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Stop going in circles! Break the barriers to hourly rounding

Shepard, Leslee H. EdD, MSN, RN, CMSRN

Nursing Management (Springhouse): February 2013 - Volume 44 - Issue 2 - p 13–15
doi: 10.1097/01.NUMA.0000426147.98903.ae
Department: Team Concepts

Leslee H. Shepard is an associate professor of Nursing at Winston-Salem State University and a clinical nurse educator at Novant Health Forsyth Medical Center in Winston-Salem, N.C.

The author has disclosed that she has no financial relationships related to this article.

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Hourly rounding, as the name implies, is the practice of nurses and unlicensed assistive personnel making scheduled visits to the rooms of hospitalized patients and performing specific nursing interventions every hour. The goal is to improve patient outcomes by addressing their needs in a proactive manner. The original concept was developed and introduced in 2005 and has since inundated the literature with reports of the benefits of hourly rounding on patient outcomes while saving valuable time for nurses who use it.13

Hourly rounding interventions typically performed include pain management; addressing elimination needs; offering nourishment; and ensuring applicable musculoskeletal needs are met, such as ambulation, range of motion, or proper positioning. Other tasks include, but aren't limited to, a visual scan of the room to ensure there's adequate lighting, the call bell and phone are within reach, medical equipment is properly functioning, and walk areas are free from clutter.

The primary purpose of hourly rounding is to improve patient outcomes by enhancing patient safety and patient satisfaction.2,4 An additional benefit of hourly rounding is improved time management. When patients understand that a healthcare provider will visit their room every hour, they're less likely to request services between nursing rounds. Less interruption allows time for nurses to work more productively.

Despite the benefits of hourly rounding, compliance rates may be lower than expected. One study on hourly rounding reported that nurse managers made leadership rounds three times a week to ensure nurses were making the required patient rounds.4 The need to round on the rounders gives reason to pause and speculate whether improved compliance rates are the result of personal behaviors being adapted to what's expected when a person knows he or she is being watched.

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Hitting the wall

Barriers to hourly rounding include buy-in, acuity levels, time management, and unexpected interruptions.

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Buy-in

Nurses who don't accept a new practice or don't believe that a practice is worthwhile can be a barrier to successful rounding.5 Nurses who've been in practice for years may tell stories of how things “used to be.” Some may proudly report how they once took care of up to 16 patients, yet administered every medication on time, completed all head-to-toe assessments, changed wound dressings, admitted new patients, and completed the required documentation. And it was done all in an 8-hour shift! (Don't forget this was done without one bathroom break or lunch.) These stories are hyperbole in most cases; nonetheless, the perception that these nurses have is that hourly rounding didn't occur then and they got through their shift without untoward events, so why change?

Nurses with years of experience may show cynicism toward the idea of hourly rounding, and it's these nurses who are socializing the new nurses to the role and can influence mindsets. It's worthwhile to devote time and energy to help influential, experienced nurses on your unit understand and accept the concept of hourly rounding, which will motivate others to get on board. The sooner you get buy-in from formal and informal nurse leaders on your unit, the sooner you make the process of hourly rounding a unit practice.

One potential strategy for gaining buy-in from seasoned nurses is to show the evidence of proven success. Provide staff members with reports of actual accounts of the benefits seen as a result of hourly rounding. The data can be generated from literature reviews of journal databases, but the most prevailing evidence is in-house data that the nurse can relate to first hand.

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Acuity levels

Shifts in healthcare have led to a fundamental change in patient acuity on the average medical-surgical unit. Advanced technology and better community-based healthcare programs have allowed for fewer readmissions. A lack of insurance among many in the United States encourages patients to enter the unit “sicker” and leave “quicker.” As a result, when patients are admitted, they're given a higher acuity level. Undoubtedly, sicker patients require more direct hands-on time and energy.

When a nurse on a typical medical-surgical unit is assigned to care for six or more patients with moderate to high care demands, organizing and prioritizing the plan of care becomes a barrier that interferes with hourly rounding.5 An important factor is to ensure a tool is used to adequately measure acuity levels, which will help appropriately distribute workloads.

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Time management

Take a walk through the typical acute care facility and, in many cases, it's obvious that the nursing units weren't designed with the nurse in mind. Most have the nurses' station strategically placed in the center of the unit. To the layperson, this makes perfect sense. However, ask the nurse who has an assignment with patient rooms located at the lower end of the unit or ask the patient who's annoyed at listening to the I.V. pump alarms sounding for what seems like hours because the nurse is at the nurses' station unable to hear the alarms. Without concerted efforts to plan daily nursing activities, nurses can lose valuable time maneuvering back and forth.

It goes without saying that time management is an essential skill required by nurses to be successful in any work setting. The amount of documenting that must be done continues to be a major time stealer for nurses. Increased technology has allowed for much of the charting to be done electronically; however, the perception of many nurses is that electronic charting has created more supplemental processes to manage. Time management is a complex strategy to master and, ironically, given the purpose of making hourly rounds, the key to managing time is to perfect the art of hourly rounding.

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Unexpected interruptions

In some cases, all the planning in the world can't prevent those pesky unexpected interruptions: the phone call from the irate physician, the lab with the wrong requisition sheet, the food trays that arrived with the wrong food choices, or more serious interruptions such as the patient who deteriorated without obvious cause, which could easily consume more than an hour of a nurse's concentrated efforts.

The notion of team nursing (nursing staff members who care for a group of patients together) is one possible solution to reducing interruptions. There are a variety of team nursing models that can be implemented. Each model has a different variation of job roles to include RNs, LPNs, and certified nursing assistants (CNAs).6 All teams, despite their unique make-up, are led by the RN. Irrespective of the type of team nursing model used, the additional staff will help support compliance with hourly rounding. The added team members allow for alternating rounding schedules that enhance workflow by limiting interruptions. As the nurses perform activities that are within their scope of practice, such as medication administration, the CNA(s) can make patient rounds and vice versa.

The contributions of the CNA in hourly rounding are just as significant as those of the nurse. Basic care and comfort needs related to grooming, hygiene, nourishment, positioning, cleanliness of the room, and removal of safety hazards are important to the overall well-being of the patient. Moreover, patient satisfaction scores improve when patients see that their basic care and comfort needs are adequately met.6

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Stopping the cycle

Hourly rounding is undoubtedly advantageous to patient outcomes and overall satisfaction rates. Frontline direct care nurses have the ultimate power to facilitate such important shifts in practice. However, any one of the potential barriers alone could be a major deterrent to nurses complying with hourly rounding. The truth of the matter is that most nurses are faced with the combined list of barriers during each and every shift worked. With a typical nurse-patient ratio on a medical-surgical unit of 1:6 compounded by the aforementioned barriers, hourly rounding may not be the most popular idea despite the volumes of documented benefits.

Nurse leaders within facilities committed to hourly rounding should assess barriers faced by their nurses then take immediate steps to alleviate or modify them. The goal should be no more rounding on the rounders to ensure compliance. Make the commitment to change the culture. Otherwise, efforts may be counterproductive as nurses become resentful about the increasing work demands with the perception of inadequate resources and support. As with any implementation of new practice standards, comply with continuous evaluation and subsequent revisions. Identifying the modifiable barriers early is the key to your success.

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REFERENCES

1. Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds: on patients' call light use, satisfaction, and safety. Am J Nurs. 2006;106(9):58–71.
2. Ford BM. Hourly rounding: a strategy to improve patient satisfaction scores. Medsurg Nurs. 2010;19(3):188–191.
3. Weisgram B, Raymond S. Using evidence-based nursing rounds to improve patient outcomes. Medsurg Nurs. 2008;17(6):429–430.
4. Olrich T, Kalman M, Nigolian C. Hourly rounding: a replication study. Medsurg Nurs. 2012:21(1):23–26.
5. Orr N, Tranum K, Kupperschmidt B. Hourly rounding for positive patient and staff outcomes: fairy tale or success story? Okla Nurse. 2006;51(4):11.
6. Deitrick LM, Baker K, Paxton H, Flores M, Swavely D. Hourly rounding: challenges with implementation of an evidence-based process. J Nurs Care Qual. 2012;27(1):13–19.
© 2013 by Lippincott Williams & Wilkins, Inc.