Mitchell, Matthew D. PhD; Lavenberg, Julia G. PhD, RN; Trotta, Rebecca L. PhD, RN; Umscheid, Craig A. MD
Hospital stays subject patients and their families to significant stress. In addition to facing bewildering medical conditions that require tests and treatments from physicians, nurses, and other healthcare personnel, patients are placed in dependent roles and become socially and emotionally vulnerable. They are compelled to request assistance with basic needs such as repositioning, eating, and elimination. Unfamiliar with hospital routines and how to get needs met, patients access the primary mechanism at their disposal: the nurse call button. Expectations and perception regarding responsiveness to this means of communication may depend on the reason for initiating the request. For example, if a patient has a question about a scheduled procedure, waiting a short period may be acceptable. If a patient has received a diuretic and is experiencing bladder fullness and a sense of urgency, waiting a short period for bathroom assistance may seem too long. Intentionally checking on patients at regular intervals, known more colloquially as hourly rounding, has been suggested as a primary mechanism to address basic patient needs as well as enhance patient safety and experience.1
Published reports have suggested that systematic and purposeful rounding by nursing results in improved patient satisfaction.2 This observation is especially relevant in our current era of value-based purchasing, where reimbursements are directly tied to patient satisfaction scores.3 Nursing responsiveness is an important factor in a patient’s experience of care during hospitalization and is captured in most patient satisfaction surveys. For example, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a publicly reported survey that informs Medicare reimbursement levels,4 has 2 questions relating to nursing responsiveness. Patients are asked “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” and “How often did you get help in going to the bathroom or in using a bedpan as soon as you wanted?”
The practice of proactive and regular checks of hospitalized patients to decrease patient anxiety has been included in nursing curricula since the mid-1970s, although not tested in formal trials. More recently, Woodard5 articulated an underlying rationale for proactive rounding in the “help uncertainty” model. When patients are unable to comprehend nursing workflow and cannot predict when a nurse will be available for physical and emotional assistance, they worry that no one will be available to respond to immediate needs (ie, they experience “help uncertainty”), anxiety levels rise, and inappropriate coping mechanisms may come into play (eg, getting up to go to the bathroom alone shortly after receiving a pain medication). By taking the initiative to address basic needs such as use of the bathroom (“potty”), positioning, pain control, and proximity of personal items using a structured format, nurses can decrease patient anxiety and minimize help uncertainty.1
In addition to reducing patient anxiety and fear, systematic and proactive nurse rounding has been associated with decreased use of call lights. Surveys conducted with nurses and patients indicate that pain management, personal assistance, bathroom assistance, and equipment alarms (ie, intravenous pumps) were among the top 5 reasons for pushing the call bell.6,7 Structured hourly rounding that addresses these important “Ps” may thus allow nurses to provide more responsive and uninterrupted care.
The only summary appraisal of structured rounding interventions to date is a narrative review published by Halm8 in 2009. She concluded that hourly rounding reduced call light use and increased patient satisfaction but did not report the quantitative results. Because that review lacked the latest evidence as well as important details about the interventions, we performed an updated systematic review to help inform evidence-based decision making at the hospital and health system levels.
Introducing structured hourly rounding to nursing practice may be challenging for nurse administrators for a variety of reasons, particularly at a time when future hospital reimbursement levels are uncertain. Nurse administrators must account for any changes in how nurses spend their time and determine whether increases in staffing are needed and will provide benefits that exceed costs. To make a persuasive case for changing nursing care delivery processes, nursing leaders must understand the evidence supporting the change and use it to gain the support of other hospital and health system administrators. Systematic reviews of clinical evidence are an effective way to inform stakeholders regarding the value of changes in nursing practice. This systematic review on hourly nursing rounds provides hospital nurse administrators with the evidence necessary to make decisions around program implementation and allocation of nursing resources.
The systematic review process followed the PICO structure (patients, intervention, comparison, outcomes)9,10 for defining the scope of the review and the studies to be considered. The a priori protocol (see Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A318) is a key component of a systematic review that ensures an objective process for including and excluding studies to be reviewed.11
Medline, EMBASE, and CINAHL were searched for published studies including systematic reviews. Searches were completed in December 2012 and updated in July 2013. We did not restrict search results by language or date of publication. The general approach was to combine a term for patient satisfaction or responsiveness with a term for hourly rounding or call buttons using an “AND” Boolean search operator and then combine all of the individual results with an “OR” operator. We also included a search combining terms for responsiveness and patient satisfaction with filters for controlled clinical studies. Detailed syntax of the searches is provided in the supplemental tables (see Supplemental Digital Content 2, http://links.lww.com/JONA/A319; Supplemental Digital Content 3, http://links.lww.com/JONA/A320; and Supplemental Digital Content 4, http://links.lww.com/JONA/A321). In addition to searching the above databases, we reviewed the bibliography of Halm’s8 review for articles that may have been missed by the searches. Duplicate references were deleted before articles were screened for further review.
Article inclusion and exclusion were done in accordance with the stated protocol. An experienced research analyst (M.D.M.) reviewed the titles and abstracts of all articles found by the searches and marked articles for retrieval. In uncertain cases, the article was marked for retrieval. A total of 100 randomly selected search results were audited by a 2nd analyst (J.G.L.) for quality assurance; there was complete agreement between the 2 analysts. All marked articles were retrieved in full text, and the 2 research analysts independently determined whether each retrieved article met the stated inclusion criteria. When studies were excluded, the reason for exclusion was documented (see Table, Supplemental Digital Content 5, http://links.lww.com/JONA/A322). Disagreements between the 2 analysts were minimal and were resolved through joint review of full-text articles and discussion.
The methods and results of each included study were abstracted into evidence tables by the 1st research analyst. The analyst also identified potential sources of bias or uncertainty in the studies, noting them in a comments column. Both abstracted data and assessment of bias for all included studies were verified by the 2nd analyst. The protocol included a systematic assessment of study quality using a modified version of the Jadad scale12 for evaluating available randomized trials and quantitative synthesis of study results using meta-analysis if the quantity and quality of data permitted.
After data abstraction was complete, the strength of the overall evidence base for each outcome of interest was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.13-15 GRADE uses a 4-point scale for evidence quality: high, moderate, low, and very low. Evidence for a particular outcome is assigned an initial category based on the type of studies (randomized or nonrandomized) informing that outcome, and then the grade is decreased or increased based on criteria of quality, quantity, consistency, directness, and magnitude of effect.
From an initial result of 1,279 database hits and 11 review citations, we identified 16 published studies meeting the inclusion criteria. There were numerous duplicate references in the results from the different searches, suggesting that the searches did capture nearly all of the relevant studies. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram (see Figure, Supplemental Digital Content 6, http://links.lww.com/JONA/A323) shows the number of articles under consideration at each step of the process.
Nine articles we identified were not included in Halm’s review. Eight of them were published after the searches for the previous review were conducted, and 1 article16 was missed by that review. Of the 11 studies cited by Halm’s review, 5 were not found by our searches. Three of them were published only in abstract form and had not been indexed. They did not meet our a priori inclusion criteria because abstract publications are not detailed enough for us to evaluate the quality of the study. The others17,18 met our inclusion criteria and were included in the analysis.
Table 1 describes the design of each of the studies meeting our inclusion criteria. There were no randomized controlled trials, and nearly all the articles described studies of a “pre-post” design. Because of the lack of randomized trials, we could not apply the modified Jadad scale as planned.
Table 2 summarizes the interventions tested in these studies. Some had hourly rounding, some had 2-hourly, and some had hourly during day and evening hours and 2-hourly during late nights and early mornings. Nearly all the studies reported use of a script or structure of tasks to be performed for each patient. Those tasks usually corresponded to the 4 Ps and some of the investigators cited the seminal report of Meade et al,1 defining that intervention as the model for their programs. Cann and Gardner19 tested a “Practice Partnership Model of Care” in which hourly rounding was combined with changes to the layout of the nursing unit, regular handoff of patients at the bedside, and partnerships between nurses. Because the investigators made all the changes in care at the same time, the effects of the additional changes in care beyond the hourly rounding program could not be assessed.
There was little consistency in how results were reported across studies. A variety of patient survey instruments were used to assess perceived responsiveness of hospital staff, including Press Ganey and HCAHPS. Many studies did not fully report patient satisfaction and responsiveness results, instead reporting only the direction and significance, if any, of the effect. This heterogeneity of reporting precluded any quantitative synthesis of the data.
Study results are shown in Table 3. Of the 11 studies that reported overall patient satisfaction scores, 9 found improvements in that measure; none reported any decrease. Of the 7 studies that reported a significance test on the results, 4 found statistically significant improvements in patient satisfaction.
“Responsiveness” is a component of most patient satisfaction surveys. Although the wording of the question varies, it typically refers to whether nurses or other caregivers responded promptly when the patient activated the call light. This was not reported as frequently as overall patient satisfaction. When it was reported (Table 3), results tended to fall into 1 of 2 extremes: either little or no effect (3 studies) or a large and statistically significant positive effect (2 studies). One additional study reported increased responsiveness but did not provide numeric results. The studies reporting a significant gain in responsiveness had the lowest baseline scores on this item, suggesting that there is a ceiling effect and that hourly rounding will have the greatest impact in units where there is a perceived problem with responsiveness.
Ten of the published studies of hourly rounding reported the effect on patients’ use of call lights, an outcome that is of particular interest to nurse administrators. Call light use fell substantially in all the studies where it was measured. Decreases ranged from 23% to 70%; the median reduction was 54%. In most studies, the results had strong statistical significance. Investigators consistently said that hourly rounds reduced calls for patient assistance with positioning, toileting, and other minor needs, where calls for more serious needs were not affected.
One might expect that proactive rounds in which patients are regularly and frequently asked if they need assistance with using the toilet would also reduce patient falls, because patients are less likely to have an urgent need to go to the toilet before a caregiver can assist them. Among the studies in our review, 9 also measured this outcome. The reported reduction in falls ranged from 24% to 80%, with a median reduction of 57%. Falls were not common events in these studies, so the statistical power to detect differences was limited, but 2 studies were able to report a statistically significant decrease in falls.
Another element in most hourly rounding programs was to change the patient’s position if necessary. This would be expected to reduce pressure ulcers, but only 1 study actually measured the impact of an hourly rounding program on this outcome, finding too few instances of pressure ulcers to make any conclusions possible.20
In some studies, rounding was done every 2 hours instead of every hour.1,5,16 Beneficial effects on patient satisfaction and call light use were still observed, but the magnitude of the effects seems to be less than with hourly rounding. The 1 trial that did compare rounding intervals1 also found this kind of “dose effect.”
The GRADE analysis (Table 4) systematically evaluates the quantity, quality, and consistency of evidence and the effect size of the results to assign a rating to the evidence base as a whole for the effect of each intervention type on each outcome of interest. Given that the evidence base for all interventions and outcomes consisted of observational pre-post studies, the initial grade of evidence for all outcomes was low. Evidence on perceived responsiveness of nursing staff was downgraded for inconsistency because some studies found little or no effect while others found a large effect.
The GRADE system allows for upgrading of the final rating if there is evidence that the effect of an intervention is large or dose dependent. A single-level upgrade can be applied if the magnitude of an effect is a factor of 2 or more. This criterion was met for the outcomes of call light use and patient falls, but because the size of the effect only slightly surpassed the threshold, we opted not to apply a 2nd upgrade for the limited evidence suggesting a dose-response effect. We considered the impact of hourly rounding on patient satisfaction and perceived responsiveness to also be large enough to merit an upgrade, although in the case of responsiveness, that upgrade was canceled out by the downgrade for inconsistency. The final evidence grade was “moderate” for 3 of the 5 outcomes evaluated.
Discussion and Implications for the Nurse Executive
This systematic review of 16 published articles found that there is substantial evidence that hourly rounding has beneficial effects, particularly on the outcomes of patient satisfaction, call light use, and patient falls. The benefits on patient satisfaction scores and perceived responsiveness seem to be larger for units that do not perform well at baseline, which supports a hypothesis that there is a ceiling effect on the impact of hourly rounding. Application of the systematic review methodology uncovered several important limitations to the applicability of the results, which may not have been recognized had the articles been analyzed in a less rigorous way. Familiarity with issues such as methodological bias, publication bias, and generalizability can provide nurse executives with important insights into this literature as they consider using it as a foundation for implementing hourly rounding in their institutions.
Among the articles included in this review, there was considerable variability in the study protocols (ie, the way the studies were carried out and how the results were measured). Interventions consistently aligned around the 4 Ps of pain control, toilet or bedpan needs (“potty”), patient positioning, and a reassuring presence of the nurse. There were, however, variations in the frequency of rounding and staff members completing the rounds (registered nurses vs assistive personnel), which could be a major consideration for nurse executives. None of the studies provided data from which we could compare the effectiveness of these variations, aside from the hourly and 2-hourly rounding in the study of Meade et al as described above.
The methodological approaches of the studies included in this analysis may bias their results in favor of hourly rounding and/or make them less generalizable to units outside the study setting. Of particular note is that none of the studies were randomized; they instead were of pre-post study design. The ability to account for the impact of interventions or changes that may have occurred concurrent to the study intervention is limited with pre-post study designs. Therefore, a conclusive causal relationship between the implementation of hourly rounds and the study outcomes cannot be established. This limitation is particularly relevant if units with particularly poor patient satisfaction or responsiveness scores are more likely to study hourly rounding. Regression to the mean suggests that these particular units will likely improve regardless of any changes in care, making it difficult for nurse executives to understand the true impact of the intervention and plan future initiatives.
An evidence base composed mostly of pre-post studies also is at increased risk of publication bias. Not only will investigators opt not to seek publication when practice changes do not produce the desired effect, but also, to encourage others to adopt these practices, the authors of published studies may emphasize their most positive results and omit results that did not favor their intervention.
When evaluating published reports of pre-post studies, nurse executives should identify whether the authors followed an a priori research protocol. Few of the studies in this systematic review reported using such a protocol, so the extent of possible reporting bias is not known. One exception is the report by Meade et al, 1 who reported the fact that results from about one-third of participating hospitals were excluded because more than 5% of data elements were missing from their logbooks.
The selection, training, and supervision of personnel in the studies may have also introduced bias and limited generalizablity. In the study of Kessler et al,21 project leaders took pains to ensure maximum staff compliance with the hourly rounding protocol, including biweekly meetings about the program and having staff members sign pledges to complete the rounds. The level of intervention and availability of resources in the study of Kessler et al exceed the level of resources that typically would be available in most clinical environments, making replication challenging for nurse administrators. In the study of Berg et al,22 some staff members declined to give consent for having records from their shifts used in the study. If the hourly rounding program was more or less effective for the patients of these staff members, the results published in the study may not accurately represent the overall effect of the program.
Moreover, bias can arise when nurses know that their performance and the impact of a practice change are being monitored for research purposes. If data are collected only during the last week of each month, for example, such as in the study by Culley et al,23 then staff may feel less motivation to carry out the hourly rounding program during the other weeks. Automated data collection, which is often used to measure call light usage, allows for more complete collection of data and reduces risk of this bias. The selection of units may also limit generalizability of the findings. For their study, Berg et al22 selected a unit that had stable patient census and acuity, a climate where one would expect changes in practice to be easiest to implement. Woodard5 selected a medical-surgical unit where the charge nurse conducted scripted rounds and the 12-hour shift patient-nurse ratio was 3:1 on days and 4:1 or 5:1 on nights. The authority figure of the nurse conducting the rounding intervention and the relatively low patient ratio are additional plausible explanations for increases in patient satisfaction.
This systematic review determined that the evidence supporting the use of hourly rounding in inpatient care was of low to moderate strength. Although the individual studies are of weak research design and have inconsistent reporting quality, the quantity and consistency of the evidence on hourly rounding lead us to conclude that it improves patients’ perceptions of nursing staff responsiveness in units where this may have been a problem, reduces patient falls and call light use, and improves patient satisfaction scores. Additional evidence is not likely to refute these conclusions; therefore, nurse administrators should invest in the development of hourly rounding programs adapted to their local circumstances. Accordingly, this presents an opportunity for nurse executives to support nursing research initiatives within their institutions. Trials of different ways to meet the hourly rounding imperative are warranted. Sustaining hourly rounding places a considerable strain on nursing resources, and although it may be more cost effective for nursing aides to fulfill the 4 Ps protocol, we do not know whether they will have the same impact on patient satisfaction scores as hourly rounding by registered nurses. Future studies should measure and report all of the outcomes outlined in Table 3. Such research will yield more precise findings regarding hourly rounding processes and their impact on patient outcomes.
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