JONA Volume 42, Number 2, pp 83-88 Copyright B 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Nurses’ Perceptions of Patient Rounding Kathleen Neville, PhD, RN Kristen Lake, MS, RN, PCCN Danielle LeMunyon, MSN, APN, ANP-BC
Darilyn Paul, MS, APN, ACNS-BC, CCRN Karen Whitmore, MS, RN-BC, CWS
Objective: This descriptive pilot study explored hospital staff nurses’ perceptions toward the practice of patient rounding. Background: Rounding has re-emerged as a standard practice initiative among nurses in hospitals and has been associated with a decrease in call lights and falls, increased patient satisfaction and safety, and quieter nursing units. Regardless of these outcomes, controversy exists among nurses regarding rounding. Methods: The Nurses’ Perception of Patient Rounding Scale (K. Neville, unpublished manuscript, 2010) was developed to gain an understanding of nurses’ perceptions of rounding. Results: Nurses identified rounding as valuable and perceived hourly rounding to be beneficial to patients and families but significantly less beneficial to their own professional practice. Challenges to rounding as a practice include issues of documentation, patient ratios, and skill mix. Conclusion: Findings support the need for further research to address the challenges of patient rounding for nursing.
dearth of literature exists regarding the perceptions and attitudes of staff nurses toward rounding. Further research is needed to determine if nurses value the required practice and what factors influence their views. In addition, information is needed about factors that facilitate or serve as barriers in the provision of successful rounding. Somerset Medical Center (SMC), a 350-bed community medical center in suburban New Jersey, implemented a 6-month project of patient rounding on an oncology unit. Based on an identified need to improve patient satisfaction scores, decrease incidence of falls, decrease call bell use, and provide more effective pain management, a unit-based performance improvement project was formulated. Postproject evaluations revealed a decrease in patient falls and an improvement in patient satisfaction scores. Based on these outcomes, the concept of patient rounding was endorsed by nursing administration. The practice of hourly rounding, along with an hourly documentation record, was initiated on all nursing units. The postproject evaluation did not include an evaluation of the nurses’ perceptions regarding the practice change. The purpose of this descriptive exploratory pilot study was to gain an understanding of staff nurses’ values, beliefs, and attitudes toward the practice of patient rounding at this institution. Knowledge gained from this study will be used to evaluate the current practice and implement modifications as needed for further improvement in practice and nurse satisfaction if indicated.
Hourly rounds, defined as the intentional checking on patients at regular intervals,1 have re-emerged as a standard practice initiative among nurses in acute care settings. The literature is highly supportive of patient rounding as an appropriate, safe, and useful practice, yielding substantial nurse and patient benefits, yet debate among nurses remains.1,2 Although nurse managers are introducing hourly and 2-hour rounding on a national and international level,1 a Author Affiliations: Professor (Dr Neville), School of Nursing, Kean University, Union; Nurse Practitioner (Mss Lake and LeMunyon); Clinical Nurse Specialist (Mss Paul and Whitmore), Somerset Medical Center, Somerville, New Jersey. The authors declare no conflict of interest. Correspondence: Dr Neville, School of Nursing, Kean University, 1000 Morris Avenue, Union, NJ 07083 ([email protected]). DOI: 10.1097/NNA.0b013e318243365e
Literature Review Routine unit rounds have been practiced in both medicine and nursing. However, in recent years, nursing rounds have re-emerged as a valuable nursing practice with substantial research to support its return to practice nationwide.3 Recent evidence supports the use of rounding in improved patient outcomes; namely,
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
83
patient satisfaction, decreased call light use, and reduction of falls in hospitalized adult patients.3-6 A comprehensive clinical evidence review of studies on hourly rounding with level II evidence reported that 7 of 11 rounding studies resulted in decreased incidence of falls and 8 of 11 studies demonstrated increased levels of patient satisfaction.1 Evidence reveals that patients’ perception of excellence in care is based on the perceived availability and visibility of nurses, rather than the nurses’ level of knowledge or competence.7,8 Furthermore, hospital satisfaction is associated with the care that patients receive from nurses; that is, quality nursing care implies effective communication, kindness, being readily available to patients, making time for patients, effective pain management, timely response to call bells, and how well nurses are able to meet their needs.9-12 Uncertainty related to the illness condition, about symptoms, treatments, diagnosis, and other medical events is frequently experienced during hospitalization. This uncertainty can be further troubling when patients perceive the ambiguity of not knowing or are lacking the assurance about when a nurse will return to provide care during a shift. Routine rounding has been demonstrated to have a relationship with the perception of the nurses’ presence, patient safety, and less uncertainty in care by the patient.8 Rounding is successful when the visible presence of the nurses by hospitalized patients and/or families improves patient outcomes, including satisfaction. Evidence supports that rounding enhances the work environment for nurses in terms of improved patient care management and achievement of greater work efficiency. There is a strong correlation between nurse and patient satisfaction.11,13 Despite the increasing proliferation of rounding protocols in nursing practice, Halm1 identified 4 factors contributing to the debate regarding patient rounding. Formal scripting represents 1 factor because nurses perceive scripting as being rehearsed and thereby compromising nurses’ individual autonomy in their practice. Skill mix of healthcare personnel must be considered, as rounding success is contingent on nurses partnering with supportive personnel who possess highly effective communication skills to prevent nurses from becoming overtaxed in hourly assessments. Patient acuity level is another factor, which frequently necessitates the nurse to alter rounding protocols by remaining with acutely ill patients and omitting rounds on other less acute patients. In addition, Halm1(p584) addressed nurses’ extensive time demands of documentation and how the additional requirement of rounding documentation ‘‘may breed resentment and wavering adherence.’’
84
About the Study Methodology Using a convenience sampling approach, the volunteer participants consisted of registered nurses (RNs) on 5 separate adult medical-surgical inpatient units at SMC. Eligible participants were full-time, parttime, and per diem nurse employees. Charge nurses who engaged in rotational patient assignments were eligible to participate in the study. Agency personnel were excluded. A total of 150 questionnaires were distributed, with 49 (33%) participants returning the questionnaires. To reduce the response set bias of providing socially desirable responses, this study was anonymous. No identifying demographic data other than the unit in which nurses practiced were obtained. A team of 4 advanced practice RNs (APRNs) introduced the study on each unit, explained the purpose and nature of the study, and discussed anonymity provisions, voluntary participation, and the right to withdraw at any point during the study. Completed questionnaires were placed in an unmarked sealed envelope in a drop-off box located on each unit within a 4 week period. Completion of the questionnaire implied consent. Before data collection, institutional review board approval was obtained from both SMC and Kean University. A descriptive exploratory design was used. A newly constructed questionnaire, the Nurses’ Perceptions of Patient Rounding Scale (NPPRS) (K. Neville, unpublished manuscript, 2010), was developed to measure staff nurses’ perceptions of rounding practices. Face validity was first established by having staff nurses evaluate the tool for content and to determine the ability of the tool to measure nurses’ perception of their required rounding practice. Initial item development resulted in 60 items. Through focus groups with staff nurses, feedback resulted in the reduction of 18 items to eliminate redundancy and facilitate timely completion of the NPPRS. Content validity of the revised instrument was established by a panel of APRN experts. The resultant scale consists of 42 items in a 5-point Likert format, ranging from strongly disagree (1) to strongly agree (5), and can be completed in 10 minutes. Through principal components factor analysis with varimax rotation, 3 factors emerged. The NPPRS yields 3 subscales (communication, patient benefits, and nurse benefits) and 1 total score. The communication subscale consists of 15 items. Examples include ‘‘Rounding is a practice that facilitates improved verbal and nonverbal communication between patients and nurses’’ and ‘‘During rounding, I tailor my terminology to facilitate effective communication with patients and families.’’
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nurse benefits consist of 8 items. Examples include ‘‘Rounding is a constructive use of nurses’ time’’ and ‘‘The benefit of rounding is that it creates a quieter, less chaotic nursing unit.’’ Patient benefits consisted of 9 items and examples include ‘‘Rounding reduces patient and family uncertainty about their illness’’ and ‘‘Patients benefit from my visible presence every 2 hours.’’ Ten items reflect rounding schedules and cultural, ethical, and confidentiality issues regarding privacy and were subsequently not included in the 3 subscales. Because of the relevance to the practice of rounding, these items were retained in the NPPRS. Three additional qualitative items were addressed to gain more descriptive information on the practice of rounding and solicited information regarding suggestions and recommendations as well as identification of patient issues influencing rounding practices. Possible total scores on the NPPRS ranged from 42 to 210, with higher scores reflecting more positive responses toward rounding.
Results Using SPSS version 18 (SPSS, Inc, Chicago, Illinois), internal consistency of the NPPRS was established as evidenced by the strong support for the homogeneity of the items within this initial measurement (Table 1). Possible mean scores for the total perception of patient rounding ranged from 42 to 210. Total NPPRS scores across all units were reflective of favorable overall perceptions of rounding (Table 2), with no statistically significant differences noted among units. Possible mean scores on the communication subscale ranged from 16 to 80. Mean scores on the communication subscale (Table 3) were relatively homogenous among units and generally reflected that nurses valued the positive aspects of patient rounding on nurse-patient communication (mean [SD], 64.40 [3.84]). Similar to the total score, there were no significant differences among the various units on the subscale of communication. Because of the small sample size, the power of these statistical analyses was insufficient to detect difference. A power analysis revealed that a sample size of 135 subjects was needed to detect statistical significance.14
Table 1. NPPRS Reliability Coefficients Scale Subscale: communication Subscale: patient benefits Subscale: nurse benefits Total score: NPPRS
Cronbach ! .83 .87 .73 .92
Table 2. One-Way Analysis of Variance: Total Perception Score by Unit Unit
Mean
SD
Geriatric Orthopedic/neurology Hematology/oncology Surgery Medical-surgical Total
171.50 148.71 161.10 159.55 162.60 159.62
10.63 19.76 13.96 14.70 19.52 18.02
P = .35.
Items capturing nurses’ perceptions of the benefits of rounding were further dichotomized by the distinct subscales of nurse and patient benefits (Table 4). The possible range of scores for nurse benefits was 8 to 40. Scores were homogenous, ranging from 24.55 (4.61) to 29.50 (5.08). Among patient benefits, possible scores ranged from 9 to 45, and patient benefit scores reflected higher scores, ranging from 33.90 (5.17) to 38.57 (4.42). An independent t test revealed a statistically significant difference between nurse and patient perceived benefits. Nurses identified a real benefit for their patients, but not for themselves. Three open-ended items in the NPPRS were developed to explore nurses’ views regarding the practice of rounding. Although data saturation (when information provided by participants becomes repetitive and data collection can cease) did not determine the sample size in this study, the responses elicited below by nurse participants reflected consistently identified patterns or themes. Inquiry regarding nurses’ conceptualization of patient rounding was explored, and from the conceptual definitions provided, findings reveal that nurses consistently articulated a current perspective of the practice of rounding. For example, 2 participants stated: Rounding is checking to make sure all patients’ needs are met by assessing pain, comfort and by making sure call bells are within reach, belongings and drinks are nearby as well as safety needs are met.
Table 3. One-Way Analysis of Variance: Communication Score by Unit Unit
Mean
SD
Geriatrics Orthopedic/neurology Hematology/oncology Surgery Medical-surgical Total
64.40 56.42 57.25 57.66 59.40 58.42
3.84 7.87 6.00 5.95 9.68 6.81
P = NS.
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
85
Table 4. Nurse and Patient Benefits Unit
Nurse Benefit
Patient Benefit
Geriatric Orthopedic/ neurology Hematology/ oncology Surgery Medical-surgical Total
29.50 (5.08) 24.55 (4.61)
38.57 (4.42) 33.90 (5.17)
28.71 (3.60)
36.46 (3.52)
28.18 (4.14) 28.33 (8.61) 27.83 (5.03)
37.41 (4.60) 36.54 (8.43) 36.54 (5.06)
Values are presented as Means (SD). P G .001.
Rounding is visiting each of your patients each hour to see if there is anything they need or anything you can do for them.
Throughout numerous conceptualizations describing rounding, nurses consistently identified assessment as an integral and key component of nursing practice. Assessment was reported to be continuously conducted regardless of rounding protocol. A predominant theme was that rounding was perceived as an important and valued practice, as evidenced by the following statements: I believe rounding is an effective way to meet patient needs in a timely manner and to reduce call bell usage. Rounding is extremely important; to round on your patients should be part of every nurses’ practice.
Although the findings above support the practice of rounding, thematic analysis revealed that nurses’ strong sense of professional autonomy and identification of patient needs through assessment were the most important factors in determining the frequency and duration of time spent with patients. Findings revealed that a mandated rounding protocol minimized the sense of professional autonomy and selfdirected practice. It was felt that their presence at the bedside was oftentimes far more frequent than every 1 hour. Nurses reported challenges in the provision of rounding due to increased patient acuity levels, time constraints, and the nurses’ awareness of their need to be physically present. One nurse stated: Patients who have cancer sometimes need more of your time just to listen and be with them. Tonight, one of my patients asked me if dying is like getting a lethal injection they give in jail and will it hurt? I needed to stay.
Documentation of the rounding protocol was another predominant theme. Nurses reported that the
86
additional documentation required by the rounding protocol was burdensome and unnecessary. In some responses, it became evident that rounding was valued by nurses, but the ‘‘signing of the sheet’’ was the problematic issue and that the rounding protocol should be ‘‘paperless.’’ For example, nurses stated: I believe it is extremely important to round on your patients; however, I did not find that signing a paper proves that I am doing this effectively. It is just another task that I find I am unable to do because to me it is more important to talk to the patient and family than to look for the paper to sign. I often see my patients a lot more than once an hour. The concept of initialing a piece of paper is useless, I am in the room, but signing a paper is not a priority and it takes time I often don’t have.
Skill mix refers to having adequate staff to partner with RNs,1 as well as the effective collaboration between nurses and ancillary personnel. Skill mix was deemed important by nurses in this study and either facilitated the nurse in the performance of successful rounding or resulted in concern and frustration if nurses and patient care technicians (PCTs) were not collaborative. Nurses described: Oftentimes, I am tied up with blood transfusions, chemotherapy or other nurse intensive procedures. Sometimes I am unable to leave a room to assess other patients as frequently as I am comfortable with. Some of the PCTs are wonderful and pick up the slack, but others are not as engaged in the process, leaving much of the burden of responsibility on the RN. If PCTs would round together and work as a team to meet patient needs, it would allow nurses to get their meds more rapidly and do for the patient what they need to do. I may get delayed with confused or patients requiring complete care; then I’m not able to ensure that the PCTs are consistently rounding.
The above responses attest to the need for stronger delegation, collaboration, team building, and role clarity between nurses and ancillary personnel, whereby nurses facilitate PCTs’ understanding of their responsibilities. Recommendations regarding improvements for the rounding protocol were identified. Responses included suggestions to improve rounding practices through formal educational orientation and flexibility in determining nurse-patient ratios in managing patient assignments. Several recommendations pertained to the importance of PCTs and nurses working collaboratively in concert with others to enhance patient rounding.
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Discussion The findings in this study identify that these nurses value the practice of rounding, yet consistent with findings in the literature, rounding is controversial. Through rounding, nurses can be more present, address patient concerns, be proactive in the management of patient care, and provide for patient needs based on clinical assessment data. In the literature about patient rounding, far greater evidence supports rounding as a means to provide improved safety, decreased falls, and quiet nursing units through decreased call bell usage, leading to improved patient satisfaction. In this study, the nursing staff perceived hourly rounding to be beneficial to patients and families but significantly less beneficial to their own professional practice. The question remains, ‘‘Why do nurses in this study perceive the benefits of rounding for their patients, but they do not perceive the benefits of rounding for themselves?’’ Several explanations are offered. Although the quantitative data reflect relatively high mean scores and support the perception of rounding as positive, the qualitative data provide evidence regarding the challenges of rounding. The predominant challenges identified in this study were that assessment determines patient needs and is not dependent on rounding, increased documentation required by protocols is time intensive, patient acuity affects rounding, and skill mix issues affect the provision of rounding. Documentation of rounding was unfavorably viewed in this study. Nurses perceived that the protocol required additional documentation that was time-consuming, unnecessary, and frequently not completed in a timely and consistent manner. A possible factor for the above findings may be that the rounding record, although mandated, is not a permanent patient record and therefore may be perceived as less important and/or nonessential. Nurses identified patient acuity as an important factor influencing their perception of rounding. Nurses described how complex patients, necessitating additional and prolonged time, frequently altered their rounding protocol, leaving them concerned and frustrated about caring and rounding for other patients. A conflict may exist in that nurses recognize the need to adhere to standard protocols, but patients with high acuity can alter the structure of hourly rounding. Nurses felt staffing assignments must be determined by patient condition. Congruent with previous research,1 skill mix and communication were important factors for successful rounding in this study. Effective collaboration and communication between staff nurses and assistive personnel were deemed essential to ensure that patient
needs were being met. Although nurses in this study reported collaborative practices between themselves and PCTs, other nurses identified lack of communication with PCTs as a significant barrier to effective rounding. For hourly rounding to be most successful, it is essential that a milieu of collaborative, interactive practice exists among team members.
Implications for Nurse Executives Because nurses did not perceive rounding as a nurse benefit, an opportunity exists for nurse executives to engage staff in adapting hourly rounds into work flow redesign of the care delivery models. Through unit councils or committees, staff can explore perceptions and rationale for the lack of integration of hourly rounds into current care models. Leadership at each level can facilitate discussion with staff to linking the value of rounding and desired outcomes for patient care. Nurses’ perceptions of rounding were influenced by documentation requirements. Documentation of hourly rounds warrants the creative use of computer technology and automation to reduce the nurseperceived time constraints and inflexible processes of traditional paper documentation. Communication and delegation are 2 important aspects of the RN role. Nurse executives support the effective use of these skills for patient care by securing resources and facilitating the care delivery model. Hourly rounding is one tool that can improve the delegation skills of the RN with the team. Communication is formalized by the presence of the nurse with the patient when rounding, as well as with the PCT when sharing data gathered during rounds. Effective rounding impacts how patients and their family perceive nursing care. Scores for patient satisfaction including the hospital consumer assessment of healthcare providers and systems (HCAHPS) are publically recorded on Web sites for hospitals, impacting where patients go for care and hospital reimbursement. Rounding by the nurse, positively impacting patients’ experience scores, affects both these indicators. Limitations, Conclusions, Implications for Future Research Limitations of this pilot study include use of a nonprobability sample, a small sample size, and the bias that may exist with the low response rate. Few studies to date report statistical significance regarding rounding and improved patient and nurse outcomes; thus, additional research with larger samples and in diverse patient care settings will be essential to more fully understand the practice of patient rounding. This study indicates that rounding is perceived as valuable by nurses and of greater benefit to patients
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
87
than to the nurse and that substantial controversy regarding the practice remains among the nursing community. Further research is necessary to explore these issues. This initial use of the NPPRS was found to demonstrate sound psychometric properties. Additional study of the NPPRS is essential for psychometric validation and future modification of this tool.
Acknowledgments The authors acknowledge Maureen A Schneider, PhD candidate, MSN, MBA, RN, senior vice president of Clinical Program Development and chief nursing officer, and Kathleen Cummins, MS, RN, APN, ACNS-BC, vice president of nursing operations, for their support of this research initiative.
References 1. Halm M. Hourly rounds: what does the evidence indicate? Am J Crit Care. 2009;18(6):581-584. 2. Duffin C. Hourly ward rounds improve care and reduce staff stress. J Nurs Manag. 2010;17(7):6-7. 3. Bourgault A, King M, Hart P, Campbell M, Swartz S, Lou M. Circle of excellence: does regular rounding by nursing associates boost patient satisfaction? J Nurs Manag. 2008;39(11): 18-24. 4. Castledine G, Grainger M, Close A. Clinical nursing rounds part 3: patient comfort rounds. Br J Nurs. 2005;14(17):928-930. 5. Meade C. Round bounty. Mark Health Serv. 2007;27(1):23-27. 6. Tea C, Ellison M, Feghali F. Proactive patient rounding to increase customer service and satisfaction on an orthopaedic unit. Orthop Nurs. 2008;27(4):233-240. 7. Gurney C. Nursing rounds improve patient outcomes. Research news you can use: begin your practice on evidence. Available at www.nynsa.org/publications/report/2006/oct-nov/research .htm. Accessed March 3, 2010.
88
8. Woodard J. Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Clin Nurse Spec. 2009;23(4):200-206. 9. Davis L. A phenomenological study of patient expectations concerning nursing care. Holist Nurs Pract. 2005;19(3):126-133. 10. Detrick L, Bokovoy J, Stern G, et al. Dance of the call bells: using ethnography to evaluate patient satisfaction with quality of care. J Nurs Care Qual. 2006;21(4):316-324. 11. Meade C, Bursell A, Ketelsen L. Effects of nursing rounds on patients’ call light use, satisfaction, and safety. Am J Nurs. 2006; 106(9):58-69. 12. Sterman E, Gauker S, Krieger J. A comprehensive approach to improving cancer pain management and patient satisfaction. Oncol Nurse Forum. 2003;30(5):857-864. 13. Larson L. Restoring the relationship: the key to nurse and patient satisfaction. Trustee. 2004;57(9):9-14. 14. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF NURSING ADMINISTRATION
Nurses’ Perceptions of Patient Rounding Kathleen Neville, PhD, RN Kristen Lake, MS, RN, PCCN Danielle LeMunyon, MSN, APN, ANP-BC
Darilyn Paul, MS, APN, ACNS-BC, CCRN Karen Whitmore, MS, RN-BC, CWS
Objective: This descriptive pilot study explored hospital staff nurses’ perceptions toward the practice of patient rounding. Background: Rounding has re-emerged as a standard practice initiative among nurses in hospitals and has been associated with a decrease in call lights and falls, increased patient satisfaction and safety, and quieter nursing units. Regardless of these outcomes, controversy exists among nurses regarding rounding. Methods: The Nurses’ Perception of Patient Rounding Scale (K. Neville, unpublished manuscript, 2010) was developed to gain an understanding of nurses’ perceptions of rounding. Results: Nurses identified rounding as valuable and perceived hourly rounding to be beneficial to patients and families but significantly less beneficial to their own professional practice. Challenges to rounding as a practice include issues of documentation, patient ratios, and skill mix. Conclusion: Findings support the need for further research to address the challenges of patient rounding for nursing.
dearth of literature exists regarding the perceptions and attitudes of staff nurses toward rounding. Further research is needed to determine if nurses value the required practice and what factors influence their views. In addition, information is needed about factors that facilitate or serve as barriers in the provision of successful rounding. Somerset Medical Center (SMC), a 350-bed community medical center in suburban New Jersey, implemented a 6-month project of patient rounding on an oncology unit. Based on an identified need to improve patient satisfaction scores, decrease incidence of falls, decrease call bell use, and provide more effective pain management, a unit-based performance improvement project was formulated. Postproject evaluations revealed a decrease in patient falls and an improvement in patient satisfaction scores. Based on these outcomes, the concept of patient rounding was endorsed by nursing administration. The practice of hourly rounding, along with an hourly documentation record, was initiated on all nursing units. The postproject evaluation did not include an evaluation of the nurses’ perceptions regarding the practice change. The purpose of this descriptive exploratory pilot study was to gain an understanding of staff nurses’ values, beliefs, and attitudes toward the practice of patient rounding at this institution. Knowledge gained from this study will be used to evaluate the current practice and implement modifications as needed for further improvement in practice and nurse satisfaction if indicated.
Hourly rounds, defined as the intentional checking on patients at regular intervals,1 have re-emerged as a standard practice initiative among nurses in acute care settings. The literature is highly supportive of patient rounding as an appropriate, safe, and useful practice, yielding substantial nurse and patient benefits, yet debate among nurses remains.1,2 Although nurse managers are introducing hourly and 2-hour rounding on a national and international level,1 a Author Affiliations: Professor (Dr Neville), School of Nursing, Kean University, Union; Nurse Practitioner (Mss Lake and LeMunyon); Clinical Nurse Specialist (Mss Paul and Whitmore), Somerset Medical Center, Somerville, New Jersey. The authors declare no conflict of interest. Correspondence: Dr Neville, School of Nursing, Kean University, 1000 Morris Avenue, Union, NJ 07083 ([email protected]). DOI: 10.1097/NNA.0b013e318243365e
Literature Review Routine unit rounds have been practiced in both medicine and nursing. However, in recent years, nursing rounds have re-emerged as a valuable nursing practice with substantial research to support its return to practice nationwide.3 Recent evidence supports the use of rounding in improved patient outcomes; namely,
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
83
patient satisfaction, decreased call light use, and reduction of falls in hospitalized adult patients.3-6 A comprehensive clinical evidence review of studies on hourly rounding with level II evidence reported that 7 of 11 rounding studies resulted in decreased incidence of falls and 8 of 11 studies demonstrated increased levels of patient satisfaction.1 Evidence reveals that patients’ perception of excellence in care is based on the perceived availability and visibility of nurses, rather than the nurses’ level of knowledge or competence.7,8 Furthermore, hospital satisfaction is associated with the care that patients receive from nurses; that is, quality nursing care implies effective communication, kindness, being readily available to patients, making time for patients, effective pain management, timely response to call bells, and how well nurses are able to meet their needs.9-12 Uncertainty related to the illness condition, about symptoms, treatments, diagnosis, and other medical events is frequently experienced during hospitalization. This uncertainty can be further troubling when patients perceive the ambiguity of not knowing or are lacking the assurance about when a nurse will return to provide care during a shift. Routine rounding has been demonstrated to have a relationship with the perception of the nurses’ presence, patient safety, and less uncertainty in care by the patient.8 Rounding is successful when the visible presence of the nurses by hospitalized patients and/or families improves patient outcomes, including satisfaction. Evidence supports that rounding enhances the work environment for nurses in terms of improved patient care management and achievement of greater work efficiency. There is a strong correlation between nurse and patient satisfaction.11,13 Despite the increasing proliferation of rounding protocols in nursing practice, Halm1 identified 4 factors contributing to the debate regarding patient rounding. Formal scripting represents 1 factor because nurses perceive scripting as being rehearsed and thereby compromising nurses’ individual autonomy in their practice. Skill mix of healthcare personnel must be considered, as rounding success is contingent on nurses partnering with supportive personnel who possess highly effective communication skills to prevent nurses from becoming overtaxed in hourly assessments. Patient acuity level is another factor, which frequently necessitates the nurse to alter rounding protocols by remaining with acutely ill patients and omitting rounds on other less acute patients. In addition, Halm1(p584) addressed nurses’ extensive time demands of documentation and how the additional requirement of rounding documentation ‘‘may breed resentment and wavering adherence.’’
84
About the Study Methodology Using a convenience sampling approach, the volunteer participants consisted of registered nurses (RNs) on 5 separate adult medical-surgical inpatient units at SMC. Eligible participants were full-time, parttime, and per diem nurse employees. Charge nurses who engaged in rotational patient assignments were eligible to participate in the study. Agency personnel were excluded. A total of 150 questionnaires were distributed, with 49 (33%) participants returning the questionnaires. To reduce the response set bias of providing socially desirable responses, this study was anonymous. No identifying demographic data other than the unit in which nurses practiced were obtained. A team of 4 advanced practice RNs (APRNs) introduced the study on each unit, explained the purpose and nature of the study, and discussed anonymity provisions, voluntary participation, and the right to withdraw at any point during the study. Completed questionnaires were placed in an unmarked sealed envelope in a drop-off box located on each unit within a 4 week period. Completion of the questionnaire implied consent. Before data collection, institutional review board approval was obtained from both SMC and Kean University. A descriptive exploratory design was used. A newly constructed questionnaire, the Nurses’ Perceptions of Patient Rounding Scale (NPPRS) (K. Neville, unpublished manuscript, 2010), was developed to measure staff nurses’ perceptions of rounding practices. Face validity was first established by having staff nurses evaluate the tool for content and to determine the ability of the tool to measure nurses’ perception of their required rounding practice. Initial item development resulted in 60 items. Through focus groups with staff nurses, feedback resulted in the reduction of 18 items to eliminate redundancy and facilitate timely completion of the NPPRS. Content validity of the revised instrument was established by a panel of APRN experts. The resultant scale consists of 42 items in a 5-point Likert format, ranging from strongly disagree (1) to strongly agree (5), and can be completed in 10 minutes. Through principal components factor analysis with varimax rotation, 3 factors emerged. The NPPRS yields 3 subscales (communication, patient benefits, and nurse benefits) and 1 total score. The communication subscale consists of 15 items. Examples include ‘‘Rounding is a practice that facilitates improved verbal and nonverbal communication between patients and nurses’’ and ‘‘During rounding, I tailor my terminology to facilitate effective communication with patients and families.’’
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nurse benefits consist of 8 items. Examples include ‘‘Rounding is a constructive use of nurses’ time’’ and ‘‘The benefit of rounding is that it creates a quieter, less chaotic nursing unit.’’ Patient benefits consisted of 9 items and examples include ‘‘Rounding reduces patient and family uncertainty about their illness’’ and ‘‘Patients benefit from my visible presence every 2 hours.’’ Ten items reflect rounding schedules and cultural, ethical, and confidentiality issues regarding privacy and were subsequently not included in the 3 subscales. Because of the relevance to the practice of rounding, these items were retained in the NPPRS. Three additional qualitative items were addressed to gain more descriptive information on the practice of rounding and solicited information regarding suggestions and recommendations as well as identification of patient issues influencing rounding practices. Possible total scores on the NPPRS ranged from 42 to 210, with higher scores reflecting more positive responses toward rounding.
Results Using SPSS version 18 (SPSS, Inc, Chicago, Illinois), internal consistency of the NPPRS was established as evidenced by the strong support for the homogeneity of the items within this initial measurement (Table 1). Possible mean scores for the total perception of patient rounding ranged from 42 to 210. Total NPPRS scores across all units were reflective of favorable overall perceptions of rounding (Table 2), with no statistically significant differences noted among units. Possible mean scores on the communication subscale ranged from 16 to 80. Mean scores on the communication subscale (Table 3) were relatively homogenous among units and generally reflected that nurses valued the positive aspects of patient rounding on nurse-patient communication (mean [SD], 64.40 [3.84]). Similar to the total score, there were no significant differences among the various units on the subscale of communication. Because of the small sample size, the power of these statistical analyses was insufficient to detect difference. A power analysis revealed that a sample size of 135 subjects was needed to detect statistical significance.14
Table 1. NPPRS Reliability Coefficients Scale Subscale: communication Subscale: patient benefits Subscale: nurse benefits Total score: NPPRS
Cronbach ! .83 .87 .73 .92
Table 2. One-Way Analysis of Variance: Total Perception Score by Unit Unit
Mean
SD
Geriatric Orthopedic/neurology Hematology/oncology Surgery Medical-surgical Total
171.50 148.71 161.10 159.55 162.60 159.62
10.63 19.76 13.96 14.70 19.52 18.02
P = .35.
Items capturing nurses’ perceptions of the benefits of rounding were further dichotomized by the distinct subscales of nurse and patient benefits (Table 4). The possible range of scores for nurse benefits was 8 to 40. Scores were homogenous, ranging from 24.55 (4.61) to 29.50 (5.08). Among patient benefits, possible scores ranged from 9 to 45, and patient benefit scores reflected higher scores, ranging from 33.90 (5.17) to 38.57 (4.42). An independent t test revealed a statistically significant difference between nurse and patient perceived benefits. Nurses identified a real benefit for their patients, but not for themselves. Three open-ended items in the NPPRS were developed to explore nurses’ views regarding the practice of rounding. Although data saturation (when information provided by participants becomes repetitive and data collection can cease) did not determine the sample size in this study, the responses elicited below by nurse participants reflected consistently identified patterns or themes. Inquiry regarding nurses’ conceptualization of patient rounding was explored, and from the conceptual definitions provided, findings reveal that nurses consistently articulated a current perspective of the practice of rounding. For example, 2 participants stated: Rounding is checking to make sure all patients’ needs are met by assessing pain, comfort and by making sure call bells are within reach, belongings and drinks are nearby as well as safety needs are met.
Table 3. One-Way Analysis of Variance: Communication Score by Unit Unit
Mean
SD
Geriatrics Orthopedic/neurology Hematology/oncology Surgery Medical-surgical Total
64.40 56.42 57.25 57.66 59.40 58.42
3.84 7.87 6.00 5.95 9.68 6.81
P = NS.
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
85
Table 4. Nurse and Patient Benefits Unit
Nurse Benefit
Patient Benefit
Geriatric Orthopedic/ neurology Hematology/ oncology Surgery Medical-surgical Total
29.50 (5.08) 24.55 (4.61)
38.57 (4.42) 33.90 (5.17)
28.71 (3.60)
36.46 (3.52)
28.18 (4.14) 28.33 (8.61) 27.83 (5.03)
37.41 (4.60) 36.54 (8.43) 36.54 (5.06)
Values are presented as Means (SD). P G .001.
Rounding is visiting each of your patients each hour to see if there is anything they need or anything you can do for them.
Throughout numerous conceptualizations describing rounding, nurses consistently identified assessment as an integral and key component of nursing practice. Assessment was reported to be continuously conducted regardless of rounding protocol. A predominant theme was that rounding was perceived as an important and valued practice, as evidenced by the following statements: I believe rounding is an effective way to meet patient needs in a timely manner and to reduce call bell usage. Rounding is extremely important; to round on your patients should be part of every nurses’ practice.
Although the findings above support the practice of rounding, thematic analysis revealed that nurses’ strong sense of professional autonomy and identification of patient needs through assessment were the most important factors in determining the frequency and duration of time spent with patients. Findings revealed that a mandated rounding protocol minimized the sense of professional autonomy and selfdirected practice. It was felt that their presence at the bedside was oftentimes far more frequent than every 1 hour. Nurses reported challenges in the provision of rounding due to increased patient acuity levels, time constraints, and the nurses’ awareness of their need to be physically present. One nurse stated: Patients who have cancer sometimes need more of your time just to listen and be with them. Tonight, one of my patients asked me if dying is like getting a lethal injection they give in jail and will it hurt? I needed to stay.
Documentation of the rounding protocol was another predominant theme. Nurses reported that the
86
additional documentation required by the rounding protocol was burdensome and unnecessary. In some responses, it became evident that rounding was valued by nurses, but the ‘‘signing of the sheet’’ was the problematic issue and that the rounding protocol should be ‘‘paperless.’’ For example, nurses stated: I believe it is extremely important to round on your patients; however, I did not find that signing a paper proves that I am doing this effectively. It is just another task that I find I am unable to do because to me it is more important to talk to the patient and family than to look for the paper to sign. I often see my patients a lot more than once an hour. The concept of initialing a piece of paper is useless, I am in the room, but signing a paper is not a priority and it takes time I often don’t have.
Skill mix refers to having adequate staff to partner with RNs,1 as well as the effective collaboration between nurses and ancillary personnel. Skill mix was deemed important by nurses in this study and either facilitated the nurse in the performance of successful rounding or resulted in concern and frustration if nurses and patient care technicians (PCTs) were not collaborative. Nurses described: Oftentimes, I am tied up with blood transfusions, chemotherapy or other nurse intensive procedures. Sometimes I am unable to leave a room to assess other patients as frequently as I am comfortable with. Some of the PCTs are wonderful and pick up the slack, but others are not as engaged in the process, leaving much of the burden of responsibility on the RN. If PCTs would round together and work as a team to meet patient needs, it would allow nurses to get their meds more rapidly and do for the patient what they need to do. I may get delayed with confused or patients requiring complete care; then I’m not able to ensure that the PCTs are consistently rounding.
The above responses attest to the need for stronger delegation, collaboration, team building, and role clarity between nurses and ancillary personnel, whereby nurses facilitate PCTs’ understanding of their responsibilities. Recommendations regarding improvements for the rounding protocol were identified. Responses included suggestions to improve rounding practices through formal educational orientation and flexibility in determining nurse-patient ratios in managing patient assignments. Several recommendations pertained to the importance of PCTs and nurses working collaboratively in concert with others to enhance patient rounding.
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Discussion The findings in this study identify that these nurses value the practice of rounding, yet consistent with findings in the literature, rounding is controversial. Through rounding, nurses can be more present, address patient concerns, be proactive in the management of patient care, and provide for patient needs based on clinical assessment data. In the literature about patient rounding, far greater evidence supports rounding as a means to provide improved safety, decreased falls, and quiet nursing units through decreased call bell usage, leading to improved patient satisfaction. In this study, the nursing staff perceived hourly rounding to be beneficial to patients and families but significantly less beneficial to their own professional practice. The question remains, ‘‘Why do nurses in this study perceive the benefits of rounding for their patients, but they do not perceive the benefits of rounding for themselves?’’ Several explanations are offered. Although the quantitative data reflect relatively high mean scores and support the perception of rounding as positive, the qualitative data provide evidence regarding the challenges of rounding. The predominant challenges identified in this study were that assessment determines patient needs and is not dependent on rounding, increased documentation required by protocols is time intensive, patient acuity affects rounding, and skill mix issues affect the provision of rounding. Documentation of rounding was unfavorably viewed in this study. Nurses perceived that the protocol required additional documentation that was time-consuming, unnecessary, and frequently not completed in a timely and consistent manner. A possible factor for the above findings may be that the rounding record, although mandated, is not a permanent patient record and therefore may be perceived as less important and/or nonessential. Nurses identified patient acuity as an important factor influencing their perception of rounding. Nurses described how complex patients, necessitating additional and prolonged time, frequently altered their rounding protocol, leaving them concerned and frustrated about caring and rounding for other patients. A conflict may exist in that nurses recognize the need to adhere to standard protocols, but patients with high acuity can alter the structure of hourly rounding. Nurses felt staffing assignments must be determined by patient condition. Congruent with previous research,1 skill mix and communication were important factors for successful rounding in this study. Effective collaboration and communication between staff nurses and assistive personnel were deemed essential to ensure that patient
needs were being met. Although nurses in this study reported collaborative practices between themselves and PCTs, other nurses identified lack of communication with PCTs as a significant barrier to effective rounding. For hourly rounding to be most successful, it is essential that a milieu of collaborative, interactive practice exists among team members.
Implications for Nurse Executives Because nurses did not perceive rounding as a nurse benefit, an opportunity exists for nurse executives to engage staff in adapting hourly rounds into work flow redesign of the care delivery models. Through unit councils or committees, staff can explore perceptions and rationale for the lack of integration of hourly rounds into current care models. Leadership at each level can facilitate discussion with staff to linking the value of rounding and desired outcomes for patient care. Nurses’ perceptions of rounding were influenced by documentation requirements. Documentation of hourly rounds warrants the creative use of computer technology and automation to reduce the nurseperceived time constraints and inflexible processes of traditional paper documentation. Communication and delegation are 2 important aspects of the RN role. Nurse executives support the effective use of these skills for patient care by securing resources and facilitating the care delivery model. Hourly rounding is one tool that can improve the delegation skills of the RN with the team. Communication is formalized by the presence of the nurse with the patient when rounding, as well as with the PCT when sharing data gathered during rounds. Effective rounding impacts how patients and their family perceive nursing care. Scores for patient satisfaction including the hospital consumer assessment of healthcare providers and systems (HCAHPS) are publically recorded on Web sites for hospitals, impacting where patients go for care and hospital reimbursement. Rounding by the nurse, positively impacting patients’ experience scores, affects both these indicators. Limitations, Conclusions, Implications for Future Research Limitations of this pilot study include use of a nonprobability sample, a small sample size, and the bias that may exist with the low response rate. Few studies to date report statistical significance regarding rounding and improved patient and nurse outcomes; thus, additional research with larger samples and in diverse patient care settings will be essential to more fully understand the practice of patient rounding. This study indicates that rounding is perceived as valuable by nurses and of greater benefit to patients
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
87
than to the nurse and that substantial controversy regarding the practice remains among the nursing community. Further research is necessary to explore these issues. This initial use of the NPPRS was found to demonstrate sound psychometric properties. Additional study of the NPPRS is essential for psychometric validation and future modification of this tool.
Acknowledgments The authors acknowledge Maureen A Schneider, PhD candidate, MSN, MBA, RN, senior vice president of Clinical Program Development and chief nursing officer, and Kathleen Cummins, MS, RN, APN, ACNS-BC, vice president of nursing operations, for their support of this research initiative.
References 1. Halm M. Hourly rounds: what does the evidence indicate? Am J Crit Care. 2009;18(6):581-584. 2. Duffin C. Hourly ward rounds improve care and reduce staff stress. J Nurs Manag. 2010;17(7):6-7. 3. Bourgault A, King M, Hart P, Campbell M, Swartz S, Lou M. Circle of excellence: does regular rounding by nursing associates boost patient satisfaction? J Nurs Manag. 2008;39(11): 18-24. 4. Castledine G, Grainger M, Close A. Clinical nursing rounds part 3: patient comfort rounds. Br J Nurs. 2005;14(17):928-930. 5. Meade C. Round bounty. Mark Health Serv. 2007;27(1):23-27. 6. Tea C, Ellison M, Feghali F. Proactive patient rounding to increase customer service and satisfaction on an orthopaedic unit. Orthop Nurs. 2008;27(4):233-240. 7. Gurney C. Nursing rounds improve patient outcomes. Research news you can use: begin your practice on evidence. Available at www.nynsa.org/publications/report/2006/oct-nov/research .htm. Accessed March 3, 2010.
88
8. Woodard J. Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Clin Nurse Spec. 2009;23(4):200-206. 9. Davis L. A phenomenological study of patient expectations concerning nursing care. Holist Nurs Pract. 2005;19(3):126-133. 10. Detrick L, Bokovoy J, Stern G, et al. Dance of the call bells: using ethnography to evaluate patient satisfaction with quality of care. J Nurs Care Qual. 2006;21(4):316-324. 11. Meade C, Bursell A, Ketelsen L. Effects of nursing rounds on patients’ call light use, satisfaction, and safety. Am J Nurs. 2006; 106(9):58-69. 12. Sterman E, Gauker S, Krieger J. A comprehensive approach to improving cancer pain management and patient satisfaction. Oncol Nurse Forum. 2003;30(5):857-864. 13. Larson L. Restoring the relationship: the key to nurse and patient satisfaction. Trustee. 2004;57(9):9-14. 14. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.
JONA Vol. 42, No. 2 February 2012
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
