JBI Database of Systematic Reviews & Implementation Reports 2016;14(1):248-267

Purposeful and timely nursing rounds: a best practice

implementation project

Juli F Daniels1

1. UCSF JBI Center for Synthesis and Implementation: an Affiliate Center of the Joanna Briggs Institute

Corresponding author:

Juli F Daniels

[email protected]

Key dates
Commencement date: September 24, 2014

Completion date: March 23, 2015

Executive summary
Background

Purposeful and timely rounding is a best practice intervention to routinely meet patient care
needs, ensure patient safety, decrease the occurrence of patient preventable events, and
proactively address problems before they occur. The Institute for Healthcare Improvement (IHI)
endorsed hourly rounding as the best way to reduce call lights and fall injuries, and increase
both quality of care and patient satisfaction. Nurse knowledge regarding purposeful rounding
and infrastructure supporting timeliness are essential components for consistency with this
patient centred practice.

Objectives

The project aimed to improve patient satisfaction and safety through implementation of
purposeful and timely nursing rounds. Goals for patient satisfaction scores and fall volume were
set. Specific objectives were to determine current compliance with evidence-based criteria
related to rounding times and protocols, improve best practice knowledge among staff nurses,
and increase compliance with these criteria.

Methods

For the objectives of this project the Joanna Briggs Institute’s Practical Application of Clinical
Evidence System and Getting Research into Practice audit tool were used. Direct observation of
staff nurses on a medical surgical unit in the United States was employed to assess timeliness
and utilization of a protocol when rounding. Interventions were developed in response to
baseline audit results. A follow-up audit was conducted to determine compliance with the same

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criteria. For the project aims, pre- and post-intervention unit-level data related to
nursing-sensitive elements of patient satisfaction and safety were compared.

Results

Rounding frequency at specified intervals during awake and sleeping hours nearly doubled. Use
of a rounding protocol increased substantially to 64% compliance from zero. Three elements of
patient satisfaction had substantive rate increases but the hospital’s goals were not reached.
Nurse communication and pain management scores increased modestly (5% and 11%,
respectively). Responsiveness of hospital staff increased moderately (15%) with a significant
sub-element increase in toileting (41%). Patient falls decreased by 50%.

Conclusions

Nurses have the ability to improve patient satisfaction and patient safety outcomes by utilizing
nursing round interventions which serve to improve patient communication and staff
responsiveness. Having a supportive infrastructure and an organized approach, encompassing
all levels of staff, to meet patient needs during their hospital stay was a key factor for success.
Hard-wiring of new practices related to workflow takes time as staff embrace change and
understand how best practice interventions significantly improve patient outcomes.

Keywords

Nursing rounds; patient satisfaction; HCAHPS; patient safety; patient falls

Background
The mission of many hospitals is to provide compassionate and innovative care for the whole person.
Patient satisfaction and patient safety outcomes are viewed by hospital leadership as crucial
determinants of success for meeting this mission. Reimbursement to the organization is also directly
related to performance measures, such as patient satisfaction4 and patient safety initiatives.5

Gnida6 reported that each year, the Centers for Medicare and Medicaid Services (CMS) withhold
money from hospitals, with the option to earn some of it back based on the five domains (efficiency – 25
%, HCAHPS – 25 %, clinical care process – 5%, clinical care outcomes – 25%, and safety – 20 %). The
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) surveys are surveys
conducted to determine the hospital’s reimbursement scores. There are 12 core measures which
account for 70% of the weight while the other 30% are eight composited measures from HCAHPS.7 The
eight HCAHPS measures include nursing communication, doctor communication, responsiveness of
staff, pain management, communication of medications, discharge information, cleanliness and
quietness of hospital environment and overall rating.

Olrich, Kalman and Nigolian reported with their 2012 review of literature that 25% of falls result from
falling out of bed and approximately 30% of these falls result in injury with 4-6% listed as serious.
Injuries included either fracture or death. In addition, hospital costs for patients injured during falls are
US$4200 higher than for patients who do not fall.5 The Institute for Healthcare Improvement (IHI), in
2012, considered hospital fall injuries “never events” associated with morbidity and mortality, and
endorsed every one to two hourly rounding for the purposes of pain relief, toileting and positioning.2

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Multiple studies have been conducted in the past six years to assess the effectiveness of nursing
rounds on outcomes such as call light use, patient satisfaction and patient safety. Patient rounding has
shown to have positive impacts on decreasing call light usage1,4,5,9,11,16,19,20,22, decreased fall
rates1,4,5,12,16,19,20,22, decreased skin breakdown rates4,19, and increased patient satisfaction, with nursing
care resulting in improved patient satisfaction scores.1,4,5,7-20,22 A 2014 systematic review by Mitchell,
Lavenberg, Trotta, and Umscheid revealed there was little consistency in how results of hourly rounds
were measured.18 Their review did show there was moderate strength evidence that hourly rounding
programs improved patient perceptions of nursing responsiveness and reduced falls, as well as call
light use. Review of structure, process, and outcomes by Rondinelli, Ecker, Crawford, Seelinger, and
Omery revealed that rounding behaviors, a library of tools, and patient satisfaction were common
themes associated with hourly rounding implementation.19

Purposeful and timely rounding is a best practice intervention used to meet basic patient care needs
routinely, ensure patient safety, decrease the occurrence of patient preventable events, and proactively
address problems before they occur.1 The IHI endorsed hourly rounding in 2009 as the best way to
reduce call lights and increase both the quality of care and the satisfaction of patients.2 Prior to that,
Studer found hospitals that proactively instituted rounding increased patient satisfaction by 8.9%. 22

Rounding methods using protocols, such as 12 Steps or 4Ps (pain, personal needs, positioning and
placement) can be used to standardize practice. The Joanna Briggs Institute (JBI) Evidence Summary,
Nursing Rounds: Clinician Information, describes the following best practice recommendations for
purposeful and timely hourly rounding25:

1. The hourly or two-hourly nursing rounds are recommended in hospital to reduce call lights, falls,
and increased patient satisfaction.
2. The “12 step” or “4P” protocols can be used while performing nursing rounds.

However, multiple barriers and challenges to implementing or sustaining purposeful and timely rounds
were also noted in the literature. These included staffing fluctuations based on daily census, patient
acuity levels, staff buy-in, competing priorities and tasks, lack of a sense of ownership, knowledge
regarding the use of a protocol, no visible cues to remind staff of rounding processes, understanding the
link of rounding to patient safety, sustainability of the rounding process, and leadership support to
facilitate rounds when unit activities prevented staff from performing this function. 4,12,14,15,17,19

This implementation project was conducted on an adult medical surgical unit at a tertiary care facility.
The unit provides care to oncology and bariatric patients and had experienced a decrease in patient
satisfaction as well as patient safety scores, compared to other units in the hospital. Although nursing
rounds was an expected patient care activity to be performed and documented in the patient record,
standardized times and processes based on best practice had not been a priority for this unit’s staff.
Additionally, the unit was experiencing staffing challenges and leadership change. The infrastructure
supporting rounds was, therefore, not optimal.

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Aim and objectives

The project aimed to improve patient satisfaction and safety on a medical surgical unit through
implementation of purposeful and timely nursing rounds. The specific nurse-influenced components of
patient satisfaction focused on were nurse communication, responsiveness of hospital staff and pain
management. The specific nursing-sensitive safety parameter trended was the number of patient falls
on this unit.

The project objectives were to:

 Determine current compliance with evidence-based criteria regarding timeliness and

purposefulness of nursing rounds.
 Improve knowledge regarding best practice interventions amongst staff nurses regarding
nursing rounds.
 Improve compliance with evidence-based criteria regarding timeliness and purposefulness of
nursing rounds.

Methods
This project was conducted on a 28-bed medical surgical unit at a tertiary care non-academic
faith-based facility in the United States. The setting was chosen because patient satisfaction and patient
safety scores had decreased and the processes of nursing rounds (times and purposefulness) were not
standardized. A mixed method approach was utilized to assess and evaluate the test of change.

Direct observation was employed to assess nurses’ timeliness and use of a protocol when rounding. In
addition, bedside nurses and nursing directors were surveyed, using tools developed by Blakley, Kroth,
and Gregson to determine respondents’ perspectives on the impact of nursing rounds on delivery of
care in the unit9 (see Appendix I). Interventions were developed based on baseline data results and
post intervention data was collected on the same criteria. Statistical analysis was completed to
determine the significance of study results.

Additionally, for future and comparative purposes, collection of pre-implementation data from another
like unit was planned. These results will be reported at a later date.

This implementation project used the Joanna Briggs Institute Practical Application of Clinical Evidence
System (JBI-PACES) and Getting Research into Practice (GRiP) audit and feedback tool. The
JBI-PACES and GRiP framework for promoting evidence based health care involves three phases of
activity:

1. Establishing a team for the project and undertaking a baseline audit based on criteria informed
by the evidence.
2. Reflecting on the results of the baseline audit and designing and implementing strategies to
address non-compliance found in the baseline audit informed by the JBI GRiP framework.
3. Conducting a follow-up audit to assess the outcomes of the interventions implemented to
improve practice, and identifying future practice issues to be addressed in subsequent audits.

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Ethical considerations
The project was registered as a quality improvement activity within the hospital and received
Institutional Review Board approval from Chamberlain College of Nursing.

Phase 1: Stakeholder engagement; quality and safety indicators; and baseline audit

In December 2014, hospital- and unit-based stakeholders were identified and meetings were
with the nursing leadership team and nursing staff to collect baseline data regarding the most recent
patient satisfaction and patient safety scores for the medical surgical unit (intervention unit) and
telemetry step down unit (control unit). Stakeholder positions included two medical surgical day-shift
and night-shift nurses, the director of professional practice, the administrative director of medical
surgical services, the medical surgical professional development specialist, the nurse manager of the
telemetry step-down unit, the regulatory and compliance manager, the performance improvement
coordinator, the director of service excellence, the vice president for patient care services and a nurse
researcher.

The Hospital Consumer Assessment of Healthcare Providers (HCAHP) report was used to identify
specific quality improvement goals for the project aim of increased patient satisfaction. Achievement of
the 75th percentile was set by the group as the benchmark. As displayed in Figure 1, the three HCAHP
categories directly related to outcome measurements for nursing rounds were: a) nurse
communication (achieve 82% score); b) responsiveness of hospital staff (achieve 73% score); and c)
pain management (achieve 74% score).

For the project aim of improved patient safety, the fall reports from the National Database of Nursing
Quality Indicators (NDNQI) were used. The identified goal was to reduce the amount of falls from
current baseline. Staff submitted monthly falls information to NDNQI based on fall events submitted to
the hospital’s incident/event reporting system.

75th percentile HCAHPS goals

84
82
80
78
76
74
72
70
68
Nurse Communication Responsiveness of Hospital Staff Pain Management

Figure 1: HCAHPS percentile goals

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Unit staff meetings were also conducted to discuss the topic of Nursing Rounds. Nurse champions on
day shifts and night shifts were identified by the nursing leadership team to promote the “hard wiring” of
accountability for the evidence-based interventions that staff established. An external researcher
conducted direct observations of unit staff to collect baseline data on the following three audit criteria:

1. Hourly nursing rounds are conducted at a stipulated time during awake hours.
2. Hourly or 2 hourly nursing rounds are conducted during sleeping hours.
3. A protocol is used by nurses when conducting rounds.

Table 1 contains the evidence informed audit criteria used in the project (baseline and follow up audit)
together with a description of the sample and approach to measuring compliance with best practice for
each audit criterion.

Table 1: Audit criteria, sample, and measurement criteria

Audit criterion Sample Method used to measure percent
compliance with best practice

1. Hourly nursing rounds 32 rounding sessions on day Direct observation of the time the
are conducted at a shift by nursing staff on a round started
stipulated time during medical surgical unit
awake hours

2. Hourly or 2 hourly 12 rounding sessions on night Direct observation of the time the
nursing rounds are shift by nursing staff on a round started
conducted during medical surgical unit
sleeping hours

3. A protocol is used by 44 rounding sessions on day Direct observation of:

nurses when shift and night shift by nursing  Verbal use of the “4P script”
conducting rounds staff on a medical surgical unit  Completion of each “P” of the
4P rounding method (pain,
position, potty [urination],
possessions)

The baseline audit started on September 24, 2014 and ended on March 23, 2015.

Concurrent with post-intervention audit criteria collection, the nurse researcher asked unit nurses and
the nursing manager/director post intervention survey questions. Qualitative questions were derived
from an article published by Blakley, Kroth and Gregson and can be found in Appendix I.9 A more in
depth discussion of the qualitative trends from this study will be published at a later date.

Phase 2: Design and implementation of strategies to improve practice (GRiP)

One month later, a staff meeting was held with the nursing leadership and medical surgical unit nurses
to discuss the results of the baseline data collected on the three criteria, as well as to identify barriers,
strengths, resources and outcomes for nursing rounds. Patient perspectives of care, using the HCAHP
scoring system, were used to communicate patient satisfaction results. Patient safety outcomes were
also disseminated using the NDNQI fall report results.22

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Nurses identified initial barriers to rounding which primarily focused on staffing, new unit management,
and lack of knowledge of best practice interventions. Additionally, as a strategy to create buy-in, staff
divided into small groups and journal articles on nursing rounds were distributed to each group for
them to review. Nurses reported back to the group the key interventions they felt could be integrated
into their current nursing practice activities.

Interventions for unit support processes

To address the staffing barrier, the nursing unit manager and director reviewed a three-month staffing
pattern and patient assignment log. They identified gaps to determine additional full-time equivalents
(FTEs) needed to address this concern. This information was presented to the Vice President for
Nursing to obtain approval to hire the needed FTEs. The unit manager and director then worked with
the human resources department to advertise, interview and hire experienced nurses to fill this gap.

While addressing new unit management to the organization, it was agreed the processes of
implementing purposeful and timely nursing rounds should not be delayed. The unit manager and
director actively engaged with the unit charge nurses to evaluate daily unit staffing and acuity, as well
as promote the hardwiring of intentional nursing rounds with staff on all shifts. In addition, the new
nurse manager created a lead nursing assistant position to fill potential staff communication gaps
between nurses and nursing assistants when high acuity situations occur. The nursing assistant would
meet with each nurse during the shift to determine if the staff nurse assignment had changed or patient
care needs had increased. This information, in turn, would be relayed to the assigned nursing assistant
to ensure hourly rounds continued seamlessly and patient care needs were met.

At the hospital’s administrative level, the Vice President of Nursing disseminated project information
and progress updates to other healthcare providers in the organization. This strategy generated quality
feedback and maintained leadership support for the project.

Interventions for nurse education

A multi-pronged approach was used to address lack of knowledge on best practice interventions for
nursing rounds. First, a journal club was formed and articles on the topic were circulated. Next, a
journal club/quality improvement (QI) bulletin board on the unit was developed to collect best practice
interventions on nursing rounds. The board content included monthly updates comparing compliance
with the three audit criteria to patient satisfaction and safety data outcomes. A GRiP matrix table was
also posted. Additionally, to keep rounding at the forefront of patient care, updated monthly data
collection results were disseminated to key stakeholders during the daily unit shift huddles.

Staff stated that when they rounded, they did assess for most of the “4Ps” (pain, position, potty,
possessions) but did not communicate to the patient and family what they were actually doing.
Therefore, as a third strategy, a script was developed. The purpose of the script was for staff to use a
standardized communication tool at specific times during the patient’s hospitalization: while completing
the admission assessment; during rounds throughout the patient’s hospital stay; and upon discharge.
Script cards, as displayed in Appendix II, were developed from Studer resources and placed on each
computer in each patient’s room to provide visual cues to staff as a reminder to ask about the 4Ps.24
(Also it was planned for this script and the 4Ps to be added to the nursing rounds documentation
section in the electronic health record.)

Initial and on-going support of rounding was also provided by the unit’s nurse educator and nurse
champions. The educator created a presentation as part of staff re-education to “hourly rounding”.

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Both the champions and educator reinforced with staff the essential components of the scripting used
to explain hourly rounding to the patients and families during the admission process and throughout
their length of stay.

Phase 3: Follow-up audit post implementation of change strategy

In the third month of the project, a follow-up audit was conducted using the same evidence-based audit
criteria as those used in the baseline audit. A total of 32 observations were completed on the day shift
and 12 on the night shift for timeliness of nursing rounds. The 4P protocol script that nurses developed,
as one of the interventions, was assessed on both day shift and night shift observations.

Results
Phase 1: Baseline audit

The baseline compliance with the audit criteria was entered into JBI-PACES. As can be seen in Figure
2, baseline data for Criterion 1 revealed 34% compliance (11 out of 32 observations) with hourly
rounds occurring on the day shift (considered the awake hours). For Criterion 2 there was 42%
compliance (five out of 12 observations) with at least every two-hour rounds occurring on the night shift
(considered the sleeping hours). Use of a protocol was not observed for either day or night shift
rounds, which represents 0% compliance for Criterion 3.

Figure 2: Baseline compliance with best practice for audit criteria (%)
Audit criteria legend and sample:

1. Hourly nursing rounds are conducted at a stipulated time during awake hours. (N=32)
2. Hourly or 2 hourly nursing rounds are conducted during sleeping hours. (N=12)
3. A protocol is used by nurses when conducting rounds. (N=44)

Baseline HCAHPS scores for the unit for October 2014 were obtained and are displayed in Figure 3.
The HCAHPS survey categories directly related to nursing rounds are: a) nurse communication; b)
responsiveness of hospital staff; and c) pain management. Each category contained sub-component
survey questions/scores.

For the category of communication with nurses, the pre-implementation score reached 64%.
Sub-component scores for this category included: listen carefully (58%) and explain things (63%). The
score for responsiveness of hospital staff was 39% with sub-component scores of 45% for call light and
24% for bedpan or bathroom. The pain management score was 62%. Its sub-component scores were
similar, with pain controlled at 56% and pain help at 68%.

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90
80
70
60
50
Baseline Data
40
75th Percentile HCAHP Goals
30
20
10
0
Nurse communication Responsiveness of Pain management
hospital staff

Figure 3: Baseline HCAHP scores

The baseline fall data for each of the pre-implementation months presented in Table 2 demonstrated a
slight rise in the amount of falls on the unit. The average was two falls.

Table 2: NDNQI data – medical surgical unit patient falls volume per month

Pre-intervention Pre-intervention Pre-intervention

1 3 2

Phase 2: Strategies for Getting Research into Practice (GRIP)

As can be seen in the GRIP Matrix (Table 3), each barrier was addressed with multiple interventions.

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Table 3: GRIP matrix

Barrier Strategy Resources Outcomes
Staffing Nursing unit manager Staffing schedules Four nurses were hired and
and director will Patient assignment completed orientation prior
review a three-month logs for last three to the March 3, 2015
staffing pattern and months follow-up audit cycle.
identified gaps to
determine additional
FTEs needed
Vice President for
Nursing will approve
budget for hiring
needed FTEs
Unit manager and
director then will work
with human resources
department to
advertise, interview,
and hire experienced
nurses
New unit Unit manager will Charge nurse New unit manager presence
management actively engage with availability at the on the unit has yielded
the unit charge nurse beginning of each positive comments from
to evaluate the daily shift nursing staff to build
unit acuity Manager following teamwork and stabilize unit
Unit manager will audit criteria for daily functions
assist in performing rounding on the unit
nursing rounds when
needed
Lack of knowledge A journal club will be Nursing educator to Timeliness of day shift
of best practice formed and articles on obtain materials for rounding compliance
interventions the topic will be the board increased 25%; night shift
circulated to nursing rounding increased 33%,
staff and using a protocol when
A journal club/QI Journal club team to rounding increased 64%
board was developed post articles on
to collect best practice nursing rounds
interventions on the
topic of nursing
rounds
A script was
developed and put on Nurse educator to
a reminder card by update compliance
each computer for with the three audit
staff to use as a criteria

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communication tool
on patient admission
assessment, during
rounds while the
patient was in the
hospital, and upon
discharge
The script and the 4Ps
added to the nursing
rounds documentation
section in the
electronic health
record

Phase 3: Follow-up audits

Results of follow-up audits for the three types of data, compared to the baseline results, are displayed
in Figures 4, 5 and 6. First, for the JBI criteria, as seen in Figure 4, there were moderate improvements
in compliance for timeliness of rounds, as well as use of a protocol. Timeliness of day shift (awake
hours) rounding nearly doubled (42%), increasing from 34% to 59%. Night shift (sleeping hours)
rounding had a similar result (44%), increasing from 42% to 75%. As expected, use of a protocol when
rounding increased to 64% from 0%.

Figure 4: Compliance with best practice audit criteria in follow up audit compared to baseline
audit (%)

Audit criteria and post-audit sample:

1. Hourly nursing rounds are conducted at a stipulated time during awake hours. (N=32)

2. Hourly or 2 hourly nursing rounds are conducted during sleeping hours. (N=12)

3. A protocol is used by nurses when conducting rounds. (N=44)

Secondly, for patient satisfaction outcomes, the scores for three HCAHP categories are presented in
Figure 5 and the sub-categories in Table 4. Overall the post-intervention HCAHPS scores increased
somewhat. Baseline communication with nurses scores moderately increased from 64% (with
sub-categories scores for listen carefully at 58% and explain things at 63%) to 69% (with scores for
listen carefully at 71% and explain things at 71%). Responsiveness of hospital staff significantly

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increased from 39% (with sub-categories scores for call light at 45% and bedpan/bathroom at 24%) to
54% (with scores for call light at 45% and bedpan/bathroom at 65%). Pain management modestly
increased from 62% to 73% (with sub-category scores for pain controlled at 68% and pain help at
77%). Post-intervention scores for the three categories did not reach the goals set by the organization,
although pain management came within 1%.

90
80
70
60
50 Pre-Intervention Data
40 Post-Intervention Data
30 75th Percentile HCAHPS Goals
20
10
0
Nurse Responsiveness of Pain Management
Communication Hospital Staff

Figure 5: HCAHPS score comparison of baseline to post intervention audits

Table 4: HCAHPS sub-categories improvement rates

HCAHPS sub-category Pre-intervention Post-intervention Change Rate of

compliance compliance improvement

Nurse communication
Listen carefully 58 % 71 % ↑ 13% 18 %
Explain things 63 % 71 % ↑8% 11 %
Responsiveness – staff
Call light 45 % 45 % 0 0
Bedpan or bathroom 24 % 65 % ↑ 41 63 %
Pain management
Pain control 56 % 68 % ↑ 12 18 %
Pain help 68 % 77 % ↑9 12 %

Patient falls was the third type of data comparing pre- and post-intervention outcomes. As shown in
Table 5, the amount of falls on the unit increased in the months prior to implementation of hourly
rounding and decreased modestly with implementation of timeliness of rounding and protocol use.

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Table 5: NDNQI data – medical surgical unit patient falls volume per month

Pre-intervention Pre-intervention Pre-intervention Implementation Post intervention

1 3 2 1 1

Discussion
This project established quality improvement benchmarks aimed at improving patients’ perspectives
of, and satisfaction with, their care, as well as increasing patient safety during hospitalization. Timely
and purposeful rounding was the intervention determined to have the greatest impact on
accomplishing this. Multi-level strategies were developed and implemented on the medical-surgical
unit to address the three specific objectives regarding nursing rounds: determine compliance with the
evidence-based criteria; improve staff nurse knowledge; and improve compliance with evidence-based
rounding criteria. The unit’s baseline fall numbers and HCAHPS satisfaction scores focusing on the
nursing-sensitive categories most closely related to rounding were obtained. Pre-intervention data on
the evidence-based criteria were gathered. The post-implementation outcome data revealed all the
objectives and the safety aims were successfully met. However, though there were increases in
satisfaction scores, the desired goals were not reached after the first month. Frontline staff and
managers expect the scores will continue to rise over several months as rounding becomes a
hard-wired practice.

Although nursing staff may be aware of call bell activation, they may not always respond as promptly as
needed or expected. When staff awareness increased, an improvement was seen in response to
patient calls and rate of falls. Interestingly, when staff awareness of patient needs increased through
hourly rounding programs, to some degree, the rate of falls decreased and patient satisfaction
increased. Initial themes from the concurrent survey conducted during this project revealed that
challenges exist when patient census or staffing fluctuates, and that nursing leadership rounds could
assist in hardwiring rounding interventions for staff. Thus, strong nursing leadership focused on
re-educating and emphasizing the importance of an intentional hourly rounding protocol may assist in
meeting organizational goals of decreasing falls and increasing patient satisfaction. Additionally,
reimbursement would increase and the organization would be in an excellent position to improve other
patient care initiatives.

Clearly, initial improvement was made toward the established satisfaction benchmarks for the project.
Responsiveness of staff, the HCAHPS category with the lowest scores, had a robust 28%
improvement rate (a gain of 15%). However, scores for the sub-category call light did not change. This
most likely reflects that timely answering of call lights was not one of the rounding interventions. The
call light usage rate by patients was not evaluated. Pain management, with pre- and
post-implementation scores most similar to those for nurse communication, realized a 15%
improvement rate (a gain of 11%). The sub-categories pain controlled and pain help had improvement
rates of 18% and 12%, respectively. Nurse communication, the category with the highest starting and
ending scores, had a modest but lackluster 7% improvement rate (a gain of 5%). Interestingly, the
improvement rates for sub-categories listen carefully and explain things had higher improvement rate
gains, 18% and 11%, respectively. These sub-category results indicate a higher quality of

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purposefulness and intentionality when rounding and are most likely due to adoption of the
standardized scripting protocol.

Nurse communication and pain management scores were expected to be more closely aligned as
pain/comfort management is a nurse domain (that is, other non-nurse unit staff would not be actively
treating patients’ pain) and is dependent on focused nurse-patient interactions for assessing and
re-evaluating pain/comfort levels. The category responsiveness of staff included all unit members and
the substantial rate gain pointed to heightened engagement of all levels of staff, teamwork and
accountability for providing patient-centred care. It also reflects the impact of increased nurse staffing
levels on having time to consistently carry out rounding, as well as, caring practices of the leaders and
administrative managers.

Keeping patients safe from harm is another basic nursing domain. The project aim of improved safety,
indicated by a decreased volume of falls, was achieved. The average three-month fall volume prior to
implementation was two and it was halved after the first month of timely and purposeful rounding.
Because of the low volumes, data trending over the next several months will be important to show that
timeliness and purposefulness are sustainable. However, the bedpan/bathroom sub-component score
for the HCAHPS category staff responsiveness also substantiates success because falling is highly
associated with toileting needs. The improvement rate was 63% (with a gain of 41%). This result was
encouraging to staff, but they also realized improvement could be made in order to advance the actual
HCAHPS score beyond the 75th percentile.

The process of generating ideas, and developing and implementing the 4P rounding program was
empowering to staff due to experiential learning. Results demonstrated that not only meeting patient
care needs but also anticipating them and being proactive directly impacted on patient safety and
perceptions of feeling cared for and important. Some staff members acknowledged they did not realize
how standardizing a unit routine, such as rounding at a particular time of day and using a protocol,
could actually create a more healing environment through open lines of communication and a higher
frequency and quality of interactions. Results from this project validate why high standards are set for
NDNQI falls (a nursing-sensitive indicator) and the American Nurses Credentialing Center’s Magnet ®
Recognition Program for nursing excellence outcome requirements on nursing-sensitive indicators
such as falls with injury and patient satisfaction.

Shoring up the unit’s infrastructure for this project was akin to moving up through the levels in Maslow’s
Hierarchy of Needs model.26 Basic safety staffing needs had to be met first before staff nurses could
concentrate on higher level care needs such as nursing rounds. Daily staffing level challenges and the
impact of leadership change to a new unit manager from outside the organization were immediate
barriers recognized by top level hospital and nursing administrators. Their responsive actions of more
intensely supporting the unit’s nurse manager, as well as hiring additional nurses allowed staff to use
their abilities to develop and implement strategies aimed at improving patient satisfaction and safety.
Use of dedicated nurse champions was another key structure put in place in order to resource staff and
role-model practices. This position also bridged communication between clinical nurses and
managers, and between clinical nurses and unlicensed nursing staff.

In response to the outcomes and experiences acquired during the project, nursing staff began
developing new processes to hardwire the rounding protocol for new and seasoned employees. A
proposal was forwarded for the 4P protocol to be a competency which would be included in the new
employee orientation simulation experience, as well as part of the annual skills fair. In addition, some

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nurses who also served as clinical instructors for local academic institutions planned to request
integration of a structured nursing round protocol into the curriculum for nursing students. Although
project outcomes generated new ideas, there were limitations noted for this project to be considered
with future project implementation on other units.

The main limitations of the project were:

1. Barriers identified for this unit that may not be generalizable to other units in the hospital
because nursing workflows and patient populations with their specific needs differ in each
unit.
2. Results of the intervention unit were not compared to a control unit.
3. Direct observation could have biased nursing behaviors.
4. The call light usage rate by patients was not evaluated.
5. Sustainability measures needed to be established to maintain the gains and to continue to
improve the outcomes.

The second limitation was anticipated. Therefore, nursing leadership determined at the beginning of
the project to collect data from a like unit, as a “control unit” for baseline data comparison. Results from
this continued project will be reported at a later date.

The main successes of the initiative were the use of best practice evidence to promote practice change
and management staff teambuilding. This project has empowered and re-energized nurses to initiate a
journal club focusing on nurse driven practices to improve patient care outcomes. Future directions for
promoting best practice in this unit are to identify and address other medical-surgical practice issues
related to oncology and bariatric patients by applying the learned concepts of process improvement.

This organization is seeking Magnet® recognition and is on a “Pathway to Excellence” to promote

positive practice environments where nurses excel.27 As a best practice exemplar, the processes and
interventions of this project will be introduced to other units in the organization, and to other hospitals in
the system, for nurses to evaluate and implement in their particular practice setting. Unit leadership
has planned to disseminate the rounding project results at the hospital’s annual safety fair as a
stimulus for encouraging nurses from other units to improve evidence-based practice as the
organization progresses on their pathway to excellence to achieve Magnet® designation.

Conclusion
Nurses have the ability to improve patient satisfaction and patient safety outcomes by utilizing nursing
round interventions which serve to improve patient communication and staff responsiveness. Having
an appropriate infrastructure and an organized approach, encompassing all levels of staff, to meet
patient needs during their hospital stay was a key factor for success. The aims and objectives of the
project were realized as staff embraced the change and comprehended how best practice
interventions could significantly improve patient outcomes. However, the desired satisfaction goals
were not yet reached after the first month because rounding was still becoming hard-wired. The project
did not provide future directions for sustaining evidence-based practice change, but a monthly audit
format has been developed to monitor, communicate and help maintain the current practice change.
Plans to improve HCAHP satisfaction scores have been placed on future staff meeting agendas.

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Conflict of interest
The author declares that there were no conflicts of interest in the implementation of this quality
improvement project.

Acknowledgements
The author would like to gratefully acknowledge:

The nursing staff, the nursing leadership team, and Jeff Doucette, Vice President, Patient Care
Services, and Chief Nursing Officer, Mary Immaculate Hospital Nursing

Chamberlain College of Nursing, for their generous support in completing the JBI Clinical Fellows
training

Douglas Turner, my JBI Clinical Fellow coach and the UCSF JBI Centre for Synthesis and
Implementation, for their assistance in writing this evidence-based project report

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Appendix I: Staff Survey and Nursing Director Interview Questions on the 4Ps
Rounding Process 9

Staff Survey on the 4 Ps Rounding Process

• Have you been able to incorporate 4 P rounding every 2 hours in to your practice?

• What system problems have you identified with the 4 P rounding system?

• What call light changes have you observed since 4 P rounding started?

• Do you have any specific comments you’d like to share about the 4 P process? How can it be
improved? (Nursing

Medical-Surgical and other Nursing Director Interview Questions

• What is the role of rounding from a nursing director’s perspective?

• What does patient satisfaction mean to you?

• Since the inception of the 4 P program, have you noticed a reduction in call light usage?

• Are the nurses still performing 4 P rounding every 2 hours?

• What relationship do you see between patient safety and 4 P rounding?

• Do you think 4 P rounding adequately addresses patients’ more mundane and common problems?

One of the things the staff mentioned in a questionnaire was how to maintain 4 P rounding when the
floor gets busy. What are your ideas to keep the 4 P rounding going when things get busy?

• What are your ideas for sustaining the gains in patient and staff satisfaction?

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Appendix II: Hourly Rounding Staff Communication Tool 24

4 P’s of

Hourly Rounding

Pain How is your pain?

Position Are you comfortable?

Potty Do you need to use the bathroom?

Possessions Place phone, call light, trash, bedside table, tissues, and
water pitcher within reach.

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