Intentional Rounding: An Evidence-Based Approach



Intentional Rounding: An Evidence-Based Approach

Kelli Erb, Jamie Kruger, Sarah Lutz, Jessica Rochefort

Ferris State University

Abstract

Intentional rounding is the act of nursing staff seeing each patient at a specified time and usually involves taking care of patient needs and offering presence of self to the patient. It is used to increase patient satisfaction and comfort while decreasing falls and the anxiety of being hospitalized. Numerous studies have been done to evaluate the effectiveness of rounding on patient care. Four research articles on intentional rounding were evaluated for how strong the evidence is for rounding. Articles by Gardner (2009), Tucker et al. (2009), Woodard (2009), and Olrich (2012) were summarized and analyzed to best understand how intentional rounding would affect patient care and if implementing it into a healthcare setting would be beneficial. Registered nurses share their experiences with intentional rounding. The authors describe in detail the contents of each article reviewed and evaluate whether the research supports hourly rounding enough to implement and possible ideas for research in the future.

Keywords: hourly rounding, intentional rounding

Intentional Rounding: An Evidence-Based Approach

Research is an important component to healthcare as it gives a rationale for the care that patients receive. Nursing research is used to validate and refine “existing knowledge and generates new knowledge that directly and indirectly influences nursing practice” (Burns & Grove, 2011, p. 4). It is also vital to providing evidence-based practice to patients. Intentional rounding is a standard of practice being instituted in healthcare facilities across the country. It is important to look back at the research of intentional rounding prior to implementing it in a healthcare institution. Strong evidence is needed to support evidence-based practice.

The idea of rounding is not entirely new. One of the earliest research articles related to rounding can date back to 1989 where a hospital in Birmingham was trying to improve patient satisfaction (Woodard, 2009, para. 10). Additional studies add that “a patient’s perception of high-quality nursing care is not reflected in the nurse’s knowledge and competence but in the patient’s perception of her availability, physical presence, and response to the call light” (Woodard, 2009, para. 9). Intentional rounding is a way to create a habit on nursing floors to see the patient at a scheduled time and ensuring to the patient that the nurse will be back. Research articles were reviewed for evidence to support rounding and the benefits to implementing a rounding program.

Descriptive Summary of Articles Reviewed

Article One

Purpose and Hypothesis. The first article chosen for review is titled Measuring the effect of patient comfort rounds on practice environment and patient satisfaction: A pilot study. This study had a twofold purpose; the first was to determine if hourly rounding had any effect on patient satisfaction and/or practice environment(s) and the second if the methods and tools used for the study were feasible for use for a proposed larger study (Gardner, Woollett, Daly, & Richardson, 2009, p. 289). There were two, clearly identified hypotheses:

1) An acute care surgical ward that has 1-hourly patient comfort rounds will record higher patient satisfaction scores than a ward without patient comfort rounds.

2) An acute care surgical ward that has 1-hourly patient comfort rounds will record more positive nurse perceptions of the practice environment than a ward without patient comfort rounds (Gardner et al., 2009, p. 289).

Design. This was a quasi-experimental, pilot study developed by four registered nurses in Australia. It was conducted on two acute surgical floors that studied one hundred twenty-nine patients; sixty-one on the intervention floor and sixty-eight on the control floor over an eight week period (Gardner et al., 2009). All of the nurses and patients that were a part of the study received information on the study and were required to sign consent prior to being enrolled in the study.

Intervention. The nurses conducting the study ensured that the hourly rounding intervention was standardized to ensure each patient received the same initial contact. Depending on what the patient required, subsequent interventions were then tailored to the patient’s need at the time. The rounding was initiated by a trained nurse assistant, who then brought in a registered nurse when needed interventions required a higher license (Gardner et al., 2009). The rounding took place Monday through Friday between the hours of four and ten in the evening.

Data Collection. To measure patient satisfaction, the researchers developed a tool called, The Patient Satisfaction Survey. The survey was unique to the study and was tested for reliability prior to the start of the study (Gardner et al., 2009). Patients were given the survey to complete at the time of discharge and items addressed were, “having their needs met in a timely fashion, individualized care, timely attention to call bells, and nursing care” (Gardner et al., 2009, p. 289). The respondents were asked to rate the statements on a scale from one to five with one meaning strongly agree and five meaning strongly disagree, with three meaning uncertain (Gardner et al., 2009).

To measure effects on the practice environment, the researchers chose to use, “the Practice Environment Scale of the Nursing Work Index, which had been a previously validated instrument” (Gardner et al., 2009, p. 289). Nurses participating in the study used this scale at three points during the study. This scale asked perceptions on, “nurse participation in hospital affairs, nursing foundations for quality care, nurse manager ability, leadership and support of nurses, and staffing and resource adequacy” (Gardner et al., 2009, p. 289). Scoring of the scale was ranked from one to four with four being a more positive perception (Gardner et al., 2009).

Article Two

Purpose and Hypothesis. The second article chosen for review is titled Outcomes and Challenges in Implementing Hourly Rounds to Reduce Falls in Orthopedic Units. The purpose of this study was to, “evaluate the feasibility and outcomes of adapting and translating hourly structured nursing rounds to reduce the risk and incidence of patient falls” (Tucker, Bieber, Attlesey-Pries, Olson, & Dierkhising, 2012). There were three, clearly stated hypotheses for this study; The first is, “that patient fall rates will be lower during the structured nursing rounds intervention”, the second, “patient fall rates will be higher for patients at greater risk”, and three, “greater documented dosage of the structured nursing rounds intervention will be associated with lower patient falls” (Tucker et al., 2012, p. 19).

Design. This was a qualitative study using multiple conceptual frameworks; however, only one is mentioned: the Promoting Action on Research in Health Services. The researchers, four registered nurses and one statistician, conducted the study over a twelve week period on two separate orthopedic units consisting of twenty nine beds each at a large, academic medical center (Tucker et al., 2012). The researchers used a descriptive and repeated measures design to collect information on fall related data in three months prior to the study, during the twelve week period, and one year after completion of the study (Tucker et al., 2012). The study was approved prior to the start and all participants signed consents.

Intervention. The intervention for this study was a structured nursing rounds intervention protocol that was based on a previously tested protocol (Tucker et al., 2012). The interventions were standardized and included toileting, position changes, placing items within reach of the patient, emphasizing that staff would be back in an hour, and assuring patients that staff were prepared to help patients rather than patients acting independently (Tucker et al., 2012). In addition, the intervention list was expected to be modified if the patient was sleeping (Tucker et al., 2012).

Data Collection. Data was collected foremost by collecting information about the patient’s initial fall risk and then the amount of times the patient actually fell (Tucker et al., 2012). A patient fall profile was created using information from nursing charting. The adherence to the structured nursing rounding intervention was monitored by a form that nursing filled out each time they participated in a rounding session. This information was patient specific, where more than one nurse could add notes as they participated in subsequent rounding sessions. Data from this form was extracted for the calculation at discharge on what the patient’s fall risk was, and if any falls occurred (Tucker et al., 2012).

Article Three

Purpose and Hypothesis. The third article chosen for review is titled Hourly Rounding: A Replication Study. The purpose of the study was to, “determine the effect of hourly rounding on fall rates, call light usage, and patient satisfaction in an inpatient medical-surgical patient population” (Olrich, Kalman, & Nigolian, 2012, p. 23). Unlike the previous articles, this article did not have a stated hypothesis and the study’s aims were not clearly identified in a discrete section.

Design. This study was a quasi-experimental study that was designed by three registered nurses and conducted at a large teaching hospital on two separate medical-surgical units. One unit was used as the experimental unit and the other unit was used as a control (Olrich et al., 2012). For this study, patients were not identified; therefore the approval board did not require consents to be signed (Olrich et al., 2012).

Intervention. Hourly rounding was carried out between six in the morning and ten at night. There were eight specific interventions that nursing personnel were required to follow. The eight interventions included an introduction, pain assessment, toileting, positioning, environment check, and informing patient when next round would occur (Olrich et al., 2012). For this study, a log sheet was kept outside the door of the patient room where the interventions were recorded. The log sheet was also used for recording the needs of the patient when a call light was used unrelated to events that occurred during an hourly rounding session.

Data Collection. Data collection for this study was obtained in a variety of ways. Occurrence reports were used to determine the number of falls that happened during six months prior to the start of the study, the six months the study took place, and six months after the study was completed (Olrich et al., 2012). The call light system had a feature where call light usage could be recovered for each patient room (Olrich et al., 2012). This information was matched against the log sheets the nursing staff kept outside the patient room.

Article Four

Purpose and Hypothesis. The fourth and final article chosen for review is titled Effects of Rounding on Patient Satisfaction and Patient Safety on a Medical-Surgical Unit. The purpose of this article was, “to evaluate a routine rounding charge nurse program to lower uncertainty regarding nurse availability for response to immediate needs” (Woodard, 2009, p. 200). While there was no hypothesis, there were three study questions the researcher developed to measure outcomes. The questions were related to differences in fall rates, patient satisfaction, frequency of call light usage, help uncertainty, and barriers to implementing and sustaining routine rounding (Woodard, 2009).

Design. This study was a qualitative study that used Mishel’s Uncertainty of Illness model for a theoretical framework (Woodard, 2009, p. 201). The study was designed and carried out by a clinical nurse specialist that took place at a teaching hospital on a twenty-seven bed medical-surgical unit over a ten month period. All patients that were admitted to this unit during the ten month period were included in the study (Woodard, 2009).

Intervention. Hourly rounds were conducted by a charge nurse assigned to a twelve hour shift on the patient unit. The charge nurse made rounds every two hours on each patient and addressed “the four P’s: pain, potty, position, and presence” (Woodard, 2009, p. 203). The four P’s were used as a guide for the charge nurse to assess the needs of the patient at the time of the rounds, who then documented interventions in the medical record and informed the primary care nurse (Woodard, 2009).

Data Collection. Data was collected using a few different methods. The unit manager received reports for patient falls that occurred on the unit along with patient satisfaction surveys that were already implemented (Woodard, 2009). The call light information was retrieved from the call light system with several exclusions: calls made from the bathroom, emergency calls initiated by staff, and accidental calls (Woodard, 2009). The incident of help uncertainty was measured by a paper survey that was administered to random patients on the floor at random times (Woodard, 2009).

Critical Appraisal of Evidence

Article One

Problem. In Article One, the problem statement is not clearly stated, however, within the first page of the paper, the authors make an attempt to point out why this area of study is needed. The researchers point out that in Australia, there is a push for an improvement in quality of care along with an improvement in operational costs (Gardner et al., 2009). The authors go on to say that nursing is in a key position to identify areas that will address these concerns. While no problem statement is clearly stated, the aim of the study is declared as, “to test the effect of a model of practice that optimized the role of the assistant-in-nursing (AIN) in skill mix” (Gardner et al., 2009, p. 288). The researchers point out that with the help of AIN’s, patient satisfaction and safety may increase, while the burden may be taken off the registered nurse (Gardner et al., 2009). The authors do not postulate that operational costs may decrease with the use of additional non-licensed staff such as AIN’s, even though they point out that operational costs are of a concern in Australia.

Purpose. According to Burns and Grove (2011), a research purpose is a clear, concise statement of the specific goal or focus of a study that includes the variables, population, and often the setting of the study” (Burns & Grove, 2011, p. 146). This study did have two clear and concise purpose statements. The variables are identifiable within the statements, but are not specifically identified outside of the purpose statements. The population is only identified as “practice environment”, which could mean any setting where nurses are practicing. The setting is not included in the statements.

Literature Review. There are twenty research articles cited in this study with the majority of them coming from nursing journals. Burns and Grove (2011) stipulate that current sources should not be older than five years old and, “a good-quality literature review logically builds a case for the study being reported” (Burns & Grove, 2011, p. 193). Seven of the studies the authors cited were older than five years with the oldest being published in 1994.

The sources cited were chosen to support different ideas the authors wished to express, ideas that did indeed build a case for the existence of their study. Several studies illustrate the type of work that fills a nurse’s day. Other studies reflect patient perceptions of nursing care and the atmosphere of being in the hospital. Additional studies cited demonstrate call bell usage and the different reasons patients initiate a ring of their call bell. One study that is explored in detail in relation to comfort care rounds is the Castledine study that was performed in the United Kingdom in 2005. The authors point out that this study, while was specific to hourly rounding, has “not been systematically trialled” (Gardner et al., 2009, p. 288). The Castledine study is considered a primary study as it was written by the researchers that performed the study (Burns & Grove, 2011).

Framework. There is no framework identified by the authors in this study.

Methods.

Research Design. The research design, as previously mentioned, was a quasi-experimental pilot study using a non-randomized parallel group trial design (Gardner et al., 2009). The design exhibited causality (Burns & Grove, 2011), as the authors attempted to demonstrate the relationship between the variables of comfort rounds and patient satisfaction and/or practice environment (Gardner et al., 2009). Bias was attempted to be reduced, as there was a unit chosen to be a control floor where comfort rounds were not performed. The authors stipulated that the control floor was a “matched” acute surgical floor, but make no attempt to describe what types of patients are accepted on both floors (Gardner et al., 2009).

Treatment. The treatment, or intervention, that was chosen by the authors for this particular study was the patient comfort rounds. As mentioned previously, patients on the test floor were subjected to patient comfort rounds that were initiated by an AIN. The patients on the control floor were not subjected to these rounds, but standard of care was not neglected and all patients received normal care from staff. The standard of care was not clearly stated in the article; even though for the control group and experimental group to be uniformly evaluated the authors must give a detailed description of the standard of care the patients were to receive (Burns & Grove, 2011).

Setting and Sample. As discussed earlier, the researchers conducted the study on two acute surgical floors that were matched. While all patients on the experimental floor received the comfort care rounds, only sixty-one patients were sampled for their responses to the intervention (Gardner et al., 2009). There was no explanation on how the sixty-one patients on the experimental floor were selected for sampling, nor was there any explanation on how the sixty-eight patients on the control ward were sampled. According to Burns and Grove (2011), a sample must be representative in terms of characteristics such as age, gender, ethnicity, income, and education, which often influence study variables” (Burns & Grove, 2011, p. 294). In the results section, however, there was demographic information provided on the age, length of stay, and sex of the patients sampled, but still no indication on how they were chosen.

Measurement. Measurement for the Patient Satisfaction Survey was quantified by using an ordinal-scale measurement, as “data were assigned to categories that could be ranked” (Burns & Grove, 2011, p. 330). For the patient satisfaction survey, patient responses were instructed to assign a number value to each of the statements pertaining to satisfaction. This scale was a Likert scale by design. By assigning a numerical value to the statements, the researchers were able to quantify the responses so measurement could take place. The authors included in their text that this tool was subjected to testing to prove reliability, but they omit any indication of validity.

For the Practice Environment Scale, measurement took place in the same way as the Patient Satisfaction Survey. Numerical values were assigned to statements pertaining to nursing satisfaction in a Likert scale fashion. Scores to choose from were one through four, where four indicated a more positive response (Gardner et al., 2009). Again, by assigning a numerical value to a non-numerical, subjective statement, the researchers were able to quantify the response. The authors state that this instrument has been previously validated, but make no mention of the tool’s reliability.

Findings. For the Patient Satisfaction Survey, results showed no statistical difference between the control floor and the experimental floor (Gardner et al., 2009). Seventy percent of the sample patients had ages greater than forty-two years of age, there was an equal mix of male to female, and the average length of stay was relatively the same (Gardner et al., 2009). It was reported that most responses were clustered in the ‘strongly agree’ and ‘agree’ options (Gardner et al., 2009).

Additionally, the reliability of the Patient Satisfaction Survey was investigated, which found the tool to have, “good reliability, but needed further testing” (Gardner et al., 2009, p. 290).

The nurses sampled for the Practice Environment Scale were similar in age, sex, level of nursing experience, and education (Gardner et al., 2009). There were findings that showed the intervention group displayed a positive trend while the control group a more negative trend with a p value of < 0.03 (Gardner et al., 2009). The nurses sampled were asked to fill out the survey at three different time points as described earlier. The trend with each group grew more positive and more negative over time, respectively (Gardner et al., 2009).

Conclusion. The researchers concluded that the study was limited by “its size and scope and produced few significant findings in terms of patient- and nurse-related data” (Gardner et al., 2009, p. 292). The evidence does indeed point to this. It has been shown that, “a greater number of cases will provide a more reliable result, but replicating more than fifty cases provides almost no meaningful advantage” (Springate, 2012, p. 161). This study surveyed a total of one hundred twenty-nine patients, so reliability was adequate.

Not providing how patients were chosen for sampling does influence the reliability of the study. By showing the sample recipients were close in age, sex, and length of stay, perhaps the authors chose patients so all recipients shared representativeness, but the reader cannot assume this. The authors point out that with a satisfaction survey, patients might wish to be polite and not show their true feelings when filling out the survey, and this can impact results (Gardner et al., 2009).

Using a tool, such as the Patient Satisfaction Survey, which has not been previously validated also impacts the results of the study. The researchers did point this out, and the intention of the study was to test this previously untested tool. As for the Practice Environment Scale, it was mentioned in the study that the tool was, "previously validated" (Gardner et al., 2009, p. 289). Burns and Grove (2011) state that "you cannot consider validity apart from reliability and that if a measurement method does not have acceptable reliability, its validity becomes a moot issue" (Burns & Grove, 2011, p. 335). In these terms, then, the Practice Environment Scale was not determined to be valid as there is no mention of previous reliability.

Taking all discussed items into consideration, this study has only weak evidence to prove its hypotheses. This is demonstrated by using a previously untested tool, not specifying how survey respondents were sampled, and using a relatively small sample size (pointed out as a detriment by the researchers). Had these items been addressed, perhaps the study results would have been stronger. Despite the weaknesses, the study is useful for further research, as the Patient Satisfaction Survey needs further testing to prove its validity and reliability.

Article Two

Problem. Article Two has no clearly stated problem statement, although the authors do make clear that the most common adverse event that occur in acute care facilities are falls and the morbidity and mortality that follow (Tucker et al., 2012). They point out that there exists in research evidence on best practices to prevent and reduce falls, which includes appraisals and actions (Tucker et al., 2012). While this evidence exists, they go on to say that a number of past research has lacked rigorous designs. The absence of a clearly stated problem statement does not detract from the author’s description of the problem that will be researched.

Purpose. The purpose statement is clearly written and easily identifiable within the article. The variables are easily identified within the statement, and the authors make a point to list the variables in a section that falls under methods. The population in question is stated clearly in this purpose statement, as well as the setting. The statement meets the criteria for a good research purpose as defined by Burns and Grove as previously described.

Literature Review. The literature review was broken down into three sections covering prevalence of falls, fall risk and screening, and fall-related evidence-based nursing practices (Tucker et al., 2012). In the first section of prevalence there were ten research articles cited, with only two of these being nursing journals. The majority of the journals referenced were public health and epidemiology journals. The study, which was accepted in February of 2011, utilized many journals for this section that were older than five years old. Eight of the ten journals were older than five years old, with the oldest one being published in 1985 (Tucker et al., 2012). Of the two nursing journals that were cited, one was older than five years and the other was published in 2009; both were primary studies.

The topics of the journals referenced were varied. Many of the journals addressed the nature of patient falls while in an acute care setting, others addressed the reasons patients fall, and others addressed how falls impact patient length of stays. One study that was referenced addressed prevention strategies, the Dykes study, which was from a nursing journal and current (Tucker et al., 2012).

For the second section, fall risk and screening, five studies were referenced; two were considered old. Only one of these journals was from a nursing journal. The biggest topic discussed in the section is the validity and reliability of fall risk and screening tools that were in existence at the time of the study. The researchers also pointed out that few tools were, “tested more than once, so no tool could be recommended for the acute care setting” (Tucker et al., 2012, p. 20).

The third section, fall-related evidence-based nursing practices, referenced thirteen studies with two referenced in previous sections. Three of these studies were considered old, and eleven were obtained from nursing journals. A majority of the studies discussed in this section discussed structured nursing rounds intervention (SNRI) and the applications, concerns, and promising nature of these rounds. A large, quasi-experimental study published in 2006 studied structured nursing rounds with specific actions and found them to be beneficial in reducing falls (Tucker et al., 2012). The authors go on to point out that several studies have been done since the 2006 study to build on this research, with findings suggesting a variable, yet positive results (Tucker et al., 2012).

Framework. The authors stressed they used many conceptual models to direct their research; however, they only write about one specific framework. The framework that is discussed is the Promoting Action on Research in Health Services (PARHIS) framework. The PARIHS (or PARHIS) framework is reported to be a framework that is used when researchers wish to implement a procedure or idea (Helfrich et al., 2010). With the researchers wishing to implement a structured nursing rounds intervention with specific actions, this was a plausible framework for them to use. The authors state that the PARHIS framework is, “useful for emphasizing the level of evidence, context, and facilitation of change as important for successful implementation” (Tucker et al., 2012, p. 20).

On an interesting note, a large retrospective study was completed in 2010 to evaluate the PARHIS framework and they concluded that, “researchers should explain the degree to which intervention design decisions and changes strategies are based on PARIHS” (Helfrich et al., 2010, p. 16). The authors of this study did not include the PARHIS framework in their design section, as will be described below. However, this does not detract from the usefulness of the framework, as it is essentially used quite properly.

Methods.

Research Design. As noted earlier, the research design was quantitative in nature and a descriptive and repeated measures design. Baseline fall data was obtained during a three month period prior to the start of the study, including historical fall rates on both floors, fall risk assessments on each patient as they were admitted to the floors, and structured nursing rounds adherence by staff (Tucker et al., 2012). By taking samples when the structured nursing rounds intervention was first implemented, and then again after one year of sustained use, the researchers were able to capture the sustainability over time (Tucker et al., 2012). The authors in this study were also able to show a causality relationship between the variables, which as mentioned before, is important.

Treatment. The treatment, or intervention, to be completed was defined in a separate section of the article. The intervention was structured nursing rounds and the authors went on to list six actions that were to be addressed upon contact with the patient at the start of the rounds. The authors did not expect staff to wake patients up if they were sleeping and no other treatments were needed at the time (Tucker et al., 2012). The actions performed all fell within the scope of all staff that were involved in the study. Because of the repeated design of the study, there was no control floor and all patients meeting criteria during the timeframe were subjected to the structured nursing rounds intervention.

Setting and Sample. The sample patients were obtained from two different post-operative orthopedic floors that were able to maintain a census of twenty-nine patients each (Tucker et al., 2012). Unlike Article One, the authors in Article Two described the variety of patients that were admitted to both floors. These floors were limited to the same kinds of post-operative patients having the same types of procedures. By defining the sort of patients that were potential to inhabit each floor, representativeness is achieved. The setting, which was a natural setting for these types of patients, is preferential and appropriate for testing the hypotheses.

Measurement. Data was measured in five ways: patient fall rates, patient fall risk, nursing SNRI fidelity, barriers and facilitators to implementing SNRI, and patient fall profiles (Tucker et al., 2012). Even though this was a qualitative study the variables that had numerical values were measured accordingly, such as patient fall rates. Patient fall risk was assessed using the evidence-based Hendrich II Fall Risk Model, which was a hospital approved method of assessing fall risk for patients (Tucker et al., 2012). With this model, a numerical value is assigned to fall risk factors, which are scale based. Nursing fidelity was measured by calculating a percent of times the SNRI was followed. The researchers state that the Hendrich II Fall Risk Model was chosen by the hospital for its sensitivity and specificity, but do not include reliability or validity testing.

The measurement of barriers and facilitators to implementing SNRI was measured by the authors conducting interviews with the staff that were performing them. The researchers compiled a short interview of four questions that asked about staff’s feelings and attitudes towards the actions. The interview method of measuring data is a good way to obtain information that is not able to be quantified.

Findings. After analyzing the data, the researchers found that there were fourteen falls during the baseline period, six falls during the intervention period, and nine falls during the one year assessment timeframe (Tucker et al., 2012). This was “translated into the number of falls per one thousand hospital days as 4.5, 1.6, and 3.2 respectively” (Tucker et al., 2012, p. 23). Statistically speaking, the first hypothesis was proven to be true, while the second one was not proven to be true, as the SNRI was not able to prevent falls over time with a p value of 0.226 (Tucker et al., 2012).

The authors discovered that their third hypothesis was not able to be adequately supported or not supported as the documentation of the SNRI was only completed by staff twenty to sixty percent of the time, so no real value could be interpreted (Tucker et al., 2012). The nurses that participated in the interviews determining the barriers and facilitators to SNRI were able to give some insight to the researchers on their thoughts and feelings about SNRI. Most of these findings discovered that nursing staff felt overwhelmed with added documentation, lack of clarity about the study, and competing staff changes on their unit (Tucker et al., 2012).

Conclusion. The researchers concluded that, while their study did not support all of their hypotheses, there were still some important discoveries made to add to the literature on SNRI (Tucker et al., 2012). The authors pointed out that conducting the study without a control group possibly affected the results, as there was an increased attention to falls for all patients on these floors (Tucker et al., 2012). If this study was conducted with a control group, there would have been tighter control over the design and results may have been more promising.

The sample in this research study was certainly adequate with at least six hundred eighty-two participants at each sampling time frame (Tucker et al., 2012). This was an advantage in this study, along with identifying what types of patients were likely to be admitted to the units. Learning that nursing staff had some valid issues with participating in the study was also a benefit. While no concrete information can be taken from this, it sheds light on the issue and begs further exploration.

This study has very few weaknesses, and despite not supporting all hypotheses, has a majority of strengths. This study also shows that there is further need to explore SNRI as an action to improve patient outcomes. Finally, there is more research needed to explore how to achieve staff satisfaction with said actions.

Article Three

Problem. Article Three does not have a stated problem statement, but within the first paragraph of the study, the problem is identifiable by the reader. The authors examine the need for better patient outcomes and the notion that hourly rounding may be an intervention that solves this dilemma (Olrich et al., 2012). Missing from this article were clearly stated aims or goals of the study. While these aims are often helpful in painting a picture for the reader, they are most often used in descriptive and correlational quantitative studies (Burns & Grove, 2011). As stated previously, this study was a quasi-experimental study.

Purpose. The purpose in this study is clearly defined in a distinct section. The reader is able to determine the variables, the population, and the setting from a single sentence. The independent variable of hourly rounding will determine if the dependent variables of fall rates, call light usage, and patient satisfaction will be influenced (Olrich et al., 2012).

Literature Review. Article Three explored three previous, primary studies that dealt specifically with hourly rounding. These studies were all from nursing journals, and were within a five year period from the time that publication was accepted. The authors did an excellent job of providing background information on each of these studies while relaying pertinent study results that demonstrated a need for further research.

Additional studies that were reviewed came from different sources, including some from nursing journals. The subject of these studies ranged from patient falls to call light usage in the acute care setting. There were a few studies that were older than five years, and most appeared to be primary studies.

Framework. There is no identified framework in this study.

Methods.

Research Design. The research design was not clearly stated in a discrete section, unlike the previous articles reviewed. The authors made no attempt to separate their research design with treatment, setting, sample, or measurement. These were all included under the heading, methods. Not clearly stating each section under its own heading may confuse the average reader. While there is no clearly stated design stated in the study, the researchers do show causality between the variables within the purpose statement, however, this is the only place this is found. The purpose statement may be the only location where causality is found (Burns & Grove, 2011).

Treatment. The treatment provided to the experimental floor consisted of an hourly rounding initiative that consisted of eight actions. The eight actions were defined in detail in a separate table within the article. Displaying the information in this way shows the reader the importance of this lengthy piece of information. The only detractor from this section was the intervention itself is buried within the methods section, making it difficult to locate.

Setting and Sample. The research setting was chosen as two medical-surgical units that accepted similar patient populations and had the same size. All patients on the experimental ward received hourly rounding, with no exclusions. The authors did not go into detail on the specific patient population, age, illness, or length of stay. Had this information been provided, the sample may have held more significance instead of achieving generalized results.

Measurement. Measurement of the variables was extracted from occurrence reports for falls, patient satisfaction surveys, and call light usage from the call light system (Olrich et al., 2012). Call light usage was tracked by nursing staff keeping a logbook for each patient and indicating when and why a call light was activated (Olrich et al., 2012). None of the tools used for measurement were previously tested devices that had proven validity or reliability.

Findings. The researchers discovered that patient fall rates, “did decrease from 3.37/1000 patient days to 2.6/1000 days” (Olrich et al., 2012, p. 25). While this evidence shows a drop in fall rate, the evidence was not statistically significant, as the p value was 0.672 (Olrich et al., 2012). Call light usage was not deemed to have a significant change, as the floor had one “delirious” patient that activated the call light numerous times, thus nullifying the data (Olrich et al., 2012). Patient satisfaction surveys showed no statistically significant results after data was analyzed, with a p value of 0.383(Olrich et al., 2012).

The researchers, although the statistics did not prove it, felt there was a benefit from the implementation of hourly rounding. The authors stated they had “anecdotal evidence” that proved patient satisfaction improved as a result of hourly rounding (Olrich et al., 2012). They also stated that the twenty-three percent decrease in falls during the time period of the intervention was, “significant clinically” (Olrich et al., 2012, p. 25).

Conclusion. The researchers concluded that their study was limited by using a non-randomized sample and the relatively small sample size (Olrich et al., 2012). They postulated had the information from the one outlier been exempt, that call light usage would have decreased as a result of the hourly rounds (Olrich et al., 2012). In addition to the above, the authors also stated the experimental floor saw a lot of nurses from other units float to the floor, and they were not trained in the hourly rounding protocol (Olrich et al., 2012).

Despite the above, the considerations, the study truly did not show any statistical significance, even though the researchers claimed clinically, there were positive changes. The study was limited by the sample size, sampling methods, not having a clearly stated hypothesis, and not using reliable measurement tools. Had there been tighter control over the intervention and measurement of such, there may have been statistically significant data. The authors do, however, point out that even the clinical improvements do support that further research and testing is needed, as hourly rounding does have the potential to improve the dependent variables identified.

Article Four

Problem. Article four has a clear problem statement that is listed in the second paragraph of the article. According to Burns and Grove (2011), a problem statement identifies a clearly expressed problem (p. 146). It assists the reader in focusing on what the problem is that will be discussed in the research article. Woodard (2009) explains that problem statement for article four is “patients are often uncertain about whether the nurse is available for immediate needs. This may result in (1) high rates of falls, (2) low patient satisfaction scores, and (3) high frequency of call-light use” (para. 2). Woodard (2009) explains the significance of this problem by stating “each of these outcomes has implications for safety and quality” (para. 2). The background of the problem is included in a later section of the article and is clearly labeled.

Purpose. The purpose is clearly stated in the second paragraph of the article. It also lists three research questions. It does not list the variables of the study. The population is noted to be patients on a 27-bed medical-surgical unit (Woodard, 2009, para. 16).

Literature Review. The focus of the study increase patient safety and satisfaction while decreasing anxiety and help uncertainty through intentional rounding. Twelve sources are cited. Six of the sources were older than five years old at the time of publishing; the oldest one from 1988. The other six sources were current sources. Seven were from nursing journals. They appear to be primary sources. The author also uses sources such as the Centers for Medicare and Medicaid Services and the New York State Nurses Organization. The studies were relevant to the current study and offered great information to enhance reader understanding of the problem at hand. One source discusses a broad study at several hospitals and the differences in outcomes if staff round every hour compared to every two hours and also patient satisfaction scores(Woodard, 2009, para. 9). One source shows the progression of the idea of rounding dated back to 1989. Hospitals had the idea of a unit hostess who would round on patients and attend to menial tasks. This was well received by patients, nurses, and physicians (Woodard, 2009, para. 10). The article contains paraphrases and no direct quotes leading to an article with smooth flow.

Framework. The study was designed with Mishel’s Uncertainty of Illness Model (Woodard, 2009, para. 4). For this model the definition of uncertainty is “the inability to determine the meaning of illness-related events and occurs when the patient cannot accurately predict the outcome” (Woodard, 2009, para. 4). The clinical nurse specialist (CNS) developed a term of help uncertainty. This is defined as “the inability to determine the meaning of nursing workflow and occurring when the patient cannot identify the predictability of the nurse being physically and emotionally available to help” (Woodard, 2009, para. 4). Woodard (2009) highlights that help uncertainty can heighten anxiety, ineffective coping mechanisms, and decrease the trust in nursing staff which will then lead to poor patient satisfaction scores (para. 4). This led the CNS to ask the important question of “would providing a routine, predictable presence of a nurse through rounding make the patient more familiar with the presence of that nurse and lead to less uncertainty of availability for help?” (Woodard, 2009, para. 5). This study evaluates “the effects of routine rounding on help uncertainty through measurements of patients’ self-report of uncertainty, patient fall rates, frequency of call-light use, and patient satisfaction scores (Woodard, 2009, para. 5).

Methods.

Research design. The CNS used a qualitative design that used Mishel’s Uncertainty of Illness model. Bias was reduced by the simple fact that data was collected from the unit manager before the study began to obtain baseline data. The unit where the study was performed was a unit with a wide variety of patients as described in a later section. Some bias may be found when discussing the help uncertainty. Another unit was used as a comparison. Perhaps enhanced nursing care or another study was being completed at the same time. The CNS used causality to determine that rounding on patients and decrease help uncertainty. Perhaps the biggest flaw with this study is that it was desired to decreased help uncertainty. Twenty-five patients were polled on both the comparison and study units. The CNS offers no information with how these patients were selected to participate in this part of the study. This can lead readers to believe that a convenience sample was taken and according to Burns and Grove (2011) it “is a wake approach because it provides little opportunity to control for biases; subjects are included in the study merely because they happen to be in the right place at the right time” (p. 305).

Treatment. The charge nurses of the unit received forty-five minutes of training on how to complete rounding, assessment findings, and probable benefits. The nurses also received the goals to decrease fall rates, increase patient satisfaction and decrease call-light use. The charge nurse was then responsible for rounding on each patient every two hours. They started with introductions to the patient and orientating patient to the shift staff. On later rounds, the charge nurse would emphasize the four P’s: pain, potty, position of patient and belongings, and presence of nurse (Woodard, 2009, 17). These assessments were then documented in the chart and discussed with the nurse caring for that patient. Primary nurses and techs play no role in rounding in this study.

Setting and sample. All patients on the unit were a part of the study. The study was performed on a twenty-seven-bed medical-surgical unit with a wide variety of patients including “general surgery, neurosurgery, otolaryngology surgery, and postprocedure patients from endoscopic retrograde cholangiopancreatography and interventional radiology. The unit includes progressive-care patients and acute-care patients” (Woodard, 2009, para. 16). Twenty-five patients from another unit was used to compare feelings of help uncertainty only, otherwise all data was collected from the same unit (Woodard, 2009, para. 21). Twenty-five patients from both the comparison unit and the study unit were evaluated for help uncertainty. It remains unclear how these patients were chosen.

Measurement. The charge nurses completed Likert scales on twenty-five patients on the study unit as well as on a comparison unit to measure help uncertainty. It is not identified how these patients were chosen. Patient satisfaction, fall rates, and call-light reports were collected from reports obtained from the unit manager each month (Woodard, 2009, para. 19).

Findings. Within the first quarter, a drop in falls and call-light frequency were noticed. Also patient satisfaction scores increased. Data was collected for a total of ten months and continued to show decreased falls and call-light usage. Over half of the patients on the comparison unit felt uncertain about their care or when a nurse would come into help them. Seventy-five percent of patients on the study floor felt very certain that a nurse would come to help them when needed (Woodard, 2009, para. 21). The charge nurses reported that half of them were usually doing the rounding and the other half was always doing the rounding (Woodard, 2009, para. 22). A graph in the article displays that patient satisfaction rose nearly twenty percent. The fall rate was cut in half and the call light frequency was cut by about ten percent (Woodard, 2009, Table 1). It would have been helpful if Woodard had listed exact percentages to go along with the graph as it would strengthen her results. Her graph makes it vague when she does not include exact numbers with it.

Conclusions. The CNS states that for the best outcome for patients further research needs to be done in the areas of best caregiver to do rounding and the best frequency to complete rounding. It would also be beneficial to research barriers to rounding and ways to decrease these barriers (Woodard, 2009, para. 32). The study’s reliability is compromised by the sample study for the help uncertainty using the Likert scale. Overall, it appears that falls, call-light usage, and help uncertainty were greatly decreased while patient satisfaction substantially increased. This is difficult to prove by lack of numbers. The readers are solely relying on the graph. Overall, “further investigation is needed to replicate these findings” (Woodard, 2009, para. 31). With further research, this may be an important study used to implement hourly rounding in hospitals throughout the world.

Integration of Evidence

Article One

According to Gardner et al. (2009) research has shown patients’ perception of receiving quality health care is related to the nurse’s timely response to their physical needs. Gardner et al (2009), cited a study conducted by Potter et al, finding “nurses moved from one location on the ward to another thirteen different times every hour, with approximately two activities carried out at each location” (p. 288). Other sources of research state “that nurses are called to each patient’s room or bedspace 12-15 times a day for non-urgent requests and each call takes at least 4 min of nursing time” (p. 288). The most frequent times for these calls are before meals and after meals and during the shift change, which is when staff is already busy. Gardner et al. (2009) found that when patients call lights and requests are unanswered, this leads to patients becoming frustrated, dissatisfied with care, and threats to patient safety are introduced. Hourly rounding has been considered one of the many ways to decrease call light usage and increase patient satisfaction and safety.

The study that was conducted used the Practice Environment Scale instrument and this study found that “nurses who participated in the comfort rounds experienced improvements in their perceptions of quality of care, resource adequacy and professional relations” (Gardner et al., 2009, p. 292). The conclusion to this study found it did have a positive outcome. The study “confirmed that nurse-led, patient-centered and quality-of-care oriented therapeutic interventions can have a positive effect on the nursing practice environment, and therefore potentially on patient safety and satisfaction measures such as call bell usage, patient falls and pressure injury rates” (Gardner et al., 2009, p.292).

Article Two

The next article to be discussed is Outcomes and Challenges in Implementing Hourly Rounds to Reduce Falls in Orthopedic Units written by Tucker et al (2012). This article discusses how structured nursing rounds interventions (SNRI) are important to help decrease patient falls as well as decreasing call light usage. It shows improvements in patient satisfaction with quality of health care and pain management. This study found there was some apprehension or push back from the staff after they implemented hourly rounding. Some of the barriers that were identified were a lack of input from the nursing staffing which made them less likely to participate appropriately. It was identified that nursing staff felt like hourly rounding on healthier, more independent patients was not realistic. It was reported some nurses already felt hourly rounding was part of their original routine.

According to Tucker et al (2012), they found during the short term evaluation that patient fall rates had decreased after the implementation of structured nursing rounding interventions. Once the one year evaluation came up, they found the falls rates had basically come back down to the original numbers. The researchers believe the reason behind this outcome is due to some staff nurses not following through with the SNRIs. After the completion of this study, it was found to be inconclusive.

Article Three

A replication study was conducted by a group of Clinical Nurse Specialists on a Med-Surg floor. Olrich et al (2012), found by implementing hourly rounding, patient falls, call-light usage, and patient satisfaction, were positively impacted. After the study was concluded, it was found falls had decreased by 23%, patients noticed the nursing staff was more attentive, therefore, increasing satisfaction. The researchers could not identify if call light usage has decreased, but they anticipated the call light usage would decrease with the nursing staff’s consistent use of hourly rounding. Some of the actions that were to be performed during this study of hourly rounding were to intentionally ask the patient if they needed to use the bathroom, if the position they were in was comfortable, making sure the patient has their call light, phone, tissues, water, and TV control in reach. All of these actions would proactively decrease the reasons for the patient to use their call light.

Article Four

According to Woodard (2009), “literature supports that a patient’s perception of high-quality nursing care is not reflected in the nurse’s knowledge and competence but in the patient’s perception of her availability, physical presence, and response to the call light” (p. 202). A six week study was done on one and two hour rounding schedules and one control group. Both of the groups that received intentional rounding had increased patient satisfaction scores as well as decreasing call light usage.

Nursing Experiences

The nurses writing this paper have had some experiences with hourly rounds as it relates to patient care and safety. Kelli Erb RN, utilizes hourly rounding every day with every patient. At her hospital, the nursing assistant and RN come up with a plan at the beginning of each shift. For example, the nursing assistant will do even hour rounding and the RN will do odd hour rounding. She says this works well and keeps patients safe. They have had a decrease in patient falls and increased patient satisfaction. On her unit, they also make sure to intentionally ask questions about using the bathroom, patient’s comfort level, and making sure the patient has all their personal items as well as the call light within reach. She feels hourly rounding is a wonderful tool to help keep patients safe and decrease call light usage.

Sarah Lutz RN has also had experience with hourly rounds. At her hospital the staff is expected to perform hourly rounding until midnight and then they begin every two hour rounding. She loves the idea of rounding and loves when rounding is done well because it really works. If she does not have a nurse tech that shares rounding, it is more difficult for her to round every hour. She also knows that rounding must be supported by every staff member. She knows the principal of rounding works if every staff member is on board and believes hospitals need to enforce hourly rounding more to improve the outcome of rounding.

At the hospital where Jessica Rochefort RN works they do not have an intentional rounding protocol. They are a small hospital with a five bed Emergency Room and thirteen bed Med-Surg. On night shift the only employees in the entire building are four to five nurses, depending on census, and occasionally a Certified Nurse's Assistant. Although her facility does not perform intentional rounding she has always made it a habit to check and chart on her patients at least every two hours. These two hour checks can be difficult if the Emergency Room is busy and nurses are pulled to assist, multiple admissions, or a failing patient. They do not have a ward clerk on night shift and someone must be present at the desk at all times in case of an ambulance call, phone call, Emergency Room patient, or unhealthy heart rhythm. If there is a patient requiring more assistance or the Emergency Room is busy a nurse is left at the desk without relief. This causes call lights to go unanswered for longer periods of time increasing risk of patient falls, patients experiencing pain longer, and an dissatisfaction with the care being provided.

Recommendations

Hourly rounding as it relates to patient satisfaction and patient safety really depends on many factors, one of them is nursing staffs’ accountability. Nursing staff need to change their daily practice to help maintain patient satisfaction and safety. Tucker et al (2012), found when nursing staff doesn’t make the change and intentionally round on patients, the chance for patient falls stays the same. The article written by Woodard (2009) used a charge nurse to round on patients. This may be effective when the primary nurse or the nursing assistant is unable to round, but there is a barrier because charge nurses also have other important roles and tasks that need to be completed to help run the unit. Another factor is making sure nursing staff intentionally round on their assigned patients and making sure they ask patients if they need to use the bathroom, if they are painful, or if they are comfortable in their current position (Woodard, 2009). Woodard (2009) identified another area of further research and that is to identify who is the most appropriate nursing staff, either registered nurse or nursing assistant, to complete routine rounding. Many times the patients’ requests can be completed by unlicensed personnel. Another idea for research Woodard (2009) identified was to “address the best or optimal frequency of rounding to make an impact on patient safety and satisfaction” (p. 206). Tucker et al (2012) also identified further research needs which include the frequency of hourly rounds, whether they should be hourly or every two hours. Another area they identified was if the intensity of hourly rounds should be greater with differing populations. Olrich et al (2012) decided future research needs to be done examining the relationship between hourly rounds and patient complications.

Intentional rounding is already implemented in many healthcare facilities due to the obvious benefits. According to the listed articles, it seems that there is still a lot of research needed yet to maximize these benefits. It will be interesting to see where rounding takes nurses and patients into the future. Understanding how to analyze and evaluate research articles will assist nurses and researchers in the future in regards to recognizing strong evidence that can be implemented into caring for patients.

References

Burns, N. & Grove, S.K. (2011). Understanding nursing research: Building an evidence-based practice. Maryland Heights, MO: Elsevier.

Gardner, G., Woollett, K., Daly, N., & Richardson, B. (2009). Measuring the effect of patient comfort rounds on practice environment and patient satisfaction: A pilot study. International Journal of Nursing Practice, 15, 287-293. doi:10.1111/j.1440-172X.2009.01753.x

Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly rounding: A replication study. MEDSURG Nursing, 21(1), 23-36. Retrieved from

Tucker, S. J., Bieber, P. L., Attlesey-Pries, J. M., Olson, M. E., & Dierkhising, R. A. (2012). Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units. Worldviews on Evidence-Based Nursing, 18-28. doi:10.1111/j.1741-6787.2011.00227.x

Woodard, J. (2009). Effects of rounding on patient satisfaction and patient safety on a

medical-surgical unit. Clinical Nurse Specialist, 23, 200-206.

doi: 10.1097/NUR0b13e3181a8ca8a

Paper #1 Evidence-Based Group Project Paper

Grading Criteria

30% of grade for paper can be deducted for APA errors including Spelling and grammar after paper graded.

|Headings |Possible points |Points |Comments |

| | |Earned | |

|Abstract and Title Page |10 |-0 | |

|Introduction |10 |-0 | |

|(What is the problem or question; Provide | | | |

|support for relevance of the question; | | | |

|Clearly describe the aim of the project & | | | |

|paper) | | | |

|A descriptive summary of the most relevant & |20 |-0 | |

|best evidence to answer the research question| | | |

|(there is not analysis here, just a | | | |

|description of what you found in the | | | |

|literature) | | | |

|An analysis of the evidence (this is a |20 | |Reads well. Some typos. See my comments. |

|critical appraisal of the evidence and what | |-0 |Overall good job. |

|you feel as a group the evidence suggests and| | | |

|whether there is strong or weak evidence to | | | |

|support the suggested findings) | | | |

|Describe how the evidence is affected by your|20 |-0 | |

|experiences as nurses, patient preferences, | | | |

|nursing's or other's values and how these | | | |

|factors would influence your decision to | | | |

|utilize the evidence in practice | | | |

| Make a recommendation as to whether or not |20 |-0 | |

|to utilize the evidence (support your | | | |

|recommendation with rationale) | | | |

|APA spelling and | | | |

|Grammar Deductions | | | |

|Total points |100 |100 | |

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