Jeri Berryman1. 1. Nursing Excellence, Columbus, OH, USA.
Abstract
BACKGROUND: The Centers for Medicare & Medicaid Services requires hospitals to meet rigorous patient satisfaction requirements for reimbursement. One metric used for patient satisfaction is call light responsiveness within a unit. AIMS: To meet target call light responsiveness benchmarks at a 45-bed telemetry, medical-surgical nursing unit within a Magnet® designated hospital. METHODS: An evidence-based practice (EBP) project model was utilized. The chief nursing officer worked with an EBP nurse mentor. A PICOT (Population, Intervention, Comparison, Outcome, and Time) question was developed to guide the literature search. Literature was critically appraised, and a resulting intervention was established. Nurse educators taught the unit nurses how to perform the intervention, and intervention integration was assessed via direct observation. Call light responsiveness data were collected to assess whether targets were met. RESULTS: Five articles were deemed as applicable to the PICOT question, and the best evidence determined that using the 4Ps (pain, presence, "potty," and positioning) during structured registered nurse (RN) care rounding every 2 h improved patient outcomes. After RN education and implementation, hospital call light responsiveness began to improve. LINKING EVIDENCE TO ACTION: Rounding without intention increases RN workload and does not result in improved patient outcomes or a satisfied patient. RN rounding every 2 h is effective and efficient when done with intention (i.e., adhering to the 4Ps). RN patient rounds done every 2 h with intention improved patient satisfaction and other patient outcomes such as a decrease in call light usage.
BACKGROUND: The Centers for Medicare & Medicaid Services requires hospitals to meet rigorous patient satisfaction requirements for reimbursement. One metric used for patient satisfaction is call light responsiveness within a unit. AIMS: To meet target call light responsiveness benchmarks at a 45-bed telemetry, medical-surgical nursing unit within a Magnet® designated hospital. METHODS: An evidence-based practice (EBP) project model was utilized. The chief nursing officer worked with an EBP nurse mentor. A PICOT (Population, Intervention, Comparison, Outcome, and Time) question was developed to guide the literature search. Literature was critically appraised, and a resulting intervention was established. Nurse educators taught the unit nurses how to perform the intervention, and intervention integration was assessed via direct observation. Call light responsiveness data were collected to assess whether targets were met. RESULTS: Five articles were deemed as applicable to the PICOT question, and the best evidence determined that using the 4Ps (pain, presence, "potty," and positioning) during structured registered nurse (RN) care rounding every 2 h improved patient outcomes. After RN education and implementation, hospital call light responsiveness began to improve. LINKING EVIDENCE TO ACTION: Rounding without intention increases RN workload and does not result in improved patient outcomes or a satisfied patient. RN rounding every 2 h is effective and efficient when done with intention (i.e., adhering to the 4Ps). RN patient rounds done every 2 h with intention improved patient satisfaction and other patient outcomes such as a decrease in call light usage.
Hospitals in the United States must meet rigorous patient satisfaction metrics to satisfy the Centers for Medicare & Medicaid Services requirements. One Magnet® hospital in our large health system, a 45‐bed nursing unit, was challenged with meeting target call light responsiveness benchmarks (Table 1). The chief nursing officer contacted the system’s evidence‐based practice (EBP) nurse mentor to help find a solution to this dilemma. The nursing unit setting is a telemetry, medical–surgical nursing unit that recently hired a large number of new registered nurses (RNs). Their current practice was that the nursing leadership completed patient intentional rounding 90% of the time. Leadership rounds included toileting and pain assessment at 5 a.m. and 5 p.m. to decrease call light usage during shift change. However, the nurse responses to call light statistics continued to decline. The staff nurses were generally in the patient rooms at a minimum of every 2 h, but no structured patient care rounding was noted. The health system’s nursing strategic plan values every nurse as a leader and is committed to the use of EBP to improve the health of those they serve. The nursing leadership strategic plan supports that problem‐solving is done best when it is closest to and completed with the patient.
PICOT (POPULATION, INTERVENTION, COMPARISON, OUTCOME, AND TIME) QUESTION
In hospitalized patients, how does hourly rounding compared with bi‐hourly rounding affect patient satisfaction?
SEARCH STRATEGY
Search terms included (Hospitalized patients OR inpatients OR patients OR admitted) AND (hourly rounding OR hourly checks OR rounds) AND (bi‐hourly OR routine OR every two hours) AND (patient satisfaction OR patient experiences OR patient perceptions OR patient attitudes). CINAHL full text, MEDLINE full text, and Healthsource: Consumer Edition databases resulted in 208 articles returned. Filters applied in these databases were peer‐reviewed (66 articles), date limited to 2009–2019 (52 articles), English‐language only (52 articles), and United States (23 articles). Based upon the setting and patient population identified in the PICOT question, four articles were relevant, and three articles were applicable. The Cochrane Database resulted in zero articles. The PubMed database resulted in 46 articles. Filters for PubMed were free full text (19 articles) and publication dates limited to 2009–2019 (17 articles). From these articles, three were found to be relevant, and two were noted as applicable based upon the setting and patient population identified in the PICOT question.
CRITICAL APPRAISAL OF THE EVIDENCE
The literature synthesis revealed that intentional RN rounding every 2–3 hours significantly impacted patient satisfaction. The team discovered that what occurs and how patients perceive the presence of the nurse doing the rounding mattered (Sims et al., 2018). Our team further discovered that the uptake of the structured use of the 4Ps (pain, presence, “potty,” and positioning) by the RN every 2 h improves patient outcomes (Woodard, 2009). The patient outcomes impacted were an increase in patient satisfaction scores, the patient’s perception of quality nursing care, pain management, and a measurable decrease in call light use and falls.
INTEGRATION OF THE EVIDENCE WITH CLINICAL EXPERTISE AND PATIENT PREFERENCES
The nursing leadership completed 16 direct observation audits of RN rounding (both day and night shift) to determine current practice. The key stakeholders planned implementation strategies to promote uptake of every 2‐h RN rounds. These rounds focused on the 4Ps (Woodard, 2009). The stakeholders used simulation to teach the best practices in a convenient staff space on the unit, thus permitting the nurses to attend the simulation at their convenience.The nurse educator used the simulated environment to promote the knowledge, skills, and attitudes needed for successful practice change (Field, Booth, Ilott, & Gerish, 2014). The nurse leaders used a variety of evidence‐based implementation strategies to support the change in rounding behaviors. These leaders shared data and EBP progress daily on the unit’s Key Process Indicator board (Richardson & Richardson, 2016). Progress was also discussed at staff meetings and huddles during all shifts. Nurse leaders posted flyers in strategic locations to keep the care goals in front of the team. As nurse leaders made rounds, they used just‐in‐time coaching techniques to assess the nurses’ understanding and uptake of the 4Ps intervention. Coaching was used to role model the implementation of 4Ps in real time.
OUTCOMES
In June 2020, rounding with the 4Ps intervention began and, consistent with what is reported in the literature, call light responsiveness began to improve (Table 2). Leaders celebrated by distributing Hershey Kisses and Hugs drinks to signify a job well done while honoring COVID‐19 restrictions on the nursing unit. Ongoing sustainability strategies for this best practice include strategic communication between the nurse leaders and RNs.
Table 2
Pre‐ and Post‐EBP Uptake Data
Press Ganey
Pre‐intervention Nov. 19
Pre‐intervention May 2020 (COVID delay)
Post‐intervention June 20
Post‐July 20
Post‐August 20
Post‐Sept. 20
Post‐Oct. 20
Call light Responsiveness
75.8%
65.9%
77.1%
81.8%
100%
81.3%
82.4%
Pre‐ and Post‐EBP Uptake Data
DISSEMINATION
Plans are in place to disseminate this EBP project at the local hospital Nursing Grand Rounds and at the System Nurse Practice Advisory Council to encourage lateralization across the care sites. A virtual poster presentation was presented at the STTI: Rho‐Nu‐at‐Large Chapter #419 Fall Scholarly Event. Lastly, the organization is considering showcasing this EBP project at an upcoming Magnet® conference.Rounding done without intention increases RN workload that does not result in improved patient outcomes or a satisfied patient.Hourly rounding on a high fall risk patient is current practice; however, every 2‐hour RN rounding is effective and efficient if done with intention, that is, 4Ps.RN patient rounds done every 2 h with intention improve patient satisfaction and other patient outcomes such as decrease in call light usage.