Running head: Evidence Based 1

Evidence Based Practice Paper

Natalie Russell

Ferris State University

Abstract

Evidence Based 2

There has been debate in the field of nursing regarding the benefit of performing structured

hourly rounds on patients. Many hospitals, if not already using the system, are beginning to

implement structured hourly rounds in their institutions. The decision for hospitals to implement

hourly rounding as part of patient care is primarily driven by patient satisfaction scores and

efforts to increase positive patient outcomes. Nurses and other support staff are responsible for

completing hourly rounds on patients. Using information from three research studies done on

hourly rounds, this paper will discuss the results of implementing structured hourly rounds in the

hospital setting.Remember the abstract is a summary of the paper and is not written in the future

tense.

Evidence Based Practice Paper

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Every nurse is faced with the challenges of trying to identify patient needs, as well as

providing care that fosters positive outcomes for every patient. With the numerous demands

nurses face in the hospital setting, it can be very challenging at times to fulfill all nursing

responsibilities, while maintaining emphasis on patient satisfaction and outcomes. Therefore, it

is imperative that nurses manage their time effectively and implement evidence-based practices,

such as rounding, in their daily patient care. Three research studies will be reviewed: Meade,

Bursell, and Ketelsen (2006), Woodard (2009), and Sobaski, Abraham, Fillmore, McFall, and

Davidhizar (2008). Each study address the topic of hourly rounding in the hospital setting, and

its relevance to nursing practice.

The concept of making rounds on patients is not unfamiliar to nurses, nor a new practice.

By structuring the already familiar concept, “hourly rounds provides nurses with a surveillance

mechanism to purposefully keep patients safe and comfortable by proactively meeting their

needs” (Halm, 2009, p. 582). Structured rounding is performed by the nurse and other support

staff, by intentionally checking on patients at scheduled hourly intervals. When rounding, staff

addresses the ‘4 P’s’: pain, potty, positioning, and proximity of personal items (Halm, 2009, p.

581).

The first study reviewed by Meade et al. (2006) was performed “to assess the frequency

of and reasons for patients’ call light use as well as the effects of 1 and 2check APA for

numerals-hour nursing rounds on patients’ use of the call light, patient satisfaction, and the rate

of patient falls” (Melnyk, 2007, p. 220). The study consisted of three groups: (a) hourly patient

rounding, (b) patient rounding every 2 hours, and (c) control group, no regular rounding. The

study sample included 14 hospitals across the United States, totaling twenty-seven individual

nursing units. Rounding was done by nurses over a period of four weeks, during which specific

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key actions were performed (e.g., pain assessment, offering assistance to the toilet, positioning

call light in reach, and informing patient that staff would round again at a scheduled timeframe)

(Melnyk, 2007, p. 220). The findings from this study indicated “hourly rounding was more

effective than 2-hour rounding and no rounding on call light usage, patient satisfaction, and

number of patient falls. Two-hour rounding was more effective than no rounding on patient

satisfaction” (Melnyk, 2007, p. 220). This study initially had participation from 46 units in 22

hospitals, but excluded 19 units in eight hospitals due to poor reliability and validity of data

collection, thereby threatening the internal validity of the study overall (Melnyk, 2007, pp. 220-

221). Even with consideration of the identified flaws of this study, the evidence is strong enough

to suggest hourly rounds may lead to an increase in patient satisfaction and a decrease in the

number of patient falls (Melynk, 2007, p. 221). Review of further studies was done to strengthen

the findings of this study.

The next study was performed by Woodard (2009). The purpose of this study was to

evaluate an intervention tool, routine rounding by the charge nurse, developed to increase patient

satisfaction scores and improve overall safety of patients (Woodard, 2009, pp. 200-201). The

study analyzed fall rates, patient satisfaction, and call-light usage among patients who received

the rounding intervention versus those that did not. Patient feelings of “help uncertainty”,

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, p. 201), was also analyzed by comparing a nursing unit that uses

routine rounds with one that does not. Lastly, barriers and challenges to implementing and

maintaining a routine rounding schedule identified by charge nurses were examined (Woodard,

2009, p. 201).

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Statistics for the study related to rates of falls and patient satisfaction scores were

obtained from National Research Corporation Pickers surveys. Call-light usage frequencies for

the study unit were collected from an online reporting system (Woodard, 2009, p. 202). A

Likert-type scale was used to measure “help uncertainty” on the study unit and another unit not

using routine charge nurse rounds. Twenty-five patients on each unit were asked ‘How certain

are you today that a caregiver will be available to address your immediate needs?’ The barriers

to implementing and maintaining a routine rounding schedule identified by charge nurses, were

measured by conducting a short survey with the charge nurses of the study unit (Woodard, 2009,

p. 203). The study took place at a Magnet accredited, teaching hospital, on a 27-bed medical-

surgical unit.

Results from Woodard’s (2009) study demonstrate the benefit of the use of scheduled

patient rounds, and its validity as an evidence-based practice. Data for the study was collected

from December 2006 to September 2007; results demonstrated a trending of continued decrease

in the number of falls and call-light frequency. Patient satisfaction scores increased from less

than 60% to almost 80% when patients were asked ‘Would you recommend this hospital to

family and friends?’. On the study unit, 72% of patients surveyed were very certain a caregiver

would address their immediate needs if needed (Woodard, 2009, p. 204). Nine charge nurses on

the study unit were surveyed; identified barriers to completing scheduled patient rounds included

completing patient discharges and admissions, as well as rounding on complicated patients may

require additional time to address their needs (Woodard, 2009, p. 204).

Although this study clearly demonstrates the benefits of scheduled rounding, there were

limitations to the data collected. Qualitative data related to the perception of charge nurses when

performing rounds was not collected; the feelings of nursing staff, patients, and families related

Evidence Based 6

to charge nurse rounding were not included in the study either (Woodard, 2009, p. 205).

Ultimately, no personal responses from those most affected by charge nurse rounding were

collected to identify pros and cons of the process.

The purpose of the study performed by Sobaski et al. (2008) was to demonstrate the

correlation between scheduled rounding completed by licensed and unlicensed nursing staff and

increased patient satisfaction scores measured by Press Ganey Patient Satisfaction Survey scores

(Abstract section, para. 9). Two research questions were explored in this study: ‘Does a protocol

of routine rounding on the cardiac telemetry unit by nursing staff increase the patient satisfaction

of the hospitalized patients?’ and ‘Are there set duties or protocols that nursing staff can perform

to improve the patient’s perception of the quality of healthcare they receive while hospitalized as

measured by Press Ganey Patient Satisfaction Survey scores?’ (Sobaski et al., 2008, Abstract

section, para. 9)

Scheduled rounding was done on the cardiac telemetry unit every one to two hours

between the hours of 7 a.m. and 10 p.m.; staff assessed patient pain, positioning, and comfort, as

well as assisting with toileting needs, and assuring proximity of patient call-light and other

belongings. Rounding was done with minimal activity for sleeping patients (Sobaski et al.,

2008). The study took place over a period of six months and included data from a total of 335

surveys returned from Press Ganey; the study included scores three months before

implementation of scheduled rounding and three months post-implementation (Sobaski et al.,

2008). Baseline satisfaction scores before implementation of scheduled rounding were below

90% in every category except for ‘skill of nurses’. Post-implementation average was higher than

baseline scores in every category. Satisfaction scores were higher every month that scheduled

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rounding was done, except for the second month related to ‘promptness of response to call light’

(Sobaski et al., 2008).

When reviewing the results of this study and possible flaws, one should consider the lack

of training received by nurses from other units in the hospital who worked on the telemetry unit

during the conduction of this study. Before the start of the study, the manager of the telemetry

unit presented the protocols for rounding to all unit staff, as defined by the author of the study. It

is possible that floated nurses, due to the lack of training, did not perform patient rounds as

defined by the author, nor as diligently as the trained staff (Sobaski et al., 2008, Discussion

section, para. 1). Therefore, results from the study may have been affected by this inconsistency.

With consideration of the identified area of weakness within this study, the results

ultimately confirm “increased interaction between nursing staff and patient increases the

patients’ perception of the care they receive” (Sobaski et al., 2008, Conclusion section, para. 1).

This study reveals opportunity for the nursing profession to make a positive influence in

healthcare and have an impact on patient loyalty and choice of healthcare institution in the future

(Sobaski et al., 2008, Conclusion section, para. 1).

Ida Jean Orlando developed a nursing theory that relates to the concept of rounding

discussed throughout this paper. Orlando’s nursing theory, called the Deliberative Nursing

Process, is used to help “identify the nature of the patient’s distress and his or her immediate

needs for help” (Kearney-Nunnery, 2008, p. 71). Orlando’s nursing theory discusses the

relationship between patient and nurse, and the professional responsibility of the nurse to identify

and meet patient’s immediate need for help (Alligood & Tomey, 2010, p. 66). Similarly, this

theory correlates with the desired outcomes of performing scheduled patient rounds. When

completing rounds, the goal is to anticipate patient needs and address them in a timely fashion.

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With the implementation of scheduled rounds, nurses can decrease patient anxiety by informing

the patient of the rounding schedule and at what intervals staff will be checking on them. As

addressed by Orlando’s nursing theory, patients experience feelings of helplessness and distress

when their needs for help are unmet (Alligood & Tomey, 2010, p. 66). Orlando’s theory

proposed “there is a positive correlation between the length of time the patient experiences

unmet needs and the degree of distress” (Alligood & Tomey, 2010, p.66). Orlando’s theory

emphasizes the importance of responding to patient needs with a sense of immediacy, to achieve

positive changes in the patient’s observable behavior (Alligood & Tomey, 2010, p.66). Overall,

Orlando’s theory supports the goals of performing scheduled rounds to increase patients’ sense

of well-being and reinforcing the availability of staff to meet their needs during hospitalization.

In conclusion, after reviewing studies on scheduled rounding (one hour and two hour

intervals) evidence supports the implementation of structured rounding by nurses and support

staff in the hospital setting. Results from the studies reviewed have identified increases in

patient satisfaction and positive patient outcomes while hospitalized. By structuring an

intervention that nurses already use in their practice, one can only expect patients will receive

improved care. Nurses can deliver care in a positive modality, proactively anticipating patients

needs versus reacting to problems that may have been preventable with the use of rounding.

References

Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and their work. Maryland

Heights,

MO: Mosby Elsevier.

Halm, M. A. (2009). Hourly rounds: What does the evidence indicate? American Journal of

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Critical Care, 18(6), 581-584. doi:10.4037/ajcc2009350

Kearney-Nunnery, R. (2008). Advancing your career: Concepts of professional

nursing.

Philadelphia, PA: F. A. Davis Company.

Melnyk, B. M. (2007). The latest evidence on hourly rounding and rapid response teams in

decreasing adverse events in hospitals. Worldviews on Evidence-Based Nursing,

4(4),

220-223. doi:10.1111/j.1741-6787.2007.00104.x

Sobaski, T., Abraham, M., Fillmore, R., McFall, D. E., & Davidhizar, R. (2008). The effect of

routine rounding by nursing staff on patient satisfaction on a cardiac telemetry unit.

Health Care Manager 27(4), 332-337. doi:10.1097/HCM.0b013e31819179a1

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

medical-surgical unit. Clinical Nurse Specialist, 23(4), 200-206. doi:10.1097/NUR.

0b013e3181a8ca8a

CHECKLIST FOR SUBMITTING PAPERS

CHECKDATE, TIME, & INITIAL PROOFREAD FOR: APA ISSUES

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3/8/10 1700, NR 1. Page Numbers: Did you number your pages using the automatic functions of your Word program? [p. 230 and example on p. 40)]

3/8/10 1700, NR 2. Running head: Does the Running head: have a small “h”? Is it on every page? Is it less than 50 spaces total? Is the title of the Running head in all caps? Is it 1” from the top of your title page? (Should be a few words from the title of your paper). [p. 229 and example on p. 40]

3/8/10 1700, NR 3. Abstract: Make sure your abstract begins on a new page. Is there a label of Abstract and it is centered at the top of the page? Is it a single paragraph? Is the paragraph flush with the margin without an indentation? Is your abstract a summary of your entire paper? Remember it is not an introduction to your paper. Someone should be able to read the abstract and know what to find in your paper. [p. 25 and example on p. 41]

3/8/10 1700, NR 4. Introduction: Did you repeat the title of your paper on your first page of content? Do not use ‘Introduction’ as a heading following the title. The first paragraph clearly implies the introduction and no heading is needed. [p. 27 and example on p. 42]

3/8/10 1700, NR 5. Margins: Did you leave 1” on all sides? [p. 229]

3/8/10 1700, NR 6. Double-spacing: Did you double-space throughout? No triple or extra spaces between sections or paragraphs except in special circumstances. This includes the reference page. [p. 229 and example on p. 40-59]

3/8/10 1700, NR 7. Line Length and Alignment: Did you use the flush-left style, and leave the right margin uneven, or ragged? [p. 229]

3/8/10 1700, NR 8. Paragraphs and Indentation: Did you indent the first line of every paragraph? See P. 229 for exceptions.

3/8/10 1700, NR 9. Spacing After Punctuation Marks: Did you space once at the end of separate parts of a reference and initials in a person’s name? Do not space after periods in abbreviations. Space twice after punctuation marks at the end of a sentence. [p. 87-88]

3/8/10 1700, NR 10. Typeface: Did you use Times Roman 12-point font? [p. 228]

3/8/10 1700, NR 9. Abbreviation: Did you explain each abbreviation the first time you used it? [p. 106-111]

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3/8/10 1700, NR 11. Plagiarism: Cite all sources! If you say something that is not your original idea, it must be cited. You may be citing many times…this is what you are supposed to be doing! [p. 170]

3/8/10 1700, NR 12. Direct Quote: A direct quote is exact words taken from another. An example with citation would look like this:“The variables that impact the etiology and the human response to various disease states will be explored” (Bell-Scriber, 2007, p. 1).Please note where the quotation marks are placed, where the final period is placed, no first name of author, and inclusion of page number, etc. Do all direct quotes look like this? [p. 170-172]

3/8/10 1700, NR 13. Quotes Over 40 Words: Did you make block quotes out of any direct quotes that are 40 words or longer? [p. 170-172]

3/8/10 1700, NR 14. Paraphrase: A paraphrase citation would look like this:Patients respond to illnesses in various ways depending on a number of factors that will be explored (Bell-Scriber, 2007). Do all paraphrased citations look like this? [p. 171 and multiple examples in text on p. 40-59]

3/8/10 1700, NR 15. Headings: Did you check your headings for proper levels? [p. 62-63].

3/8/10 1700, NR 16. General Guidelines for References:A. Did you start the References on a new page? [p. 37]B. Did you cut and paste references on your reference page? If so, check to make sure they are in correct APA format. Often they are not and must be adapted. Make sure all fonts are the same.C. Is your reference list double spaced with hanging indents? [p. 37]

PROOFREAD FOR GRAMMAR, SPELLING, PUNCTUATION, & STRUCTURE

3/8/10 1700, NR 13. Did you follow the assignment rubric? Did you make headings that address each major section? (Required to point out where you addressed each section.)

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3/8/10 1700, NR 14. Watch for run-on or long, cumbersome sentences. Read it out loud without pausing unless punctuation is present. If you become breathless or it doesn’t make sense, you need to rephrase or break the sentence into 2 or more smaller sentences. Did you do this?

3/8/10 1700, NR 15. Wordiness: check for the words “that”, and “the”. If not necessary, did you omit?

3/8/10 1700, NR 16. Conversational tone: Don’t write as if you are talking to someone in a casual way. For example, “Well so I couldn’t believe nurses did such things!” or “I was in total shock over that.” Did you stay in a formal/professional tone?

3/8/10 1700, NR 17. Avoid contractions. i.e. don’t, can’t, won’t, etc. Did you spell these out?

3/8/10 1700, NR 18. Did you check to make sure there are no hyphens and broken words in the right margin?

3/8/10 1700, NR 19. Do not use “etc.” or "i.e." in formal writing unless in parenthesis. Did you check for improper use of etc. & i.e.?

3/8/10 1700, NR 20. Stay in subject agreement. When referring to 1 nurse, don’t refer to the nurse as “they” or “them”. Also, in referring to a human, don’t refer to the person as “that”, but rather “who”. For example: The nurse that gave the injection….” Should be “The nurse who gave the injection…” Did you check for subject agreement? Likewise, don’t refer to “us”, “we”, “our”, within the paper…this is not about you and me. Be clear in identifying. For example don’t say “Our profession uses empirical data to support ….” . Instead say “The nursing profession uses empirical data…..

3/8/10 1700, NR 21. Did you check your sentences to make sure you did not end them with a preposition? For example, “I witnessed activities that I was not happy with.” Instead, “I witnessed activities with which I was not happy.”

3/8/10 1700, NR 22. Did you run a Spellcheck? Did you proofread in addition to running the Spellcheck?

3/8/10 1700, NR 23. Did you have other people read your paper? Did they find any areas confusing?

3/8/10 1700, NR 24. Did you include a summary or conclusion heading and section to wrap up your paper?

3/8/10 1700, NR 25. Do not use “we” “us” “our” “you” “I” etc. in a formal paper! Did you remove these words?

3/8/10 1700, NR 26. Does your paper have sentence fragments? Do you have complete sentences?

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3/8/10 1700, NR 27. Did you check apostrophes for correct possessive use. Don’t use apostrophes unless it is showing possession and then be sure it is in the correct location. The exception is with the word it. It’s = it is. Its is possessive.

Signing below indicates you have proofread your paper for the errors in the checklist:Natalie Russell 3/08/10________________________________________________________DATE:________________

A peer needs to proofread your paper checking for errors in the listed areas and sign below:Theresa Powers 3/10/10________________________________________________________DATE:_______________

Revised Fall 2009 (signature may be typewritten)

Evidence Based Practice Paper Grading Rubric

Name: ______Natalie Russell_____________________________

DESCRIPTION AND ANALYSIS OF PRACTICE

ISSUE

POINTS POSSIBLE POINTS AWARDED

Clear Introductory Description of Practice Concern/Interest: Describes reason for interest or concern and description of issue.

10 10

Practice Environment:Provides clear description of practice area.I did not see where you specifically discussed your practice area

5 2

Causal Factors: Personal Perspective and Description/Analysis of Possible Contributing or Causative Factors for the Concern

10 9

Evidence Based 14

Defined Area of Research Search: Narrows down and defines a specific area for research review and provides a clear statement of same.

5 5

RESEARCH REVIEWResearch Findings: Shares the findings of a minimum of 3 original research studies from professional journals on the selected topic. Briefly describes the research approaches and findings of each.

20 20

Critique of the Research: Attempts to point out any research limitations/credibility of the studies.

5 5

Implications For Practice: Identifies potential practice implications of research. This goes beyond implications included in the study itself, to include perceptions of implications for personal practice.

5 5

Critical Reflection: Identifies a nursing theory that this practice concern/research findings is an appropriate fit. Includes reflections on the significance/implications of integrating research into practice.Excellent use of theory

10 10

STANDARDS & APA CRITERIA

APA: Attaches and adheres APA checklist and APA manual guidelines. Length appropriate (5-6 pages of typed content excluding the reference page, abstract, and title page).

15 15

Writing: Development of a clear, logical, well-supported paper. Overall presentation: Grammar, punctuation, clean and legible.

15 15

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TOTAL POINTS 100 96

Very well written. You followed the rubric exactly as you were supposed to. Thank you.