 review of literature that 25% of falls result from falling out of bed and approximately 30% of these falls result in injury with 4-6% listed as serious. Injuries included either fracture or death. In addition, hospital costs for patients injured during falls are US$4200 higher than for patients who do not fall.5 The Institute for Healthcare Improvement (IHI), in 2012, considered hospital fall injuries “never events” associated with morbidity and mortality, and endorsed every one to two hourly rounding for the purposes of pain relief, toileting and positioning.2
doi: 10.11124/jbisrir-2016-2537
Page 249
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Multiple studies have been conducted in the past six years to assess the effectiveness of nursing rounds on outcomes such as call light use, patient satisfaction and patient safety. Patient rounding has shown to have positive impacts on decreasing call light usage1,4,5,9,11,16,19,20,22, decreased fall rates1,4,5,12,16,19,20,22, decreased skin breakdown rates4,19, and increased patient satisfaction, with nursing care resulting in improved patient satisfaction scores.1,4,5,7-20,22 A 2014 systematic review by Mitchell, Lavenberg, Trotta, and Umscheid revealed there was little consistency in how results of hourly rounds were measured.18 Their review did show there was moderate strength evidence that hourly rounding programs improved patient perceptions of nursing responsiveness and reduced falls, as well as call light use. Review of structure, process, and outcomes by Rondinelli, Ecker, Crawford, Seelinger, and Omery revealed that rounding behaviors, a library of tools, and patient satisfaction were common themes associated with hourly rounding implementation.19 Purposeful and timely rounding is a best practice intervention used to meet basic patient care needs routinely, ensure patient safety, decrease the occurrence of patient preventable events, and proactively address problems before they occur.1 The IHI endorsed hourly rounding in 2009 as the best way to reduce call lights and increase both the quality of care and the satisfaction of patients.2 Prior to that, Studer found hospitals that proactively instituted rounding increased patient satisfaction by 8.9%. 22 Rounding methods using protocols, such as 12 Steps or 4Ps (pain, personal needs, positioning and placement) can be used to standardize practice. The Joanna Briggs Institute (JBI) Evidence Summary, Nursing Rounds: Clinician Information, describes the following best practice recommendations for purposeful and timely hourly rounding25: 1. The hourly or two-hourly nursing rounds are recommended in hospital to reduce call lights, falls, and increased patient satisfaction. 2. The “12 step” or “4P” protocols can be used while performing nursing rounds. However, multiple barriers and challenges to implementing or sustaining purposeful and timely rounds were also noted in the literature. These included staffing fluctuations based on daily census, patient acuity levels, staff buy-in, competing priorities and tasks, lack of a sense of ownership, knowledge regarding the use of a protocol, no visible cues to remind staff of rounding processes, understanding the link of rounding to patient safety, sustainability of the rounding process, and leadership support to facilitate rounds when unit activities prevented staff from performing this function. 4,12,14,15,17,19 This implementation project was conducted on an adult medical surgical unit at a tertiary care facility. The unit provides care to oncology and bariatric patients and had experienced a decrease in patient satisfaction as well as patient safety scores, compared to other units in the hospital. Although nursing rounds was an expected patient care activity to be performed and documented in the patient record, standardized times and processes based on best practice had not been a priority for this unit’s staff. Additionally, the unit was experiencing staffing challenges and leadership change. The infrastructure supporting rounds was, therefore, not optimal.
doi: 10.11124/jbisrir-2016-2537
Page 250
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Aim and objectives The project aimed to improve patient satisfaction and safety on a medical surgical unit through implementation of purposeful and timely nursing rounds. The specific nurse-influenced components of patient satisfaction focused on were nurse communication, responsiveness of hospital staff and pain management. The specific nursing-sensitive safety parameter trended was the number of patient falls on this unit. The project objectives were to:
Determine current compliance with evidence-based criteria regarding timeliness and purposefulness of nursing rounds.
Improve knowledge regarding best practice interventions amongst staff nurses regarding nursing rounds.
Improve compliance with evidence-based criteria regarding timeliness and purposefulness of nursing rounds.
Methods This project was conducted on a 28-bed medical surgical unit at a tertiary care non-academic faith-based facility in the United States. The setting was chosen because patient satisfaction and patient safety scores had decreased and the processes of nursing rounds (times and purposefulness) were not standardized. A mixed method approach was utilized to assess and evaluate the test of change. Direct observation was employed to assess nurses’ timeliness and use of a protocol when rounding. In addition, bedside nurses and nursing directors were surveyed, using tools developed by Blakley, Kroth, and Gregson to determine respondents’ perspectives on the impact of nursing rounds on delivery of care in the unit9 (see Appendix I). Interventions were developed based on baseline data results and post intervention data was collected on the same criteria. Statistical analysis was completed to determine the significance of study results. Additionally, for future and comparative purposes, collection of pre-implementation data from another like unit was planned. These results will be reported at a later date.
This implementation project used the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) and Getting Research into Practice (GRiP) audit and feedback tool. The JBI-PACES and GRiP framework for promoting evidence based health care involves three phases of activity: 1. Establishing a team for the project and undertaking a baseline audit based on criteria informed by the evidence. 2. Reflecting on the results of the baseline audit and designing and implementing strategies to address non-compliance found in the baseline audit informed by the JBI GRiP framework. 3. Conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice, and identifying future practice issues to be addressed in subsequent audits.
doi: 10.11124/jbisrir-2016-2537
Page 251
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Ethical considerations The project was registered as a quality improvement activity within the hospital and received Institutional Review Board approval from Chamberlain College of Nursing. Phase 1: Stakeholder engagement; quality and safety indicators; and baseline audit In December 2014, hospital- and unit-based stakeholders were identified and meetings were with the nursing leadership team and nursing staff to collect baseline data regarding the most recent patient satisfaction and patient safety scores for the medical surgical unit (intervention unit) and telemetry step down unit (control unit). Stakeholder positions included two medical surgical day-shift and night-shift nurses, the director of professional practice, the administrative director of medical surgical services, the medical surgical professional development specialist, the nurse manager of the telemetry step-down unit, the regulatory and compliance manager, the performance improvement coordinator, the director of service excellence, the vice president for patient care services and a nurse researcher. The Hospital Consumer Assessment of Healthcare Providers (HCAHP) report was used to identify specific quality improvement goals for the project aim of increased patient satisfaction. Achievement of the 75th percentile was set by the group as the benchmark. As displayed in Figure 1, the three HCAHP categories directly related to outcome measurements for nursing rounds were: a) nurse communication (achieve 82% score); b) responsiveness of hospital staff (achieve 73% score); and c) pain management (achieve 74% score). For the project aim of improved patient safety, the fall reports from the National Database of Nursing Quality Indicators (NDNQI) were used. The identified goal was to reduce the amount of falls from current baseline. Staff submitted monthly falls information to NDNQI based on fall events submitted to the hospital’s incident/event reporting system.
75th percentile HCAHPS goals 84 82 80 78 76 74 72 70 68 Nurse Communication
Responsiveness of Hospital Staff
Pain Management
Figure 1: HCAHPS percentile goals
doi: 10.11124/jbisrir-2016-2537
Page 252
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Unit staff meetings were also conducted to discuss the topic of Nursing Rounds. Nurse champions on day shifts and night shifts were identified by the nursing leadership team to promote the “hard wiring” of accountability for the evidence-based interventions that staff established. An external researcher conducted direct observations of unit staff to collect baseline data on the following three audit criteria: 1. Hourly nursing rounds are conducted at a stipulated time during awake hours. 2. Hourly or 2 hourly nursing rounds are conducted during sleeping hours. 3. A protocol is used by nurses when conducting rounds. Table 1 contains the evidence informed audit criteria used in the project (baseline and follow up audit) together with a description of the sample and approach to measuring compliance with best practice for each audit criterion.
Table 1: Audit criteria, sample, and measurement criteria Audit criterion
Sample
Method used to measure percent compliance with best practice
1. Hourly nursing rounds are
conducted
at
a
stipulated time during
32 rounding sessions on day
Direct observation of the time the
shift by nursing staff on a
round started
medical surgical unit
awake hours 2. Hourly
or
nursing
2
hourly
12 rounding sessions on night
Direct observation of the time the
are
shift by nursing staff on a
round started
rounds
conducted
during
medical surgical unit
sleeping hours 3. A protocol is used by
44 rounding sessions on day
Direct observation of:
nurses when
shift and night shift by nursing
Verbal use of the “4P script”
conducting rounds
staff on a medical surgical unit
Completion of each “P” of the 4P rounding method (pain, position, potty [urination], possessions)
The baseline audit started on September 24, 2014 and ended on March 23, 2015. Concurrent with post-intervention audit criteria collection, the nurse researcher asked unit nurses and the nursing manager/director post intervention survey questions. Qualitative questions were derived from an article published by Blakley, Kroth and Gregson and can be found in Appendix I.9 A more in depth discussion of the qualitative trends from this study will be published at a later date. Phase 2: Design and implementation of strategies to improve practice (GRiP) One month later, a staff meeting was held with the nursing leadership and medical surgical unit nurses to discuss the results of the baseline data collected on the three criteria, as well as to identify barriers, strengths, resources and outcomes for nursing rounds. Patient perspectives of care, using the HCAHP scoring system, were used to communicate patient satisfaction results. Patient safety outcomes were also disseminated using the NDNQI fall report results.22
doi: 10.11124/jbisrir-2016-2537
Page 253
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Nurses identified initial barriers to rounding which primarily focused on staffing, new unit management, and lack of knowledge of best practice interventions. Additionally, as a strategy to create buy-in, staff divided into small groups and journal articles on nursing rounds were distributed to each group for them to review. Nurses reported back to the group the key interventions they felt could be integrated into their current nursing practice activities. Interventions for unit support processes To address the staffing barrier, the nursing unit manager and director reviewed a three-month staffing pattern and patient assignment log. They identified gaps to determine additional full-time equivalents (FTEs) needed to address this concern. This information was presented to the Vice President for Nursing to obtain approval to hire the needed FTEs. The unit manager and director then worked with the human resources department to advertise, interview and hire experienced nurses to fill this gap. While addressing new unit management to the organization, it was agreed the processes of implementing purposeful and timely nursing rounds should not be delayed. The unit manager and director actively engaged with the unit charge nurses to evaluate daily unit staffing and acuity, as well as promote the hardwiring of intentional nursing rounds with staff on all shifts. In addition, the new nurse manager created a lead nursing assistant position to fill potential staff communication gaps between nurses and nursing assistants when high acuity situations occur. The nursing assistant would meet with each nurse during the shift to determine if the staff nurse assignment had changed or patient care needs had increased. This information, in turn, would be relayed to the assigned nursing assistant to ensure hourly rounds continued seamlessly and patient care needs were met. At the hospital’s administrative level, the Vice President of Nursing disseminated project information and progress updates to other healthcare providers in the organization. This strategy generated quality feedback and maintained leadership support for the project. Interventions for nurse education A multi-pronged approach was used to address lack of knowledge on best practice interventions for nursing rounds. First, a journal club was formed and articles on the topic were circulated. Next, a journal club/quality improvement (QI) bulletin board on the unit was developed to collect best practice interventions on nursing rounds. The board content included monthly updates comparing compliance with the three audit criteria to patient satisfaction and safety data outcomes. A GRiP matrix table was also posted. Additionally, to keep rounding at the forefront of patient care, updated monthly data collection results were disseminated to key stakeholders during the daily unit shift huddles. Staff stated that when they rounded, they did assess for most of the “4Ps” (pain, position, potty, possessions) but did not communicate to the patient and family what they were actually doing. Therefore, as a third strategy, a script was developed. The purpose of the script was for staff to use a standardized communication tool at specific times during the patient’s hospitalization: while completing the admission assessment; during rounds throughout the patient’s hospital stay; and upon discharge. Script cards, as displayed in Appendix II, were developed from Studer resources and placed on each computer in each patient’s room to provide visual cues to staff as a reminder to ask about the 4Ps.24 (Also it was planned for this script and the 4Ps to be added to the nursing rounds documentation section in the electronic health record.) Initial and on-going support of rounding was also provided by the unit’s nurse educator and nurse champions. The educator created a presentation as part of staff re-education to “hourly rounding”.
doi: 10.11124/jbisrir-2016-2537
Page 254
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Both the champions and educator reinforced with staff the essential components of the scripting used to explain hourly rounding to the patients and families during the admission process and throughout their length of stay. Phase 3: Follow-up audit post implementation of change strategy In the third month of the project, a follow-up audit was conducted using the same evidence-based audit criteria as those used in the baseline audit. A total of 32 observations were completed on the day shift and 12 on the night shift for timeliness of nursing rounds. The 4P protocol script that nurses developed, as one of the interventions, was assessed on both day shift and night shift observations.
Results Phase 1: Baseline audit The baseline compliance with the audit criteria was entered into JBI-PACES. As can be seen in Figure 2, baseline data for Criterion 1 revealed 34% compliance (11 out of 32 observations) with hourly rounds occurring on the day shift (considered the awake hours). For Criterion 2 there was 42% compliance (five out of 12 observations) with at least every two-hour rounds occurring on the night shift (considered the sleeping hours). Use of a protocol was not observed for either day or night shift rounds, which represents 0% compliance for Criterion 3.
Figure 2: Baseline compliance with best practice for audit criteria (%) Audit criteria legend and sample: 1. Hourly nursing rounds are conducted at a stipulated time during awake hours. (N=32) 2. Hourly or 2 hourly nursing rounds are conducted during sleeping hours. (N=12) 3. A protocol is used by nurses when conducting rounds. (N=44)
Baseline HCAHPS scores for the unit for October 2014 were obtained and are displayed in Figure 3. The HCAHPS survey categories directly related to nursing rounds are: a) nurse communication; b) responsiveness of hospital staff; and c) pain management. Each category contained sub-component survey questions/scores. For the category of communication with nurses, the pre-implementation score reached 64%. Sub-component scores for this category included: listen carefully (58%) and explain things (63%). The score for responsiveness of hospital staff was 39% with sub-component scores of 45% for call light and 24% for bedpan or bathroom. The pain management score was 62%. Its sub-component scores were similar, with pain controlled at 56% and pain help at 68%.
doi: 10.11124/jbisrir-2016-2537
Page 255
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
90 80 70 60 50 Baseline Data
40
75th Percentile HCAHP Goals
30 20 10 0 Nurse communication Responsiveness of hospital staff
Pain management
Figure 3: Baseline HCAHP scores
The baseline fall data for each of the pre-implementation months presented in Table 2 demonstrated a slight rise in the amount of falls on the unit. The average was two falls.
Table 2: NDNQI data – medical surgical unit patient falls volume per month Pre-intervention
Pre-intervention
Pre-intervention
1
3
2
Phase 2: Strategies for Getting Research into Practice (GRIP) As can be seen in the GRIP Matrix (Table 3), each barrier was addressed with multiple interventions.
doi: 10.11124/jbisrir-2016-2537
Page 256
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Table 3: GRIP matrix Barrier
Strategy
Resources
Outcomes
Staffing
Nursing unit manager
Staffing schedules
Four nurses were hired and
and director will
Patient assignment
completed orientation prior
review a three-month
logs for last three
to the March 3, 2015
staffing pattern and
months
follow-up audit cycle.
Unit manager will
Charge nurse
New unit manager presence
actively engage with
availability at the
on the unit has yielded
the unit charge nurse
beginning of each
positive comments from
to evaluate the daily
shift
nursing staff to build
unit acuity
Manager following
teamwork and stabilize unit
Unit manager will
audit criteria for
daily functions
assist in performing
rounding on the unit
identified gaps to determine additional FTEs needed Vice President for Nursing will approve budget for hiring needed FTEs Unit manager and director then will work with human resources department to advertise, interview, and hire experienced nurses New
unit
management
nursing rounds when needed Lack of knowledge
A journal club will be
Nursing educator to
Timeliness of day shift
of
formed and articles on
obtain materials for
rounding compliance
the topic will be
the board
increased 25%; night shift
best
practice
interventions
circulated to nursing
rounding increased 33%,
staff
and using a protocol when
A journal club/QI
Journal club team to
board was developed
post articles on
to collect best practice
nursing rounds
rounding increased 64%
interventions on the topic of nursing rounds A script was developed and put on
Nurse educator to
a reminder card by
update compliance
each computer for
with the three audit
staff to use as a
criteria
doi: 10.11124/jbisrir-2016-2537
Page 257
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
communication tool on patient admission assessment, during rounds while the patient was in the hospital, and upon discharge The script and the 4Ps added to the nursing rounds documentation section in the electronic health record
Phase 3: Follow-up audits Results of follow-up audits for the three types of data, compared to the baseline results, are displayed in Figures 4, 5 and 6. First, for the JBI criteria, as seen in Figure 4, there were moderate improvements in compliance for timeliness of rounds, as well as use of a protocol. Timeliness of day shift (awake hours) rounding nearly doubled (42%), increasing from 34% to 59%. Night shift (sleeping hours) rounding had a similar result (44%), increasing from 42% to 75%. As expected, use of a protocol when rounding increased to 64% from 0%.
Figure 4: Compliance with best practice audit criteria in follow up audit compared to baseline audit (%) Audit criteria and post-audit sample: 1. Hourly nursing rounds are conducted at a stipulated time during awake hours. (N=32) 2. Hourly or 2 hourly nursing rounds are conducted during sleeping hours. (N=12) 3. A protocol is used by nurses when conducting rounds. (N=44) Secondly, for patient satisfaction outcomes, the scores for three HCAHP categories are presented in Figure 5 and the sub-categories in Table 4. Overall the post-intervention HCAHPS scores increased somewhat. Baseline communication with nurses scores moderately increased from 64% (with sub-categories scores for listen carefully at 58% and explain things at 63%) to 69% (with scores for listen carefully at 71% and explain things at 71%). Responsiveness of hospital staff significantly
doi: 10.11124/jbisrir-2016-2537
Page 258
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
increased from 39% (with sub-categories scores for call light at 45% and bedpan/bathroom at 24%) to 54% (with scores for call light at 45% and bedpan/bathroom at 65%). Pain management modestly increased from 62% to 73% (with sub-category scores for pain controlled at 68% and pain help at 77%). Post-intervention scores for the three categories did not reach the goals set by the organization, although pain management came within 1%.
90 80 70 60 50
Pre-Intervention Data
40
Post-Intervention Data
30
75th Percentile HCAHPS Goals
20 10 0 Nurse Communication
Responsiveness of Hospital Staff
Pain Management
Figure 5: HCAHPS score comparison of baseline to post intervention audits
Table 4: HCAHPS sub-categories improvement rates HCAHPS sub-category
Pre-intervention
Post-intervention
Change
Rate of
compliance
compliance
Listen carefully
58 %
71 %
↑ 13%
18 %
Explain things
63 %
71 %
↑8%
11 %
Call light
45 %
45 %
0
0
Bedpan or bathroom
24 %
65 %
↑ 41
63 %
Pain control
56 %
68 %
↑ 12
18 %
Pain help
68 %
77 %
↑9
12 %
improvement
Nurse communication
Responsiveness – staff
Pain management
Patient falls was the third type of data comparing pre- and post-intervention outcomes. As shown in Table 5, the amount of falls on the unit increased in the months prior to implementation of hourly rounding and decreased modestly with implementation of timeliness of rounding and protocol use.
doi: 10.11124/jbisrir-2016-2537
Page 259
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Table 5: NDNQI data – medical surgical unit patient falls volume per month Pre-intervention
Pre-intervention
Pre-intervention
Implementation
Post intervention
1
3
2
1
1
Discussion This project established quality improvement benchmarks aimed at improving patients’ perspectives of, and satisfaction with, their care, as well as increasing patient safety during hospitalization. Timely and purposeful rounding was the intervention determined to have the greatest impact on accomplishing this. Multi-level strategies were developed and implemented on the medical-surgical unit to address the three specific objectives regarding nursing rounds: determine compliance with the evidence-based criteria; improve staff nurse knowledge; and improve compliance with evidence-based rounding criteria. The unit’s baseline fall numbers and HCAHPS satisfaction scores focusing on the nursing-sensitive categories most closely related to rounding were obtained. Pre-intervention data on the evidence-based criteria were gathered. The post-implementation outcome data revealed all the objectives and the safety aims were successfully met. However, though there were increases in satisfaction scores, the desired goals were not reached after the first month. Frontline staff and managers expect the scores will continue to rise over several months as rounding becomes a hard-wired practice. Although nursing staff may be aware of call bell activation, they may not always respond as promptly as needed or expected. When staff awareness increased, an improvement was seen in response to patient calls and rate of falls. Interestingly, when staff awareness of patient needs increased through hourly rounding programs, to some degree, the rate of falls decreased and patient satisfaction increased. Initial themes from the concurrent survey conducted during this project revealed that challenges exist when patient census or staffing fluctuates, and that nursing leadership rounds could assist in hardwiring rounding interventions for staff. Thus, strong nursing leadership focused on re-educating and emphasizing the importance of an intentional hourly rounding protocol may assist in meeting organizational goals of decreasing falls and increasing patient satisfaction. Additionally, reimbursement would increase and the organization would be in an excellent position to improve other patient care initiatives. Clearly, initial improvement was made toward the established satisfaction benchmarks for the project. Responsiveness of staff, the HCAHPS category with the lowest scores, had a robust 28% improvement rate (a gain of 15%). However, scores for the sub-category call light did not change. This most likely reflects that timely answering of call lights was not one of the rounding interventions. The call light usage rate by patients was not evaluated. Pain management, with pre- and post-implementation scores most similar to those for nurse communication, realized a 15% improvement rate (a gain of 11%). The sub-categories pain controlled and pain help had improvement rates of 18% and 12%, respectively. Nurse communication, the category with the highest starting and ending scores, had a modest but lackluster 7% improvement rate (a gain of 5%). Interestingly, the improvement rates for sub-categories listen carefully and explain things had higher improvement rate gains, 18% and 11%, respectively. These sub-category results indicate a higher quality of
doi: 10.11124/jbisrir-2016-2537
Page 260
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
purposefulness and intentionality when rounding and are most likely due to adoption of the standardized scripting protocol. Nurse communication and pain management scores were expected to be more closely aligned as pain/comfort management is a nurse domain (that is, other non-nurse unit staff would not be actively treating patients’ pain) and is dependent on focused nurse-patient interactions for assessing and re-evaluating pain/comfort levels. The category responsiveness of staff included all unit members and the substantial rate gain pointed to heightened engagement of all levels of staff, teamwork and accountability for providing patient-centred care. It also reflects the impact of increased nurse staffing levels on having time to consistently carry out rounding, as well as, caring practices of the leaders and administrative managers. Keeping patients safe from harm is another basic nursing domain. The project aim of improved safety, indicated by a decreased volume of falls, was achieved. The average three-month fall volume prior to implementation was two and it was halved after the first month of timely and purposeful rounding. Because of the low volumes, data trending over the next several months will be important to show that timeliness and purposefulness are sustainable. However, the bedpan/bathroom sub-component score for the HCAHPS category staff responsiveness also substantiates success because falling is highly associated with toileting needs. The improvement rate was 63% (with a gain of 41%). This result was encouraging to staff, but they also realized improvement could be made in order to advance the actual HCAHPS score beyond the 75th percentile. The process of generating ideas, and developing and implementing the 4P rounding program was empowering to staff due to experiential learning. Results demonstrated that not only meeting patient care needs but also anticipating them and being proactive directly impacted on patient safety and perceptions of feeling cared for and important. Some staff members acknowledged they did not realize how standardizing a unit routine, such as rounding at a particular time of day and using a protocol, could actually create a more healing environment through open lines of communication and a higher frequency and quality of interactions. Results from this project validate why high standards are set for NDNQI falls (a nursing-sensitive indicator) and the American Nurses Credentialing Center’s Magnet ® Recognition Program for nursing excellence outcome requirements on nursing-sensitive indicators such as falls with injury and patient satisfaction. Shoring up the unit’s infrastructure for this project was akin to moving up through the levels in Maslow’s Hierarchy of Needs model.26 Basic safety staffing needs had to be met first before staff nurses could concentrate on higher level care needs such as nursing rounds. Daily staffing level challenges and the impact of leadership change to a new unit manager from outside the organization were immediate barriers recognized by top level hospital and nursing administrators. Their responsive actions of more intensely supporting the unit’s nurse manager, as well as hiring additional nurses allowed staff to use their abilities to develop and implement strategies aimed at improving patient satisfaction and safety. Use of dedicated nurse champions was another key structure put in place in order to resource staff and role-model practices. This position also bridged communication between clinical nurses and managers, and between clinical nurses and unlicensed nursing staff. In response to the outcomes and experiences acquired during the project, nursing staff began developing new processes to hardwire the rounding protocol for new and seasoned employees. A proposal was forwarded for the 4P protocol to be a competency which would be included in the new employee orientation simulation experience, as well as part of the annual skills fair. In addition, some
doi: 10.11124/jbisrir-2016-2537
Page 261
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
nurses who also served as clinical instructors for local academic institutions planned to request integration of a structured nursing round protocol into the curriculum for nursing students. Although project outcomes generated new ideas, there were limitations noted for this project to be considered with future project implementation on other units. The main limitations of the project were: 1. Barriers identified for this unit that may not be generalizable to other units in the hospital because nursing workflows and patient populations with their specific needs differ in each unit. 2. Results of the intervention unit were not compared to a control unit. 3. Direct observation could have biased nursing behaviors. 4. The call light usage rate by patients was not evaluated. 5. Sustainability measures needed to be established to maintain the gains and to continue to improve the outcomes. The second limitation was anticipated. Therefore, nursing leadership determined at the beginning of the project to collect data from a like unit, as a “control unit” for baseline data comparison. Results from this continued project will be reported at a later date. The main successes of the initiative were the use of best practice evidence to promote practice change and management staff teambuilding. This project has empowered and re-energized nurses to initiate a journal club focusing on nurse driven practices to improve patient care outcomes. Future directions for promoting best practice in this unit are to identify and address other medical-surgical practice issues related to oncology and bariatric patients by applying the learned concepts of process improvement. This organization is seeking Magnet® recognition and is on a “Pathway to Excellence” to promote positive practice environments where nurses excel.27 As a best practice exemplar, the processes and interventions of this project will be introduced to other units in the organization, and to other hospitals in the system, for nurses to evaluate and implement in their particular practice setting. Unit leadership has planned to disseminate the rounding project results at the hospital’s annual safety fair as a stimulus for encouraging nurses from other units to improve evidence-based practice as the organization progresses on their pathway to excellence to achieve Magnet® designation.
Conclusion Nurses have the ability to improve patient satisfaction and patient safety outcomes by utilizing nursing round interventions which serve to improve patient communication and staff responsiveness. Having an appropriate infrastructure and an organized approach, encompassing all levels of staff, to meet patient needs during their hospital stay was a key factor for success. The aims and objectives of the project were realized as staff embraced the change and comprehended how best practice interventions could significantly improve patient outcomes. However, the desired satisfaction goals were not yet reached after the first month because rounding was still becoming hard-wired. The project did not provide future directions for sustaining evidence-based practice change, but a monthly audit format has been developed to monitor, communicate and help maintain the current practice change. Plans to improve HCAHP satisfaction scores have been placed on future staff meeting agendas.
doi: 10.11124/jbisrir-2016-2537
Page 262
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Conflict of interest The author declares that there were no conflicts of interest in the implementation of this quality improvement project.
Acknowledgements The author would like to gratefully acknowledge: The nursing staff, the nursing leadership team, and Jeff Doucette, Vice President, Patient Care Services, and Chief Nursing Officer, Mary Immaculate Hospital Nursing Chamberlain College of Nursing, for their generous support in completing the JBI Clinical Fellows training Douglas Turner, my JBI Clinical Fellow coach and the UCSF JBI Centre for Synthesis and Implementation, for their assistance in writing this evidence-based project report
doi: 10.11124/jbisrir-2016-2537
Page 263
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
References 1. Ford B. Hourly rounding: a strategy to improve patient satisfaction scores.Medsurg Nurs.2010; 19(3):188-191. 2. Bluni R, O'Shaughnessy J. Words that save. Ensuring that "never events" never happen. Marketing Health Services. 2009; 29(3):13-17. 3. Boushon B, Nielson G., Quigley P, Rutherford P, Taylor J, Shannon, D, Rita S. (December 2012) How-to Guide:
Reducing Patient Injuries from Falls. Cambridge, MA: Institute for
Healthcare Improvement.[internet].[cited February 1, 2014 ]. Available from: http://www.www.ihi.org. 4. Reimer R, Herbener L. Round and round we go: rounding strategies to impact exemplary professional practice. Clin J Oncol Nurs 2014 18(6):654-659. 5. Olrich T, Kalman M, Nigolian C. Hourly rounding: a replication study.. Medsurg Nurs 2012; 21(1): 23-36. 6. Gnida, J.]; [Audio podcast].;CAHPS update [January 8th, 2015]. Omaha, Nebraska. 7. Grellner L. Put your money where your scores are HCAHPS and VBP. Okla Nurse. 2012; 57(3):4. 8. Berg K, Sailors C, Reimer R, O'Brien Y, Ward-Smith P. Hourly rounding with a purpose. Iowa Nurse Reporter. 2011; 24(3):12-4. 9. Blakley D, Kroth M, Gregson J. The impact of nurse rounding on patient satisfaction in a Medical- Surgical Hospital Unit. Medsurg Nurs. 2011; 20(6):327-32. 10. Butcher L. Hospitals work to prevent patient falls. [Internet]; [cited June 1st 2013]. Available from: http://www.hhnmag.com/Magazine/2013/Jun/0613HHN_coverstory. 11. Culley T. Reduce call light frequency with hourly rounds. Nursing Management. 2008; 39(3):50-52. 12. Deitrick L, Baker K, Paxton H, Flores M, Swavely D. Hourly rounding: challenges with implementation of an evidence-based process. J Nurs Care Qual. 2012; 27(1):13-9. 13. Gardner G, Woollett K, Daly N, Richardson B. Measuring the effect of patient comfort rounds on practice environment and patient satisfaction: a pilot study. Int J Nurs Pract. 2009; 15(4):287-293. 14. Halm M. Hourly rounds: what does the evidence indicate?
Am J Crit Care2009; 18(6):
581-584. 15. Kessler B, Claude-Gutekunst M, Donchez A, Dries R, Snyder M. The merry-go-round of patient rounding: assure your patients get the brass ring. MEDSURG Nursing. 2012; 21(4):240-245. 16. Meade C, Kennedy J, Kaplan J. The effects of emergency department staff rounding on patient safety and satisfaction. J Emerg Med. 2010; 38(5):666-674. 17. Meade C, Bursell A, Ketelsen L. CE Credit: Effects of nursing rounds on patients' call light use, satisfaction, and safety. Am J Nurs . 2006; 106 (9): 58-70.
doi: 10.11124/jbisrir-2016-2537
Page 264
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
18. Mitchell M, Lavenberg J, Trotta R, Umscheid C. Hourly rounding to improve nursing responsiveness. J Nurs Adm. 2014; 44(9):462-472. 19. Rondinelli J, Ecker M, Crawford C, Seelinger C, Omery A. Hourly rounding implementation: a multisite description of structures, processes, and outcomes. J Nurs Adm. 2012; 42(6):326-332. 20. Saleh BS, Nusair H, Al Zubadi N, Al Shoul S, Saleh U. The nursing rounds system: effect of patient’s call light use, bed sores, and satisfaction level. Int J Nurs Pract. 2011; 17(3):299-303. 21. Tucker S, Bieber P, Attlesey-Pries J, Olson M, Dierkhising R. Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units.. Worldviews Evid Based Nurs 2012; 9(1):18-29. 22. Woodward JL. Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Clin Nurse Spec, 2009; 23,(4):200-6. 23. Montalvo I. The National Database of Nursing Quality IndicatorsTM (NDNQI®). Online J Issues Nurs 2007; 12(3) Manuscript 2 24. Studer, O. Serious about service. [Internet]. [cited November 7th, 2007]. Available from: http://www.studergroup.com/content/tools_and_knowledge/articles/associated_files/QuintNov 07HealthExecutive.pdf. 25. Chu V. JBI Evidence Summary/Nursing Rounds: Clinician Information. Joanna Briggs Institute. 2014 [Internet]. [cited July 6th, 2014]. Available from: http://paces.jbiconnectplus.org/AuditHome.aspx 26. Maslow A. A theory of human motivation. Psychol Rev 1943; 50(4):370-96 27. American Nurses Credentialing Center. Pathway to Excellence. 2015. [Internet]. [cited July 3rd, 2014]. Available from: http://nursecredentialing.org/Pathway.aspx.
doi: 10.11124/jbisrir-2016-2537
Page 265
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Appendix I: Staff Survey and Nursing Director Interview Questions on the 4Ps Rounding Process 9
Staff Survey on the 4 Ps Rounding Process
• Have you been able to incorporate 4 P rounding every 2 hours in to your practice? • What system problems have you identified with the 4 P rounding system? • What call light changes have you observed since 4 P rounding started? • Do you have any specific comments you’d like to share about the 4 P process? How can it be improved? (Nursing
Medical-Surgical and other Nursing Director Interview Questions
• What is the role of rounding from a nursing director’s perspective? • What does patient satisfaction mean to you? • Since the inception of the 4 P program, have you noticed a reduction in call light usage? • Are the nurses still performing 4 P rounding every 2 hours? • What relationship do you see between patient safety and 4 P rounding? • Do you think 4 P rounding adequately addresses patients’ more mundane and common problems? One of the things the staff mentioned in a questionnaire was how to maintain 4 P rounding when the floor gets busy. What are your ideas to keep the 4 P rounding going when things get busy? • What are your ideas for sustaining the gains in patient and staff satisfaction?
doi: 10.11124/jbisrir-2016-2537
Page 266
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Appendix II: Hourly Rounding Staff Communication Tool 24
4 P’s of Hourly Rounding
Pain
How is your pain?
Position
Are you comfortable?
Potty
Do you need to use the bathroom?
Possessions
Place phone, call light, trash, bedside table, tissues, and water pitcher within reach.
doi: 10.11124/jbisrir-2016-2537
Page 267
2016;14(1):248-267
Purposeful and timely nursing rounds: a best practice implementation project Juli F Daniels1
1. UCSF JBI Center for Synthesis and Implementation: an Affiliate Center of the Joanna Briggs Institute
Corresponding author: Juli F Daniels [email protected]
Key dates Commencement date: September 24, 2014 Completion date: March 23, 2015
Executive summary Background Purposeful and timely rounding is a best practice intervention to routinely meet patient care needs, ensure patient safety, decrease the occurrence of patient preventable events, and proactively address problems before they occur. The Institute for Healthcare Improvement (IHI) endorsed hourly rounding as the best way to reduce call lights and fall injuries, and increase both quality of care and patient satisfaction. Nurse knowledge regarding purposeful rounding and infrastructure supporting timeliness are essential components for consistency with this patient centred practice. Objectives The project aimed to improve patient satisfaction and safety through implementation of purposeful and timely nursing rounds. Goals for patient satisfaction scores and fall volume were set. Specific objectives were to determine current compliance with evidence-based criteria related to rounding times and protocols, improve best practice knowledge among staff nurses, and increase compliance with these criteria. Methods For the objectives of this project the Joanna Briggs Institute’s Practical Application of Clinical Evidence System and Getting Research into Practice audit tool were used. Direct observation of staff nurses on a medical surgical unit in the United States was employed to assess timeliness and utilization of a protocol when rounding. Interventions were developed in response to baseline audit results. A follow-up audit was conducted to determine compliance with the same
doi: 10.11124/jbisrir-2016-2537
Page 248
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
criteria. For the project aims, pre- and post-intervention unit-level data related to nursing-sensitive elements of patient satisfaction and safety were compared. Results Rounding frequency at specified intervals during awake and sleeping hours nearly doubled. Use of a rounding protocol increased substantially to 64% compliance from zero. Three elements of patient satisfaction had substantive rate increases but the hospital’s goals were not reached. Nurse communication and pain management scores increased modestly (5% and 11%, respectively). Responsiveness of hospital staff increased moderately (15%) with a significant sub-element increase in toileting (41%). Patient falls decreased by 50%. Conclusions Nurses have the ability to improve patient satisfaction and patient safety outcomes by utilizing nursing round interventions which serve to improve patient communication and staff responsiveness. Having a supportive infrastructure and an organized approach, encompassing all levels of staff, to meet patient needs during their hospital stay was a key factor for success. Hard-wiring of new practices related to workflow takes time as staff embrace change and understand how best practice interventions significantly improve patient outcomes. Keywords Nursing rounds; patient satisfaction; HCAHPS; patient safety; patient falls
Background The mission of many hospitals is to provide compassionate and innovative care for the whole person. Patient satisfaction and patient safety outcomes are viewed by hospital leadership as crucial determinants of success for meeting this mission. Reimbursement to the organization is also directly related to performance measures, such as patient satisfaction4 and patient safety initiatives.5 Gnida6 reported that each year, the Centers for Medicare and Medicaid Services (CMS) withhold money from hospitals, with the option to earn some of it back based on the five domains (efficiency – 25 %, HCAHPS – 25 %, clinical care process – 5%, clinical care outcomes – 25%, and safety – 20 %). The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) surveys are surveys conducted to determine the hospital’s reimbursement scores. There are 12 core measures which account for 70% of the weight while the other 30% are eight composited measures from HCAHPS.7 The eight HCAHPS measures include nursing communication, doctor communication, responsiveness of staff, pain management, communication of medications, discharge information, cleanliness and quietness of hospital environment and overall rating. Olrich, Kalman and Nigolian reported with their 2012 review of literature that 25% of falls result from falling out of bed and approximately 30% of these falls result in injury with 4-6% listed as serious. Injuries included either fracture or death. In addition, hospital costs for patients injured during falls are US$4200 higher than for patients who do not fall.5 The Institute for Healthcare Improvement (IHI), in 2012, considered hospital fall injuries “never events” associated with morbidity and mortality, and endorsed every one to two hourly rounding for the purposes of pain relief, toileting and positioning.2
doi: 10.11124/jbisrir-2016-2537
Page 249
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Multiple studies have been conducted in the past six years to assess the effectiveness of nursing rounds on outcomes such as call light use, patient satisfaction and patient safety. Patient rounding has shown to have positive impacts on decreasing call light usage1,4,5,9,11,16,19,20,22, decreased fall rates1,4,5,12,16,19,20,22, decreased skin breakdown rates4,19, and increased patient satisfaction, with nursing care resulting in improved patient satisfaction scores.1,4,5,7-20,22 A 2014 systematic review by Mitchell, Lavenberg, Trotta, and Umscheid revealed there was little consistency in how results of hourly rounds were measured.18 Their review did show there was moderate strength evidence that hourly rounding programs improved patient perceptions of nursing responsiveness and reduced falls, as well as call light use. Review of structure, process, and outcomes by Rondinelli, Ecker, Crawford, Seelinger, and Omery revealed that rounding behaviors, a library of tools, and patient satisfaction were common themes associated with hourly rounding implementation.19 Purposeful and timely rounding is a best practice intervention used to meet basic patient care needs routinely, ensure patient safety, decrease the occurrence of patient preventable events, and proactively address problems before they occur.1 The IHI endorsed hourly rounding in 2009 as the best way to reduce call lights and increase both the quality of care and the satisfaction of patients.2 Prior to that, Studer found hospitals that proactively instituted rounding increased patient satisfaction by 8.9%. 22 Rounding methods using protocols, such as 12 Steps or 4Ps (pain, personal needs, positioning and placement) can be used to standardize practice. The Joanna Briggs Institute (JBI) Evidence Summary, Nursing Rounds: Clinician Information, describes the following best practice recommendations for purposeful and timely hourly rounding25: 1. The hourly or two-hourly nursing rounds are recommended in hospital to reduce call lights, falls, and increased patient satisfaction. 2. The “12 step” or “4P” protocols can be used while performing nursing rounds. However, multiple barriers and challenges to implementing or sustaining purposeful and timely rounds were also noted in the literature. These included staffing fluctuations based on daily census, patient acuity levels, staff buy-in, competing priorities and tasks, lack of a sense of ownership, knowledge regarding the use of a protocol, no visible cues to remind staff of rounding processes, understanding the link of rounding to patient safety, sustainability of the rounding process, and leadership support to facilitate rounds when unit activities prevented staff from performing this function. 4,12,14,15,17,19 This implementation project was conducted on an adult medical surgical unit at a tertiary care facility. The unit provides care to oncology and bariatric patients and had experienced a decrease in patient satisfaction as well as patient safety scores, compared to other units in the hospital. Although nursing rounds was an expected patient care activity to be performed and documented in the patient record, standardized times and processes based on best practice had not been a priority for this unit’s staff. Additionally, the unit was experiencing staffing challenges and leadership change. The infrastructure supporting rounds was, therefore, not optimal.
doi: 10.11124/jbisrir-2016-2537
Page 250
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Aim and objectives The project aimed to improve patient satisfaction and safety on a medical surgical unit through implementation of purposeful and timely nursing rounds. The specific nurse-influenced components of patient satisfaction focused on were nurse communication, responsiveness of hospital staff and pain management. The specific nursing-sensitive safety parameter trended was the number of patient falls on this unit. The project objectives were to:
Determine current compliance with evidence-based criteria regarding timeliness and purposefulness of nursing rounds.
Improve knowledge regarding best practice interventions amongst staff nurses regarding nursing rounds.
Improve compliance with evidence-based criteria regarding timeliness and purposefulness of nursing rounds.
Methods This project was conducted on a 28-bed medical surgical unit at a tertiary care non-academic faith-based facility in the United States. The setting was chosen because patient satisfaction and patient safety scores had decreased and the processes of nursing rounds (times and purposefulness) were not standardized. A mixed method approach was utilized to assess and evaluate the test of change. Direct observation was employed to assess nurses’ timeliness and use of a protocol when rounding. In addition, bedside nurses and nursing directors were surveyed, using tools developed by Blakley, Kroth, and Gregson to determine respondents’ perspectives on the impact of nursing rounds on delivery of care in the unit9 (see Appendix I). Interventions were developed based on baseline data results and post intervention data was collected on the same criteria. Statistical analysis was completed to determine the significance of study results. Additionally, for future and comparative purposes, collection of pre-implementation data from another like unit was planned. These results will be reported at a later date.
This implementation project used the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) and Getting Research into Practice (GRiP) audit and feedback tool. The JBI-PACES and GRiP framework for promoting evidence based health care involves three phases of activity: 1. Establishing a team for the project and undertaking a baseline audit based on criteria informed by the evidence. 2. Reflecting on the results of the baseline audit and designing and implementing strategies to address non-compliance found in the baseline audit informed by the JBI GRiP framework. 3. Conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice, and identifying future practice issues to be addressed in subsequent audits.
doi: 10.11124/jbisrir-2016-2537
Page 251
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Ethical considerations The project was registered as a quality improvement activity within the hospital and received Institutional Review Board approval from Chamberlain College of Nursing. Phase 1: Stakeholder engagement; quality and safety indicators; and baseline audit In December 2014, hospital- and unit-based stakeholders were identified and meetings were with the nursing leadership team and nursing staff to collect baseline data regarding the most recent patient satisfaction and patient safety scores for the medical surgical unit (intervention unit) and telemetry step down unit (control unit). Stakeholder positions included two medical surgical day-shift and night-shift nurses, the director of professional practice, the administrative director of medical surgical services, the medical surgical professional development specialist, the nurse manager of the telemetry step-down unit, the regulatory and compliance manager, the performance improvement coordinator, the director of service excellence, the vice president for patient care services and a nurse researcher. The Hospital Consumer Assessment of Healthcare Providers (HCAHP) report was used to identify specific quality improvement goals for the project aim of increased patient satisfaction. Achievement of the 75th percentile was set by the group as the benchmark. As displayed in Figure 1, the three HCAHP categories directly related to outcome measurements for nursing rounds were: a) nurse communication (achieve 82% score); b) responsiveness of hospital staff (achieve 73% score); and c) pain management (achieve 74% score). For the project aim of improved patient safety, the fall reports from the National Database of Nursing Quality Indicators (NDNQI) were used. The identified goal was to reduce the amount of falls from current baseline. Staff submitted monthly falls information to NDNQI based on fall events submitted to the hospital’s incident/event reporting system.
75th percentile HCAHPS goals 84 82 80 78 76 74 72 70 68 Nurse Communication
Responsiveness of Hospital Staff
Pain Management
Figure 1: HCAHPS percentile goals
doi: 10.11124/jbisrir-2016-2537
Page 252
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Unit staff meetings were also conducted to discuss the topic of Nursing Rounds. Nurse champions on day shifts and night shifts were identified by the nursing leadership team to promote the “hard wiring” of accountability for the evidence-based interventions that staff established. An external researcher conducted direct observations of unit staff to collect baseline data on the following three audit criteria: 1. Hourly nursing rounds are conducted at a stipulated time during awake hours. 2. Hourly or 2 hourly nursing rounds are conducted during sleeping hours. 3. A protocol is used by nurses when conducting rounds. Table 1 contains the evidence informed audit criteria used in the project (baseline and follow up audit) together with a description of the sample and approach to measuring compliance with best practice for each audit criterion.
Table 1: Audit criteria, sample, and measurement criteria Audit criterion
Sample
Method used to measure percent compliance with best practice
1. Hourly nursing rounds are
conducted
at
a
stipulated time during
32 rounding sessions on day
Direct observation of the time the
shift by nursing staff on a
round started
medical surgical unit
awake hours 2. Hourly
or
nursing
2
hourly
12 rounding sessions on night
Direct observation of the time the
are
shift by nursing staff on a
round started
rounds
conducted
during
medical surgical unit
sleeping hours 3. A protocol is used by
44 rounding sessions on day
Direct observation of:
nurses when
shift and night shift by nursing
Verbal use of the “4P script”
conducting rounds
staff on a medical surgical unit
Completion of each “P” of the 4P rounding method (pain, position, potty [urination], possessions)
The baseline audit started on September 24, 2014 and ended on March 23, 2015. Concurrent with post-intervention audit criteria collection, the nurse researcher asked unit nurses and the nursing manager/director post intervention survey questions. Qualitative questions were derived from an article published by Blakley, Kroth and Gregson and can be found in Appendix I.9 A more in depth discussion of the qualitative trends from this study will be published at a later date. Phase 2: Design and implementation of strategies to improve practice (GRiP) One month later, a staff meeting was held with the nursing leadership and medical surgical unit nurses to discuss the results of the baseline data collected on the three criteria, as well as to identify barriers, strengths, resources and outcomes for nursing rounds. Patient perspectives of care, using the HCAHP scoring system, were used to communicate patient satisfaction results. Patient safety outcomes were also disseminated using the NDNQI fall report results.22
doi: 10.11124/jbisrir-2016-2537
Page 253
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Nurses identified initial barriers to rounding which primarily focused on staffing, new unit management, and lack of knowledge of best practice interventions. Additionally, as a strategy to create buy-in, staff divided into small groups and journal articles on nursing rounds were distributed to each group for them to review. Nurses reported back to the group the key interventions they felt could be integrated into their current nursing practice activities. Interventions for unit support processes To address the staffing barrier, the nursing unit manager and director reviewed a three-month staffing pattern and patient assignment log. They identified gaps to determine additional full-time equivalents (FTEs) needed to address this concern. This information was presented to the Vice President for Nursing to obtain approval to hire the needed FTEs. The unit manager and director then worked with the human resources department to advertise, interview and hire experienced nurses to fill this gap. While addressing new unit management to the organization, it was agreed the processes of implementing purposeful and timely nursing rounds should not be delayed. The unit manager and director actively engaged with the unit charge nurses to evaluate daily unit staffing and acuity, as well as promote the hardwiring of intentional nursing rounds with staff on all shifts. In addition, the new nurse manager created a lead nursing assistant position to fill potential staff communication gaps between nurses and nursing assistants when high acuity situations occur. The nursing assistant would meet with each nurse during the shift to determine if the staff nurse assignment had changed or patient care needs had increased. This information, in turn, would be relayed to the assigned nursing assistant to ensure hourly rounds continued seamlessly and patient care needs were met. At the hospital’s administrative level, the Vice President of Nursing disseminated project information and progress updates to other healthcare providers in the organization. This strategy generated quality feedback and maintained leadership support for the project. Interventions for nurse education A multi-pronged approach was used to address lack of knowledge on best practice interventions for nursing rounds. First, a journal club was formed and articles on the topic were circulated. Next, a journal club/quality improvement (QI) bulletin board on the unit was developed to collect best practice interventions on nursing rounds. The board content included monthly updates comparing compliance with the three audit criteria to patient satisfaction and safety data outcomes. A GRiP matrix table was also posted. Additionally, to keep rounding at the forefront of patient care, updated monthly data collection results were disseminated to key stakeholders during the daily unit shift huddles. Staff stated that when they rounded, they did assess for most of the “4Ps” (pain, position, potty, possessions) but did not communicate to the patient and family what they were actually doing. Therefore, as a third strategy, a script was developed. The purpose of the script was for staff to use a standardized communication tool at specific times during the patient’s hospitalization: while completing the admission assessment; during rounds throughout the patient’s hospital stay; and upon discharge. Script cards, as displayed in Appendix II, were developed from Studer resources and placed on each computer in each patient’s room to provide visual cues to staff as a reminder to ask about the 4Ps.24 (Also it was planned for this script and the 4Ps to be added to the nursing rounds documentation section in the electronic health record.) Initial and on-going support of rounding was also provided by the unit’s nurse educator and nurse champions. The educator created a presentation as part of staff re-education to “hourly rounding”.
doi: 10.11124/jbisrir-2016-2537
Page 254
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Both the champions and educator reinforced with staff the essential components of the scripting used to explain hourly rounding to the patients and families during the admission process and throughout their length of stay. Phase 3: Follow-up audit post implementation of change strategy In the third month of the project, a follow-up audit was conducted using the same evidence-based audit criteria as those used in the baseline audit. A total of 32 observations were completed on the day shift and 12 on the night shift for timeliness of nursing rounds. The 4P protocol script that nurses developed, as one of the interventions, was assessed on both day shift and night shift observations.
Results Phase 1: Baseline audit The baseline compliance with the audit criteria was entered into JBI-PACES. As can be seen in Figure 2, baseline data for Criterion 1 revealed 34% compliance (11 out of 32 observations) with hourly rounds occurring on the day shift (considered the awake hours). For Criterion 2 there was 42% compliance (five out of 12 observations) with at least every two-hour rounds occurring on the night shift (considered the sleeping hours). Use of a protocol was not observed for either day or night shift rounds, which represents 0% compliance for Criterion 3.
Figure 2: Baseline compliance with best practice for audit criteria (%) Audit criteria legend and sample: 1. Hourly nursing rounds are conducted at a stipulated time during awake hours. (N=32) 2. Hourly or 2 hourly nursing rounds are conducted during sleeping hours. (N=12) 3. A protocol is used by nurses when conducting rounds. (N=44)
Baseline HCAHPS scores for the unit for October 2014 were obtained and are displayed in Figure 3. The HCAHPS survey categories directly related to nursing rounds are: a) nurse communication; b) responsiveness of hospital staff; and c) pain management. Each category contained sub-component survey questions/scores. For the category of communication with nurses, the pre-implementation score reached 64%. Sub-component scores for this category included: listen carefully (58%) and explain things (63%). The score for responsiveness of hospital staff was 39% with sub-component scores of 45% for call light and 24% for bedpan or bathroom. The pain management score was 62%. Its sub-component scores were similar, with pain controlled at 56% and pain help at 68%.
doi: 10.11124/jbisrir-2016-2537
Page 255
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
90 80 70 60 50 Baseline Data
40
75th Percentile HCAHP Goals
30 20 10 0 Nurse communication Responsiveness of hospital staff
Pain management
Figure 3: Baseline HCAHP scores
The baseline fall data for each of the pre-implementation months presented in Table 2 demonstrated a slight rise in the amount of falls on the unit. The average was two falls.
Table 2: NDNQI data – medical surgical unit patient falls volume per month Pre-intervention
Pre-intervention
Pre-intervention
1
3
2
Phase 2: Strategies for Getting Research into Practice (GRIP) As can be seen in the GRIP Matrix (Table 3), each barrier was addressed with multiple interventions.
doi: 10.11124/jbisrir-2016-2537
Page 256
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Table 3: GRIP matrix Barrier
Strategy
Resources
Outcomes
Staffing
Nursing unit manager
Staffing schedules
Four nurses were hired and
and director will
Patient assignment
completed orientation prior
review a three-month
logs for last three
to the March 3, 2015
staffing pattern and
months
follow-up audit cycle.
Unit manager will
Charge nurse
New unit manager presence
actively engage with
availability at the
on the unit has yielded
the unit charge nurse
beginning of each
positive comments from
to evaluate the daily
shift
nursing staff to build
unit acuity
Manager following
teamwork and stabilize unit
Unit manager will
audit criteria for
daily functions
assist in performing
rounding on the unit
identified gaps to determine additional FTEs needed Vice President for Nursing will approve budget for hiring needed FTEs Unit manager and director then will work with human resources department to advertise, interview, and hire experienced nurses New
unit
management
nursing rounds when needed Lack of knowledge
A journal club will be
Nursing educator to
Timeliness of day shift
of
formed and articles on
obtain materials for
rounding compliance
the topic will be
the board
increased 25%; night shift
best
practice
interventions
circulated to nursing
rounding increased 33%,
staff
and using a protocol when
A journal club/QI
Journal club team to
board was developed
post articles on
to collect best practice
nursing rounds
rounding increased 64%
interventions on the topic of nursing rounds A script was developed and put on
Nurse educator to
a reminder card by
update compliance
each computer for
with the three audit
staff to use as a
criteria
doi: 10.11124/jbisrir-2016-2537
Page 257
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
communication tool on patient admission assessment, during rounds while the patient was in the hospital, and upon discharge The script and the 4Ps added to the nursing rounds documentation section in the electronic health record
Phase 3: Follow-up audits Results of follow-up audits for the three types of data, compared to the baseline results, are displayed in Figures 4, 5 and 6. First, for the JBI criteria, as seen in Figure 4, there were moderate improvements in compliance for timeliness of rounds, as well as use of a protocol. Timeliness of day shift (awake hours) rounding nearly doubled (42%), increasing from 34% to 59%. Night shift (sleeping hours) rounding had a similar result (44%), increasing from 42% to 75%. As expected, use of a protocol when rounding increased to 64% from 0%.
Figure 4: Compliance with best practice audit criteria in follow up audit compared to baseline audit (%) Audit criteria and post-audit sample: 1. Hourly nursing rounds are conducted at a stipulated time during awake hours. (N=32) 2. Hourly or 2 hourly nursing rounds are conducted during sleeping hours. (N=12) 3. A protocol is used by nurses when conducting rounds. (N=44) Secondly, for patient satisfaction outcomes, the scores for three HCAHP categories are presented in Figure 5 and the sub-categories in Table 4. Overall the post-intervention HCAHPS scores increased somewhat. Baseline communication with nurses scores moderately increased from 64% (with sub-categories scores for listen carefully at 58% and explain things at 63%) to 69% (with scores for listen carefully at 71% and explain things at 71%). Responsiveness of hospital staff significantly
doi: 10.11124/jbisrir-2016-2537
Page 258
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
increased from 39% (with sub-categories scores for call light at 45% and bedpan/bathroom at 24%) to 54% (with scores for call light at 45% and bedpan/bathroom at 65%). Pain management modestly increased from 62% to 73% (with sub-category scores for pain controlled at 68% and pain help at 77%). Post-intervention scores for the three categories did not reach the goals set by the organization, although pain management came within 1%.
90 80 70 60 50
Pre-Intervention Data
40
Post-Intervention Data
30
75th Percentile HCAHPS Goals
20 10 0 Nurse Communication
Responsiveness of Hospital Staff
Pain Management
Figure 5: HCAHPS score comparison of baseline to post intervention audits
Table 4: HCAHPS sub-categories improvement rates HCAHPS sub-category
Pre-intervention
Post-intervention
Change
Rate of
compliance
compliance
Listen carefully
58 %
71 %
↑ 13%
18 %
Explain things
63 %
71 %
↑8%
11 %
Call light
45 %
45 %
0
0
Bedpan or bathroom
24 %
65 %
↑ 41
63 %
Pain control
56 %
68 %
↑ 12
18 %
Pain help
68 %
77 %
↑9
12 %
improvement
Nurse communication
Responsiveness – staff
Pain management
Patient falls was the third type of data comparing pre- and post-intervention outcomes. As shown in Table 5, the amount of falls on the unit increased in the months prior to implementation of hourly rounding and decreased modestly with implementation of timeliness of rounding and protocol use.
doi: 10.11124/jbisrir-2016-2537
Page 259
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Table 5: NDNQI data – medical surgical unit patient falls volume per month Pre-intervention
Pre-intervention
Pre-intervention
Implementation
Post intervention
1
3
2
1
1
Discussion This project established quality improvement benchmarks aimed at improving patients’ perspectives of, and satisfaction with, their care, as well as increasing patient safety during hospitalization. Timely and purposeful rounding was the intervention determined to have the greatest impact on accomplishing this. Multi-level strategies were developed and implemented on the medical-surgical unit to address the three specific objectives regarding nursing rounds: determine compliance with the evidence-based criteria; improve staff nurse knowledge; and improve compliance with evidence-based rounding criteria. The unit’s baseline fall numbers and HCAHPS satisfaction scores focusing on the nursing-sensitive categories most closely related to rounding were obtained. Pre-intervention data on the evidence-based criteria were gathered. The post-implementation outcome data revealed all the objectives and the safety aims were successfully met. However, though there were increases in satisfaction scores, the desired goals were not reached after the first month. Frontline staff and managers expect the scores will continue to rise over several months as rounding becomes a hard-wired practice. Although nursing staff may be aware of call bell activation, they may not always respond as promptly as needed or expected. When staff awareness increased, an improvement was seen in response to patient calls and rate of falls. Interestingly, when staff awareness of patient needs increased through hourly rounding programs, to some degree, the rate of falls decreased and patient satisfaction increased. Initial themes from the concurrent survey conducted during this project revealed that challenges exist when patient census or staffing fluctuates, and that nursing leadership rounds could assist in hardwiring rounding interventions for staff. Thus, strong nursing leadership focused on re-educating and emphasizing the importance of an intentional hourly rounding protocol may assist in meeting organizational goals of decreasing falls and increasing patient satisfaction. Additionally, reimbursement would increase and the organization would be in an excellent position to improve other patient care initiatives. Clearly, initial improvement was made toward the established satisfaction benchmarks for the project. Responsiveness of staff, the HCAHPS category with the lowest scores, had a robust 28% improvement rate (a gain of 15%). However, scores for the sub-category call light did not change. This most likely reflects that timely answering of call lights was not one of the rounding interventions. The call light usage rate by patients was not evaluated. Pain management, with pre- and post-implementation scores most similar to those for nurse communication, realized a 15% improvement rate (a gain of 11%). The sub-categories pain controlled and pain help had improvement rates of 18% and 12%, respectively. Nurse communication, the category with the highest starting and ending scores, had a modest but lackluster 7% improvement rate (a gain of 5%). Interestingly, the improvement rates for sub-categories listen carefully and explain things had higher improvement rate gains, 18% and 11%, respectively. These sub-category results indicate a higher quality of
doi: 10.11124/jbisrir-2016-2537
Page 260
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
purposefulness and intentionality when rounding and are most likely due to adoption of the standardized scripting protocol. Nurse communication and pain management scores were expected to be more closely aligned as pain/comfort management is a nurse domain (that is, other non-nurse unit staff would not be actively treating patients’ pain) and is dependent on focused nurse-patient interactions for assessing and re-evaluating pain/comfort levels. The category responsiveness of staff included all unit members and the substantial rate gain pointed to heightened engagement of all levels of staff, teamwork and accountability for providing patient-centred care. It also reflects the impact of increased nurse staffing levels on having time to consistently carry out rounding, as well as, caring practices of the leaders and administrative managers. Keeping patients safe from harm is another basic nursing domain. The project aim of improved safety, indicated by a decreased volume of falls, was achieved. The average three-month fall volume prior to implementation was two and it was halved after the first month of timely and purposeful rounding. Because of the low volumes, data trending over the next several months will be important to show that timeliness and purposefulness are sustainable. However, the bedpan/bathroom sub-component score for the HCAHPS category staff responsiveness also substantiates success because falling is highly associated with toileting needs. The improvement rate was 63% (with a gain of 41%). This result was encouraging to staff, but they also realized improvement could be made in order to advance the actual HCAHPS score beyond the 75th percentile. The process of generating ideas, and developing and implementing the 4P rounding program was empowering to staff due to experiential learning. Results demonstrated that not only meeting patient care needs but also anticipating them and being proactive directly impacted on patient safety and perceptions of feeling cared for and important. Some staff members acknowledged they did not realize how standardizing a unit routine, such as rounding at a particular time of day and using a protocol, could actually create a more healing environment through open lines of communication and a higher frequency and quality of interactions. Results from this project validate why high standards are set for NDNQI falls (a nursing-sensitive indicator) and the American Nurses Credentialing Center’s Magnet ® Recognition Program for nursing excellence outcome requirements on nursing-sensitive indicators such as falls with injury and patient satisfaction. Shoring up the unit’s infrastructure for this project was akin to moving up through the levels in Maslow’s Hierarchy of Needs model.26 Basic safety staffing needs had to be met first before staff nurses could concentrate on higher level care needs such as nursing rounds. Daily staffing level challenges and the impact of leadership change to a new unit manager from outside the organization were immediate barriers recognized by top level hospital and nursing administrators. Their responsive actions of more intensely supporting the unit’s nurse manager, as well as hiring additional nurses allowed staff to use their abilities to develop and implement strategies aimed at improving patient satisfaction and safety. Use of dedicated nurse champions was another key structure put in place in order to resource staff and role-model practices. This position also bridged communication between clinical nurses and managers, and between clinical nurses and unlicensed nursing staff. In response to the outcomes and experiences acquired during the project, nursing staff began developing new processes to hardwire the rounding protocol for new and seasoned employees. A proposal was forwarded for the 4P protocol to be a competency which would be included in the new employee orientation simulation experience, as well as part of the annual skills fair. In addition, some
doi: 10.11124/jbisrir-2016-2537
Page 261
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
nurses who also served as clinical instructors for local academic institutions planned to request integration of a structured nursing round protocol into the curriculum for nursing students. Although project outcomes generated new ideas, there were limitations noted for this project to be considered with future project implementation on other units. The main limitations of the project were: 1. Barriers identified for this unit that may not be generalizable to other units in the hospital because nursing workflows and patient populations with their specific needs differ in each unit. 2. Results of the intervention unit were not compared to a control unit. 3. Direct observation could have biased nursing behaviors. 4. The call light usage rate by patients was not evaluated. 5. Sustainability measures needed to be established to maintain the gains and to continue to improve the outcomes. The second limitation was anticipated. Therefore, nursing leadership determined at the beginning of the project to collect data from a like unit, as a “control unit” for baseline data comparison. Results from this continued project will be reported at a later date. The main successes of the initiative were the use of best practice evidence to promote practice change and management staff teambuilding. This project has empowered and re-energized nurses to initiate a journal club focusing on nurse driven practices to improve patient care outcomes. Future directions for promoting best practice in this unit are to identify and address other medical-surgical practice issues related to oncology and bariatric patients by applying the learned concepts of process improvement. This organization is seeking Magnet® recognition and is on a “Pathway to Excellence” to promote positive practice environments where nurses excel.27 As a best practice exemplar, the processes and interventions of this project will be introduced to other units in the organization, and to other hospitals in the system, for nurses to evaluate and implement in their particular practice setting. Unit leadership has planned to disseminate the rounding project results at the hospital’s annual safety fair as a stimulus for encouraging nurses from other units to improve evidence-based practice as the organization progresses on their pathway to excellence to achieve Magnet® designation.
Conclusion Nurses have the ability to improve patient satisfaction and patient safety outcomes by utilizing nursing round interventions which serve to improve patient communication and staff responsiveness. Having an appropriate infrastructure and an organized approach, encompassing all levels of staff, to meet patient needs during their hospital stay was a key factor for success. The aims and objectives of the project were realized as staff embraced the change and comprehended how best practice interventions could significantly improve patient outcomes. However, the desired satisfaction goals were not yet reached after the first month because rounding was still becoming hard-wired. The project did not provide future directions for sustaining evidence-based practice change, but a monthly audit format has been developed to monitor, communicate and help maintain the current practice change. Plans to improve HCAHP satisfaction scores have been placed on future staff meeting agendas.
doi: 10.11124/jbisrir-2016-2537
Page 262
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Conflict of interest The author declares that there were no conflicts of interest in the implementation of this quality improvement project.
Acknowledgements The author would like to gratefully acknowledge: The nursing staff, the nursing leadership team, and Jeff Doucette, Vice President, Patient Care Services, and Chief Nursing Officer, Mary Immaculate Hospital Nursing Chamberlain College of Nursing, for their generous support in completing the JBI Clinical Fellows training Douglas Turner, my JBI Clinical Fellow coach and the UCSF JBI Centre for Synthesis and Implementation, for their assistance in writing this evidence-based project report
doi: 10.11124/jbisrir-2016-2537
Page 263
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
References 1. Ford B. Hourly rounding: a strategy to improve patient satisfaction scores.Medsurg Nurs.2010; 19(3):188-191. 2. Bluni R, O'Shaughnessy J. Words that save. Ensuring that "never events" never happen. Marketing Health Services. 2009; 29(3):13-17. 3. Boushon B, Nielson G., Quigley P, Rutherford P, Taylor J, Shannon, D, Rita S. (December 2012) How-to Guide:
Reducing Patient Injuries from Falls. Cambridge, MA: Institute for
Healthcare Improvement.[internet].[cited February 1, 2014 ]. Available from: http://www.www.ihi.org. 4. Reimer R, Herbener L. Round and round we go: rounding strategies to impact exemplary professional practice. Clin J Oncol Nurs 2014 18(6):654-659. 5. Olrich T, Kalman M, Nigolian C. Hourly rounding: a replication study.. Medsurg Nurs 2012; 21(1): 23-36. 6. Gnida, J.]; [Audio podcast].;CAHPS update [January 8th, 2015]. Omaha, Nebraska. 7. Grellner L. Put your money where your scores are HCAHPS and VBP. Okla Nurse. 2012; 57(3):4. 8. Berg K, Sailors C, Reimer R, O'Brien Y, Ward-Smith P. Hourly rounding with a purpose. Iowa Nurse Reporter. 2011; 24(3):12-4. 9. Blakley D, Kroth M, Gregson J. The impact of nurse rounding on patient satisfaction in a Medical- Surgical Hospital Unit. Medsurg Nurs. 2011; 20(6):327-32. 10. Butcher L. Hospitals work to prevent patient falls. [Internet]; [cited June 1st 2013]. Available from: http://www.hhnmag.com/Magazine/2013/Jun/0613HHN_coverstory. 11. Culley T. Reduce call light frequency with hourly rounds. Nursing Management. 2008; 39(3):50-52. 12. Deitrick L, Baker K, Paxton H, Flores M, Swavely D. Hourly rounding: challenges with implementation of an evidence-based process. J Nurs Care Qual. 2012; 27(1):13-9. 13. Gardner G, Woollett K, Daly N, Richardson B. Measuring the effect of patient comfort rounds on practice environment and patient satisfaction: a pilot study. Int J Nurs Pract. 2009; 15(4):287-293. 14. Halm M. Hourly rounds: what does the evidence indicate?
Am J Crit Care2009; 18(6):
581-584. 15. Kessler B, Claude-Gutekunst M, Donchez A, Dries R, Snyder M. The merry-go-round of patient rounding: assure your patients get the brass ring. MEDSURG Nursing. 2012; 21(4):240-245. 16. Meade C, Kennedy J, Kaplan J. The effects of emergency department staff rounding on patient safety and satisfaction. J Emerg Med. 2010; 38(5):666-674. 17. Meade C, Bursell A, Ketelsen L. CE Credit: Effects of nursing rounds on patients' call light use, satisfaction, and safety. Am J Nurs . 2006; 106 (9): 58-70.
doi: 10.11124/jbisrir-2016-2537
Page 264
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
18. Mitchell M, Lavenberg J, Trotta R, Umscheid C. Hourly rounding to improve nursing responsiveness. J Nurs Adm. 2014; 44(9):462-472. 19. Rondinelli J, Ecker M, Crawford C, Seelinger C, Omery A. Hourly rounding implementation: a multisite description of structures, processes, and outcomes. J Nurs Adm. 2012; 42(6):326-332. 20. Saleh BS, Nusair H, Al Zubadi N, Al Shoul S, Saleh U. The nursing rounds system: effect of patient’s call light use, bed sores, and satisfaction level. Int J Nurs Pract. 2011; 17(3):299-303. 21. Tucker S, Bieber P, Attlesey-Pries J, Olson M, Dierkhising R. Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units.. Worldviews Evid Based Nurs 2012; 9(1):18-29. 22. Woodward JL. Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Clin Nurse Spec, 2009; 23,(4):200-6. 23. Montalvo I. The National Database of Nursing Quality IndicatorsTM (NDNQI®). Online J Issues Nurs 2007; 12(3) Manuscript 2 24. Studer, O. Serious about service. [Internet]. [cited November 7th, 2007]. Available from: http://www.studergroup.com/content/tools_and_knowledge/articles/associated_files/QuintNov 07HealthExecutive.pdf. 25. Chu V. JBI Evidence Summary/Nursing Rounds: Clinician Information. Joanna Briggs Institute. 2014 [Internet]. [cited July 6th, 2014]. Available from: http://paces.jbiconnectplus.org/AuditHome.aspx 26. Maslow A. A theory of human motivation. Psychol Rev 1943; 50(4):370-96 27. American Nurses Credentialing Center. Pathway to Excellence. 2015. [Internet]. [cited July 3rd, 2014]. Available from: http://nursecredentialing.org/Pathway.aspx.
doi: 10.11124/jbisrir-2016-2537
Page 265
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Appendix I: Staff Survey and Nursing Director Interview Questions on the 4Ps Rounding Process 9
Staff Survey on the 4 Ps Rounding Process
• Have you been able to incorporate 4 P rounding every 2 hours in to your practice? • What system problems have you identified with the 4 P rounding system? • What call light changes have you observed since 4 P rounding started? • Do you have any specific comments you’d like to share about the 4 P process? How can it be improved? (Nursing
Medical-Surgical and other Nursing Director Interview Questions
• What is the role of rounding from a nursing director’s perspective? • What does patient satisfaction mean to you? • Since the inception of the 4 P program, have you noticed a reduction in call light usage? • Are the nurses still performing 4 P rounding every 2 hours? • What relationship do you see between patient safety and 4 P rounding? • Do you think 4 P rounding adequately addresses patients’ more mundane and common problems? One of the things the staff mentioned in a questionnaire was how to maintain 4 P rounding when the floor gets busy. What are your ideas to keep the 4 P rounding going when things get busy? • What are your ideas for sustaining the gains in patient and staff satisfaction?
doi: 10.11124/jbisrir-2016-2537
Page 266
JBI Database of Systematic Reviews & Implementation Reports
2016;14(1):248-267
Appendix II: Hourly Rounding Staff Communication Tool 24
4 P’s of Hourly Rounding
Pain
How is your pain?
Position
Are you comfortable?
Potty
Do you need to use the bathroom?
Possessions
Place phone, call light, trash, bedside table, tissues, and water pitcher within reach.
doi: 10.11124/jbisrir-2016-2537
Page 267
