Capstone Project - Constructing the Written Evidence-Based Proposal

Capstone Project - Constructing the Written Evidence-Based Proposal
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Abstract
Patients’ safety is a critical concern among healthcare providers today. Nursing hourly rounds is one of the effective strategies that can enhance patient`s safety, offer quality nursing care, and enhance patient’s satisfaction. Hourly rounds involves checking patients on specific intervals, but initiating evidence –based practices like hourly rounding is still a challenge to many hospitals (Tzeng, 2010). Fall prevention is a challenge to healthcare providers, that is why patients prone to fall needs to be accurately identified as staff adopts evidence-based practices that can prevent falls. Hourly nurse rounds can effectively reduce falls, pressure ulcers, and reduce call light use. It can equally enhance patient`s satisfaction (Salch, Nusair, Zubadi, Shloul & Salch, 2011).
Hourly rounds continue to be a debated subject among the nursing profession; registered nurses are required to make rounds on even hours, while the support staff makes rounds at odd hours from 6 am to 10 pm and also every two hours from 10 pm to 6 am. Making hourly rounds involves engaging patients (Mitchell, Lavenberg, Trotta & Umscheid, 2014). Therefore, hourly rounds can help manage patients’ expectations and at the same time to meet their needs. Meeting patients’ needs means, ensuring patients are comfortable and safe, hence avoiding adverse events like pressure ulcers, falls, or pain.
Medical literatures support hourly rounds because it organizes workflow in several health care settings hospitals. Hourly rounds make nurses proactive in patient care. Not many studies have analyzed the relationship that exists between hourly rounds, call bells, and patient`s satisfaction. However, other research findings indicate a remarkable improvement when nursing rounds are adhered to through strict schedule. This involves monitoring patients every hour or every two hours (Emerson, Chmura & Walker, 2014).
Keywords: Call light, rounds, patients safety, patients satisfaction, hourly rounds, and patients care management.
Constructing the Written Evidence-Based Proposal
Introduction
For many patients, being hospitalized is a scary experience; patients are not in a position to perform normal tasks during this process. Nursing staffs play a significant role in assisting patients with daily needs like toileting, medication and other simple tasks like changing their sleeping positions. Patient use call bells as a way of communicating with nurses, but answering call lights is a tiresome task for nurses, hence patients have to wait longer than expected (Tzeng, 2010). In such situations, patients’ safety is compromised. Hourly rounds by nurses provide excellent nursing care during hospitalization because it is a patient-centered care approach. Nurses visit patients’ rooms to address their needs after every one to two hours. During this process, the nurse assesses patients’ needs keeping in mind the 4 Ps of position, pain, potty and possessions (Moran et al., 2011). Patient satisfaction is an important outcome in healthcare settings; healthcare providers constantly seek for innovative strategies to enhance patient satisfaction scores. Patients value their relations with nurses. Safety and trust result to quality service. Specific actions performed at set intervals are associated with reduced patient use of call light and increased patient satisfaction. Several studies prove that hourly rounds are becoming an essential practice when evaluating patient satisfaction (Dyck, Thiele, Kebicz, Klassen & Erenberg, 2013). This explains why making rounds has become an inherent part of the nursing practice. This capstone project presents an evidence-based proposal that could be implemented to reduce patients’ falls, pressure ulcers, and call light use during the time that patients are unable to get out of bed on their own. The project proposal discusses challenges facing nurses in delivering quality care and what nurse administrators can do to improve better health outcome for patients.
Background
Falls are one of the many causes of mortality among patients. Patients’ fall during hospitalization, result in adverse outcomes like injuries and prolonged hospitalization. Many of the falls occur when patients are in need of basic services like either using the washrooms or trying to reach out to their personal belongings. Although falls are avoidable, fall prevention is a complex process. Several factors can contribute to falls; these includes the patient's medical condition, bed not being positioned at the required height, and care factors like nurses not responding promptly to call lights (Salch et al., 2011).
Hospitalized patients have multiple health problems owing to medication, physical and imbalance because of advanced age among others. However, environmental factors like slippery floors, unreachable belongings, and toilet needs increase the chances of patients falling. According to the Center for Disease Control and Prevention (CDC), if fall injuries are not mitigated, health costs will be more than $ 43.8 in the next five years (Mitchell et al., 2014). Several medical institutions like CDC propose the adoption of nursing hourly rounds to reduce fall incidences and save substantial costs related to fall injuries.
Various health institutions have in the past implemented various falls prevention programs. Most of the programs are not sustainable. Hourly nurse rounds are promising strategies. Conducting proper rounding enables nurses to monitor and resolve most of the noted patients’ needs. Offering purposeful and timely hourly rounds is one of the best interventions to ensure patient safety and minimize fall events by proactively addressing patient safety. Health institutions have endorsed this practice as one of the best ways of reducing pressure ulcers, call light use and fall injuries by offering a patient-centered care (Tzeng, 2011).
Despite evidence being available supporting hourly rounds as an effective fall prevention strategy, not all nurses are willing to adopt the concept. Opponent of this concept claim that hourly rounds will increase nurse workload (Tzeng, 2011). Since hourly rounds involve documentation, nurses perceive this practice as involving. Contrary to such perceptions, studies reveal that nurse hourly rounds increase nursing efficiency, hence reducing paperwork at the same time improving the overall patient safety.
Problem Description
Patients using call light buttons and nurse responsiveness to the call lights are two concepts that are inseparable because they all determine patients’ safety. How nurses respond to the call lights is closely linked to the prevailing circumstance by the time the call is placed (Tzeng & Yin, 2010). There is a common assumption that nurses are likely to respond to call light faster, hence limiting the patients’ risk of falling. Nurses’ perception of the call light differs in the general hospital settings. Some nurses perceive these calls as noise or as disruption to their normal tasks. For patients, this is the appropriate way of requesting to be assisted (Tzeng, 2011).
Delays in answering call light buttons are a common occurrence. Time taken by nurses to handle patients request varies depending on the workload. Most patients report having felt frustrated by delays in answering call lights. Even though call light use is more of a lifeline for hospitalized patients, it comes with several responsibilities for nurses (Tzeng, 2011). The effective use of call light can be affected by staff shortage and burnout, hence affecting patients care management. Nurses have reported incidences where patients use call lights even to problems that do not require the attention of the nurse. Patients use call light button mostly at mealtime and when they need to take their medication; unfortunately these are the times when most medical staff are busy (Tzeng, 2011).
With improved care management, patients expect to be attended to promptly using the call systems. Patients experience several challenges like visual loss, limited mobility, and even cognitive impairment resulting difficulties in using the call light when in need of help from nurses. Failure to reach the call light button can result in falls due to delays in being assisted (Emerson, Chmura, & Walker, 2014).
Making hourly rounds should be a part of the nursing practice, but it has been a controversial subject for decades. One of the challenges cited by nurses is following formal scripts. Nurses believe that the script is complex and rehearsed. Other nurses prefer using their authentic abilities (Emerson, Chmura & Walker, 2014). Making hourly rounds requires consistent communication to ensure that all the needs are met. For example, if a patient reports feeling pain greater than three, during the hourly rounds, the nurse should communicate to the personnel in charge to come up with immediate measures. Owing to staff shortages, implementing immediate responses can be challenging at times (Emerson, Chmura & Walker, 2014).
Nurses believe that making hourly rounds does not have much value especially in critical care units since nurses are constantly with patients (Harrington, Bradley, Jeffers, Linedale, Kelman & Killington, 2013). Even though nurses are within the vicinity, monitoring a patient’s progress does not mean they will automatically address the 4 Ps of care. Documentation is another challenge for nurses to adopt hourly rounding. With the expanded nurse roles, nurses’ workload has increased; nurses are expected to document completion of the hourly rounds on the whiteboards. Certain unforeseen circumstances may hinder the documentation process; this includes the patient's unstable condition and the limited human resource within the hospital. Initiating structured hourly rounds within the nursing routine practice is a challenge due to the dynamic nature of health care (Harrington et al., 2013).
To come up with evidence –based persuasive cases for changing nursing care delivery process, there is need for an in-depth understanding of the evidence that supports such changes. However, there is limited literature on clinical evidence about changes in the nursing practice based on hourly rounds. The only current studies are a narrative published in 2009 by Halm (Halm, 2009). Halm concluded that hourly rounds can reduce call light use and enhance patient satisfaction. Generally, for a change in practice to be achieved and be accepted, the change needs to originate from the affected individuals to promote ownership. With limited funding to address the nurse shortage, facilitating such changes that are directed by nurses is an uphill task. Furthermore, cultivating critical thinking among nurses can be an essential role for nurse administrators but with negative perception about the nurse roles, this cannot be easily achieved (Harrington et al., 2013).
Purpose
This capstone project aims at presenting evidence-based interventions that can be emulated to increase patient safety and patient satisfaction. The project hypothesizes that intentional nursing rounds will minimize falls at the same time reduce pressure ulcers and the use of call light.
Evidence from Review of Literature
Study findings indicate that 80 percent of falls in hospitals occur in situations where patients are not assisted in activities like toileting or when patients would want to change positions during admission (Halm, 2009). According to Halm (2009), staff responsiveness to call lights is very important. However, various issues like patient workload and shortage of staff limit nurses from effectively responding to patients needs in time. According to Hutchings, Ward & Bloodworth (2013), patients' constant use of call light buttons and the nurse response time can be influenced by several factors like staff shortage. Staff unresponsiveness affects quality care; the time the nurse takes in processing the patient's request can have a negative impact on patients (Hutchings, Ward & Blood worth, 2013). For example, in cases where patients request for medication to manage his pain, the nurse will take more time to consult with other medical personnel including the doctor to confirm the request before getting medicine to the patients. At the same time, this nurse might be having other tasks at hand that might prevent her from caring for patients as required.
According to Tucker et al., (2012) patients can wait for other simple processes like billing or discharge, but when it comes to personal needs like going to the washroom, some patients become impatient, hence resulting to adverse events like falls. Several hospitals are adopting strategies to enhance quality care and elimination of falls among patients. One of the commonly used strategies is implementing hourly rounding (Tucker et al., 2012). This strategy involves nurses or other ancillary staffs visiting patients after every hour to address some of the care needs. By addressing the four Ps of potty, positioning, pain and proximity of patients’ personal items, nurses are likely to decrease the anxiety levels among patients (Tucker et al., 2012).
According to Moran et al., (2011), by incorporating hourly rounding as a part of the normal routine, there are high chances of decreasing fall rates, especially among the elderly patients by 70 percent. With the on-going health care reforms, the hospital administrators need to address issues of safety by incorporating hourly rounding protocol as a part of the clinical practices (Moran et al., 2011).
Dyck et al., (2013) studied the impact of hourly rounding on reducing falls and accidents among elderly patients who are at high risk of falls. The article highlights the problem of patient falls that is likely to affect hospitals and healthcare facilities especially when there are elderly patients. The case for hourly rounding is that past research highlights the strategies being effective in reducing falls and improving patient safety. The hourly rounding change initiative was reported to be beneficial when healthcare teams collaborated to implement the changes and integration into the organization’s culture. The research findings indicate that initiating changes in the hospital settings to implement hourly rounding should take into account the strategies that facilitate collaboration.
Mitchell et al., (2014) sought to assess evidence linking hourly rounding with improved patient safety satisfaction and how this impacted administrators. The systematic review used the GRADE analysis to evaluating evidence supporting the effectiveness of hourly rounding. The search results were selected based on relevance to patient fall, call lights and the review was based on 16 studies that met the inclusion criteria. The article’s level of evidence makes it relevant to supporting the case for changes to support hourly rounding. The results of the review showed that there was moderate evidence linking hourly rounding on call light use and patient falls.
In a study by Salch et al (2011), the researchers compared patient satisfaction with both hourly and 2-hour nursing round system (NRS). The article also highlighted how differences in the rounding affected use of call lights, patient falls, and hospital-acquired bedsores. The study was undertaken over an eight-week period and all the patients were males. Nurses recorded call light and collected data, and this may have affected how they reported the results. Nonetheless, since it was all nursing staff who took part in the program they were duly informed about what was expected. Since the study result showed that there was significant reduction in using the call bells implementing the interventions were effective in improving patient safety and patient satisfaction.
Tzeng (2010) studied how call lights usage influenced nurse response to patients and how this influenced patient safety, falls, as well as satisfaction. The study considered nurses perspective with a survey conducted in four hospitals where 808 completed the surveys. Results of the cross-sectional study showed that patients mainly initiated class when requiring toilet assistance, when there were intravenous problems and administration of pain management. Less than half of the respondents (49%) agreed that patient calls influenced patient safety, but 77% agreed that the calls were meaningful but 53% of the participants pointed out that the calls interfered with the critical care roles (Tzeng 2010). The study results can be linked to changes in call light usage since nursing staff whose perception was that this was a priority at all times were concerned about how their actions affected patient safety.
In a similar study by (Tzeng, 2011) using the same data where 81.6% of the surveyed nurses pointed out that call lights were meaningful as they influenced clinical decision-making. Since the study, highlight how nurse responsiveness affects their response to call light. There is a need to survey the nurses’ perceptions for those working in the telemetry, oncology, and surgical medical units. Nurses’ response to call lights is associated with low risk of patient falls, and in the study, patient falls were highest in patient hospitals. The implication of this study on the project is that changes should be initiated but it is necessary to conduct survey to learn about nurses’ responsiveness and perceptions on using call lights.
In another multihospital study by Tzeng & Yin (2010), the researchers emphasized that call light responsiveness and call light usage need to be considered when evaluating nurse and patient satisfaction levels. The survey included responses of 1,253 family/ patient participants as well as 988 nurses. Delay in responding to call lights increased the risk of patient fall and compromised patient satisfaction, perceptions among patients/ family that nurse responses to call lights were more satisfied and used the call lights less frequently. Both nurses and patients had similar reasons calling for using the call lights. The study’s implication is that nurse should respond to call lights to improve patient satisfaction and patient safety.
Emerson, et al (2014), studied the relationship between hourly safety rounding and patient satisfaction on the pediatric emergency department. Hourly rounding was proposed as a strategy to increase involvement of families and patients in patient care. The researchers also surveyed the families prior and after the interventions implementation. However, for the two weeks of study there was no noticeable positive change when using nursing call bell. This calls for more evidence to determine the impact of hourly rounding in pediatric emergency settings. If the study can be replicated in different hospital settings, it would provide information about the benefits of hourly rounding.
According to Harrington et al., (2013), intentional hourly rounding reduces the need for call bell usage, and this approach may be prefer since it is patient –centered. The researchers reported that implementing intentional hourly rounding was associated with improved patient care and satisfaction. There was also noticeable decrease in using the call bell, while this did not compromise patient safety, care provision, and satisfaction. Rounding should be purposeful, and when nurses make regular rounds dedicated to improving patient care, the patients expect that they will be offered assistance without requiring use of the call bell use.
Tucker et al (2012), assessed the impact of structured nursing rounds interventions (SNRI) in reducing patient falls, and the researchers sample was based on orthopedic units where there were 2 twenty-nine such units. The study method and design focused on collecting data on fall rates and risk during implementation of a fall risk prevention program and 1 year follow up after the implementation. The structured rounds that focused on the 4 Ps had mixed results the fall rates for the 1000 patient days were, 4.5, 1.6 as well as 3.2 for three phases of the implementation. Even though the fall rates decreased after the SNRI interventions were implemented the rates rose again one year after implementation. The significance of this article is that nurses need to assess evidence-based practice to determine the right course of action when making clinical decisions.
Hutchings et al (2013), proposed that hourly rounding should focus on improving patient comfort, where healthcare works anticipate the patients healthcare needs and interact with them to provide patient-centered care. The study was based on the experiences of the Nottingham University Hospitals. Hutchings also visited various hospitals and noted that those who were successful with intentional rounding encouraged nursing positive engagement with patients where leaders supported changes and rounding. The article then supports the proposed change with an engaged leadership who support that intentional rounding to improve patient health outcomes. Leaders should also consider staff and patient feedback when undertaking changes to implement intentional rounding as this demonstrates where the proposed changes are effective in improving patient safety.
Moran et al (2011) also evaluated the effectiveness of nursing hourly rounds, but in the mental health wards. The case for this study is that nursing rounding has been associated with improved patient safety for different hospital units, but few studies have looked into metal inpatients. Nursing hourly rounding was adapted to cater to the needs of the psychiatric patients, and for those who found nurses visits as intrusive there was a decrease in the number of hospital visits. As the program was implemented, most patients were comfortable with changes of hourly rounds. The results of the interventions was improved patient outcome, this implies that regular and purposeful nursing rounding is necessary, but patient needs and circumstances should be considered.
Frequency of nursing rounds differs depending on the patients’ conditions and hospital settings. Patients under intensive and critical care receive more frequent checks, with intentional rounding in many cases been on an hourly basis or after 2 hours. Halm (2009) evaluated evidence linking intentional rounding with patient safety. Among the chosen articles and reports, direct caregivers were more likely to undertake interventions at a frequency of 1 hour. Instituting intentional rounding was associated with a reduction in call light usage. In eight of the nine studies, the researchers reported improvement in patient satisfaction when nurses responded to in a timely manner and rounding programs were undertaken. Additionally, evidence suggested that 72% of the patients were certain that nurses would meet their needs when they made regular rounds compared to 52% when the nurses and caregivers failed to make regular rounds (Halm, 2009).
The process of rounding is necessary when checking patients at regular time intervals and meet their needs. Meade et al (2006) focused on the impact of hourly rounding in reducing the use of call lights among patients and how this influenced fall rates and patient satisfaction. The quasi-experimental study used a sample of 27 nursing units compared both hourly rounding and, rounding after every two hours and control group with no rounding hours. The results of the study support the proposed changes since the hourly round intervention was associated with significant patient fall reduction where there were twenty-five falls prior to the study, but only twelve falls after hourly rounding was undertaken for the 4 weeks where p=0.01.
A report by Studer Group (2007) focusing on the Sacred Heart is 76-bed acute care facility in Pensacola; Fla documented the impact of hourly rounding on patient health. Hourly rounding was initiated in 10 nursing units within 5 months and reported that patient falls were down by a third, call light usage also decreased by 40-50%. Additionally, hospital-acquired pressure ulcers were down by 56%, while patient satisfaction also improved by 71% (Studer Group, 2007). The hospital compar...