The Effects of Intentional Nurse Rounding on Patient ...



The Effects of Intentional Nurse Rounding on Patient Satisfaction and Call Bell Usage: An Integrative Literature ReviewRachel MartinkoUniversity of Central FloridaAbstractProviding quality patient care in the acute care setting is at the forefront of healthcare, as it directly impacts hospital reimbursement. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a survey tool used to measure patients’ perceptions of a hospital stay post discharge. Intentional nurse rounding is a practice that is suggested to assist nursing staff in providing superior patient care while in the hospital setting. Nursing staff routinely rounds on patients, either in hour or two-hour intervals, assessing and anticipating patient’s needs. An integrative literature review was performed to determine the effects intentional nurse rounding had on patient outcomes, specifically patient satisfaction and call light usage. A comprehensive electronic database search was completed using CINHAL, Cochrane Database of Systematic Reviews, PubMed, OneSearch, and Academic Search Premier. Quantitative research studies published after 2006 and in the English language were analyzed for this review. It was concluded that intentional nurse rounds have a positive impact on patient satisfaction and helped to decrease call light usage in the acute care setting. Recommendations for future studies include determining effects routine rounding has on different patient outcomes, such as patient safety, and rate of compliance nurses perform these rounds. Keywords: nursing round, call bell, patient satisfaction, hourly roundThe Effects of Intentional Nurse Rounding on Patient Satisfaction and Call Bell Usage: An Integrative Literature ReviewSignificanceThe American healthcare reimbursement system is changing into one that emphasizes quality patient care and positive outcomes. This focus is designed to ensure continuous transformations are made to keep up with improvements within the system (American Hospital Association [AHA], 2012). Under the Affordable Care Act, hospital reimbursement relies heavily on performance scores from patient satisfaction surveys issued after a patient is discharged from the facility. These questionnaires, known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), are designed to evaluate the quality of care provided during an inpatient stay (Centers for Medicare & Medicaid Services [CMS], 2014). The HCAHPS are part of the Value-Based Purchasing program, which incentivizes hospitals to improve performance. In 2014, 1.25% of hospital reimbursement from Medicare was at stake, and this percentage will increase each year. Hospitals must perform in the top 95th percentile of the HCAHPS and core measure scores to ensure their full 1.25% in received (CMS, 2014).Guaranteed full reimbursement from Medicare is no easy feat. Thus, leaders of healthcare organizations are looking toward ways of improving the quality of care provided to patients, while improving patient outcomes. Through this, they expect to increase customer satisfaction, and ultimately HCAHP scores, to boost their national ranking and ensure proper reimbursement for care provided (AHA, 2012). An admission to the hospital can be a scary experience, as patients are forced to rely on nursing staff to meet the simplest of needs, such as toileting or retrieving a personal item out of reach. The call bell serves as a patient’s lifeline and primary way of communicating with the nursing staff. However, answering call lights can become a tedious task for nursing staff, and patients may have to wait several minutes for their needs to be met. This has a direct effect on patient satisfaction, and the quality of care provided. A proactive approach to meeting patient’s needs is called intentional rounding, also known as hourly rounding, and serves as the foundation of providing excellent nursing care during a hospitalization (Levenson, 2013).Intentional rounding focuses on patient-centered care, as nursing staff visits patient rooms, addressing their needs on a routine basis. Rounds are typically completed on an hour or two-hour schedule (Blakely, Kroth, & Gregson, 2011). The nurse assesses the patient’s needs including the 4 P’s: potty, position, pain, and possessions. Does the patient need to use the bathroom? Offering toileting can reduce the risk of patient falls, and accidents if they attempt to go it alone. Is the patient’s position satisfactory? Repositioning helps to prevent skin breakdown and pressure ulcers. Is the patient’s pain controlled? Lastly, are the patient’s possessions within reach? Overall, these 4 P’s address several questions included on the HCAHP survey (Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS], 2015). The purpose of this review was to determine the effect of intentional rounding on call bell usage and patient satisfaction in hospitalized patients.MethodsThe objective of this integrative literature review is to examine the existing literature to determine the effects of intentional nurse rounds on call bell usage and patient satisfaction in the acute care setting. Databases used for this search included CINHAL, Cochrane Database of Systematic Reviews, PubMed, OneSearch, and Academic Search Premier. All searches were limited to peer-reviewed, research articles. Initially, the search was dated 2009-2015, but then had to be broadened to 2006-2015 when an inadequate number of studies were found for the first time frame. The language was limited to English. Keywords included: hourly round, rounds, rounding; patient satisfaction, call bell, call light; nurse, nursing round. Various keyword combinations were used in the search box and the “apply related words” box was checked to allow for synonyms to be searched.The abstracts of all the results were read, and the articles were narrowed down based on the two outcomes of interest: call bell usage and patient satisfaction. Articles were included if quantitative research studies with statistical results were discussed, i.e. systematic reviews, quasi-experimental design, controlled clinical trial, correlational study, and action research design; inpatient setting; studies published in the year 2006 and beyond, HCAHPS outcome measure. Articles were excluded if studies used experiments in the intensive care units or emergency departments, and a qualitative research study or literature review design was utilized.The quality of evidence from this integrative literature review was determined using the hierarchy of evidence rating system published by Melnyk and Fineout-Overholt (2014).ResultsSearch ResultsA total of fifty-five articles were found using a multi-database search on EBSCOhost.All duplicates were removed. Titles were skimmed, and those that appeared relevant, were further analyzed using their abstract. Ten primary studies were found to meet inclusion criteria. After carefully reading these articles, four more were excluded, as they did not present data with statistical results. Final studies used for this integrative literature review are depicted in Table 1 below. Two main themes, patient satisfaction and call light usage, were examined in regards to intentional nurse rounds. Patient SatisfactionAll studies included in this review examined the effects of routine nurse rounding, either hourly or two-hourly, on patient satisfaction. Primary studies assessed patient satisfaction using questionnaires after discharge, comments from leadership rounds, and/or Press Ganey Survey scores. Two specific questions on the Press Ganey Scores were used during data collection. These included “promptness to call” and “nurses’ attitude toward request (Berg, Sailors, Reimer, O’Brien, & Ward-Smith, 2011). Many researchers used Meade, Bursell, and Ketelsen (2006) as a guideline, as this was one of the first studies completed that evaluated the effects of routine nurse rounds.All six studies reported an increase of patient satisfaction with the implementation of routine nurse rounds. Interestingly enough, hourly rounding during the day, and two-hourly rounding during the night did not affect patient satisfaction during the second day of hospitalization, but increased significantly on day five of the inpatient stay (Negarandeh, Bahabadi, & Mamaghani, 2014). Two studies found results were statistically insignificant, although their patient satisfaction scores improved on the units (Saleh, Nusair, Zubadi, Shloul, & Saleh, 2011; Olrich, Kalman, & Nigolian, 2012).A systematic review completed by Mitchell, Lavenberg, Trotta, & Umscheid (2014) found all but two studies showing an increase in patient satisfaction with the implementation of hourly and two-hourly rounding. However, most of these studies did not report any statistical evidence supporting the data. Overall, routine nurse rounds had a positive impact on patient satisfaction.Call Light UsageFive studies reported data on call bell usage with the implementation of routine rounding on nursing units. All studies reported that routine nursing rounds decreased mean call bell usage, with the exception of the experiment by Olrich,et al. (2012), which found no significant effect. As discussed with patient satisfaction, Meade et al. (2006) was a model for many subsequent studies, which showed a reduction in call bell usage among patients for the hourly and two-hourly rounding groups. However, only the two-hour nurse rounds showed statistical significance. All other studies revealed that routine nurse rounds decreased call bell usage (Berg et al., 2011; Saleh et al., 2011). The biggest reduction was revealed in the study performed by Mitchell et al. (2014), with call light usage reduced by 54%.Table 1Primary Study, CountryDesign, Level of Evidence, SampleCharacteristics of InterventionResultsMitchell et al. (2014), United States of America‘Systematic Review’Level I16 published studies reviewed 15 pre-post studies 1 nonrandom studiesTotal sample size n=9493No direct intervention. Medline, EMBASE, and CINHAL databases were used.Systematic review of regular nurse rounds and the impact on patient satisfaction, call bell usage, falls, and nurse efficiency.Two research analysts viewed 100 randomly selected search results and 16 were determined to meet inclusion criteria. GRADE system was used to determine evidence quality for each outcome on the scale of high, moderate, low, and very low. 12 studies utilized hourly rounds with specified tasks, i.e. 4 P’s, 7 of them performed 2-hourly rounding at night. 2 studies implemented 2-hourly rounds.1 used a Practice Partnership Model of care, which used 1-2 hourly rounds.Call light usage10 studies reported call light usage. Decreased from 23%-70%, median reduction was 54%.4 studies with statistical data reported routine nurse rounding significantly reduced call light usage. Overall GRADE strength was moderate.Patient satisfaction11 total studies reported patient satisfaction scores. 9 reported improvements with hourly rounding, 7 studies reported statistical data, and 4 of these were significant.Overall GRADE strength was moderate. Berg et al., (2011), United States of America‘Longitudinal Research, Correlational study’Level IV28 bed medical/surgicalinpatient unitConvenience sample of 35 days of call light data was used pre and post rounding implementation n=70Press Ganey responses n=569Pre-Post design: Unit secretaries documented reason for call light request prior to and after implementation of hourly rounds on flow sheets. 70 randomly selected sheets (35 pre-implementation, 35 post-implementation) were used for analysis. Press Ganey scores were assessed pre and post hourly rounding. Two areas specifically were analyzed: “promptness in response to call lights” and “nurses attitude toward request”.Call light usage-Pre- 11.329 +/- 4.215-Post- 19 +/- 4.728Total pre-Total post p<0.001, 95% CI 1.727, 5.67286.Call light usage decreased from 11.32 to 7.62 per day after hourly rounding implementation. Patient satisfaction“promptness to call”pre- 88.9 (n=104)post-89.3 (n=180)“nurses’ attitude toward request pre- 90.6 (n=106)post- 92.3 (n=179)Negarandeh et al. (2014), Iran‘Clinical trial with non-equivalent control groups’Level III100 total participants 50 in experimental group 50 in control groupNurses were taught proper rounding and supervised by the researcher in 20-minute training sessions prior to implementation. In the experimental group, nurses visited patients every 1-2 hours, from 8 a.m. to 10 p.m., assessing their needs, focusing on pain, comfort, assistance, and training needs. Control group received care as usual, using task-oriented nursing care. Patient Satisfaction with Nursing Care Quality Questionnaire was completed on the second and fifth days of hospitalization.Second day of hospitalization:Control- 59.8 +/- 16.3Experimental- 57.5 +/- 17.6P=0.499Fifth day of hospitalization:Control- 55.3 +/- 12.7Experimental- 68.8 +/- 8.8P<0.001Saleh, et al., (2011), Saudi Arabia‘Quasi-experimental non-equivalent design’Level IV104 patients from a 26- bed stroke unit8 week study Nurse rounds system (NRS): Hourly rounds performed during 7 a.m. to 10 p.m., and 2-hourly rounds during 10 p.m. and 7 a.m. Baseline data was collected for 8 weeks prior to study. Call bell use was divided into 7 categories based on patient needs or requests. Unit secretaries collected data using logs, which were then compared to Hill-Rom electric call light recording system data.The study did not reveal how patient satisfaction was measured. Call light usagePre-98.8 +/- 21.2Post- 29.3 +/- 7.4z-value=24.5, p<0.001. Patient satisfaction was increased by 7.5%, but was not statistically significant. No further data given.Meade, et al., (2006), United States of America‘Quasi-experimental design with non-equivalent groups’Level IVSix-week studyData was collected from 27 nursing units in 14 hospitals nationwideHospital units were randomly assigned to a one-hour rounding, two-hour rounding, or a control group. Rounds in the one-hour rounding group were performed between 6AM and 10PM, and once every two hours between 10PM and 6AM. Two-hour rounding was defined as rounds every two hours throughout the entire 24-hours. Baseline measurements were taken for two weeks prior to implementation, and the round experiment lasted four weeks. The control groups continued usual nurse rounds. Call bell requests were logged with each call, grouped into seven categories. Both control and experimental units documented logs.Patient satisfaction was measured using nationally recognized patient surveys. Scores were converted to a 100-point scale.Call light usageHourly Rounds:Pre=13,216Post=8,315P=0.007Two-Hour Rounds:Pre=14,201Post=11.507P=0.06Control:Pre=13,494Post=13,106Patient satisfactionHourly Rounds:Pre= 79.9Post= 91.9(t=736.58, p=0.001)Two Hour Rounds:Pre= 70.4Post= 82.1(t=657.11, p=0.001)Control: No data listedOlrich, et al., (2012), United States of America‘Quasi-experimental design, with non-equivalent group’Level IV2 Medical/Surgical inpatient units divided into 1 experimental and 1 control group, sample included all discharged patients (n=4418)1-year studyHourly rounding: Baseline data for patient satisfaction reports were collected 6 months before implementation, and 6 months during hourly rounding intervention. Call light data was obtained 2 weeks before and 4 weeks during intervention. Nurses and nurse assistants were provided education on hourly rounding by their CNS. One-hour rounding occurred from 6 a.m. to 10 p.m., and 2-hour rounding from 10 p.m. to 6 a.m.Hourly rounding had no significant effect on call bell usage. No statistics reported.There was no statistical significance between patient satisfaction and hourly rounds. p=0.383Limitations of the EvidenceThis review is not without flaws in the evidence, as there were limitations present with these studies. Much of the research presented did not include randomized selection when assigning experimental and control groups, and experimental groups had small sample sizes. Considered selection bias, the validity of these studies can be compromised (Melnyk & Fineout-Overholt, 2014). The systematic review had inconsistency in the result data reported, possibly compromising the quality of the review (Mitchell et al., 2014). The patient populations were inconsistent across the studies. The call bell data might have been skewed due to confused patients on the unit, causing an increase in number of accidental calls (Olrich et al., 2012). Lastly, measuring patient satisfaction is subjective when using questionnaires during data collection. Perception of satisfaction varies from person to person, especially in the hospital setting. This depends on a patient’s experience during their stay, expectations, and attitude. Also, it may have been more difficult to see an increase in patient satisfaction on units that already had a high satisfaction rate prior to implementing intentional nurse rounds (Negarandeh et al., 2014). RecommendationsThe data analyzed from these studies shows that intentional nurse rounding has a positive effect on patient outcomes. The success for?implementation of nurse rounds lies in the support by hospital administrators and?leadership staff. Adopting programs designed specifically to teach staff the proper rounding techniques and goals can help hospital units provide cost-effective, quality patient care (Mitchell et al., 2014). Olrich?et al. (2012) suggest the use of staff unit champions, whose focus is to perfect nurse rounds, and?integrate them into everyday nursing care. It is also important to determine ways to engage staff consistency, and integrate it as a routine piece of nursing staff daily practice. Healthcare organizations should also adopt intentional nurse rounds into their policy and procedures to ensure all nursing staff consistently use this practice. Future ResearchIt is recommended, in future studies, researchers evaluate the?effectiveness of routine nurse?rounds over a longer period of time, 6 months or greater, and experiment using a larger, more diverse sample size. ?Ideas for future research include assessing how intentional rounding affects patient falls and skin breakdown and pressure ulcer development. Some research articles reviewed for this study included data in these areas, but this theme was not included in this review. Furthermore, future research should look at compliance among nurses in completing routine rounds over a long period of time. Intentional nurse rounds should be completed consistently. Some authors of the articles reviewed feared that nurses would stop using the routine rounding upon completion of the study (Saleh et al., 2011). ReferencesAmerican Hospital Association. (2012). Linking quality to payment. Retrieved April 4, 2015, from , K., Sailors, C., Reimer, R., O’Brien, Y., & Ward-Smith, P. (2011). Hourly rounding with a purpose. Iowa Nurse Reporter, 24, 12-14. Retrieved from , D., Kroth, M., & Gregson, J. (2011). The impact of nurse rounding on patient satisfaction in a medical-sugical unit. MEDSURG Nursing, 20, 327-332. Retrieved from for Medicare & Medicaid Services. (2014). Hospital value-based purchasing. Retrieved April 4, 2015, from Consumer Assessment of Healthcare Providers and Systems . (2015). CAHPS hospital survey. Retrieved April 4, 2015, from , R. (2013). A report on the implementation of intentional rounding at demonstrator sites for the nursing and quality care forum (Research Report v 3.0). Retrieved from , C. M., Bursell, A. L., & Ketelsen, L. (2006). Effects of nursing rounds on patient’s call light use, satisfaction, and safety. The American Journal of Nursing, 106, 58-70. Retrieved from , B. M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.Mitchell, M. D., Lavenberg, J. G., Trotta, R. L., & Umscheid, C. A. (2014). Hourly rounding to improve nursing responsiveness: a systematic review. The Journal of Nursing Administration, 44, 462-472. , R., Bahabadi, A. H., & Mamaghani, J. A. (2014). Impact of regular nursing rounds on patient satisfaction with nursing care. Asian Nursing Research, 8, 282-285. , T., Kalman, M., & Nigolian, C. (2012). Hourly rounding: a replication study. MEDSURG Nursing, 21, 23-36. Retrieved from , B. S., Nusair, H., Zubadi, N. A., Shloul, S. A., & Saleh, U. (2011). The nursing rounds system: effect of patient’s call light use, bed sores, fall and satisfaction level. International Journal of Nursing Practice, 17, 299-303. ................
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