The Effects of Intentional Nurse Rounding on Patient...

Running head: THE EFFECTS OF INTENTIONAL NURSE ROUNDING ON 1

The Effects of Intentional Nurse Rounding on Patient Satisfaction and Call Bell Usage: An

Integrative Literature Review

Rachel Martinko

University of Central Florida

THE EFFECTS OF INTENTIONAL NURSE ROUNDING ON 2

Abstract

Providing 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 round


The Effects of Intentional Nurse Rounding on Patient Satisfaction and Call Bell Usage: An

Integrative Literature Review

Significance

The 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.

Methods

The 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).

Results

Search Results

A 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 Satisfaction

All 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 Usage

Five 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 1

Primary Study,

Country

Design, Level of Evidence, Sample Characteristics of Intervention Results

Mitchell et al. (2014), United States of America

‘Systematic Review’Level I16 published studies reviewed 15 pre-post studies 1 nonrandom studiesTotal sample size n=9493

No 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

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


rounding at night.2 studies implemented 2-hourly rounds.1 used a Practice Partnership Model of care, which used 1-2 hourly rounds.

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=569

Pre-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 requestpre- 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 group

Nurses 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

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 +/- 8.8


usual, using task-oriented nursing care.Patient Satisfaction with Nursing Care Quality Questionnaire was completed on the second and fifth days of hospitalization.

P<0.001

Saleh, 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 nationwide

Hospital 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

Call light usageHourly Rounds:Pre=13,216Post=8,315P=0.007Two-Hour Rounds:Pre=14,201Post=11.507P=0.06Control:Pre=13,494Post=13,106

Patient satisfactionHourly Rounds:Pre= 79.9Post= 91.9(t=736.58, p=0.001)


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.

Two Hour Rounds:Pre= 70.4Post= 82.1(t=657.11, p=0.001)Control: No data listed

Olrich, 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 study

Hourly 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=0.383

Limitations of the Evidence

This 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).

Recommendations

The 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 Research

It 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).


References

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http://dx.doi.org/10.1111/j.1440172X.2011.01938.x

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