DESPITE A GROWING BODY of literature documenting the value of new evidence-based practices, some of these practices are not always implemented effectively in clinical nursing practice.1-4 Hourly rounding, as described in this study, is an example of this. Hourly rounding is a systematic, proactive nurse-driven evidence-based intervention to anticipate and address needs in hospitalized patients.3 According to the evidence, effective hourly rounding can promote patient safety,3,5 foster team communication,2-8 and improve staff ability to provide efficient patient care.2-4,8 The effectiveness of hourly rounding has been measured by tracking call bells,9 patient falls,3,5,6,8 and patient and staff satisfaction.2-8,10

BACKGROUND AND PURPOSE

A 981-bed multicampus, regional health network introduced hourly rounding to all inpatient units in 2007 with mixed results. The roll out of the network hourly rounding initiative began as a pilot program on 1 unit where the process was readily embraced by the staff. Later, other patient care units also successfully integrated hourly rounding into their unit workflow. Some patient care units, however, were less successful with rounding. This mixed success of the implementation of hourly rounding prompted the network's nursing senior management to request a study at the largest of the network's hospitals to explore the barriers to integration of the hourly rounding process on 2 units where the introduction of rounding was less successful. The results of that work are described in this article.

LITERATURE REVIEW

The practice of hourly rounding may vary from 1 institution to another, and even from 1 patient care unit to another, but there are certain aspects of the process that are common across all settings.2-4,8 Nursing staff typically begin hourly rounding by introducing themselves to the patient and explaining the process. The patient is told to expect to see a staff member for care every hour. During these visits, the staff member assesses and addresses the patient's comfort needs; personal needs, such as toileting, positioning, and pain; and the safety of the room environment. Prior to leaving the room, the staff member asks the patient about any unaddressed needs. Once these needs are met, the patient is told when a staff member will return.3,5,8

Hourly rounding outcomes

Researchers have studied the impact on quality outcome indicators resulting from the introduction of the hourly rounding process on multisite medical/surgical units,3,6 single units,5,7 and in a specific orthopedic population.4 Each study sought to measure the influence of hourly rounding on selected outcomes, such as, a decrease in the number of call bells per shift, a reduced number of patient falls, reduction in pressure ulcers, increased patient satisfaction with care, and increased satisfaction of nursing staff because of enhanced team communication and teamwork.2-8 Patient satisfaction was the most common outcome variable reported. Although different measurement tools were used, each study reported a statistically significant improvement in patient satisfaction scores.2-8

Some studies focused on the number of call bell alerts, which were considered indicators of effectively anticipating patients' needs. The number of call bell alerts was counted before and after implementing hourly rounding, and in each reported study, there were significant reductions.3,6,8 Hourly rounding also was associated with increased nurse satisfaction by providing nurses additional time for bedside care. Leighty10 described an association between hourly rounding and reductions in the number of nurses' steps. Several researchers suggest that effective hourly rounding can increase staff satisfaction because of enhanced teamwork and communication.2,6,10

Translation of evidence into practice

Translation of an evidence-based practice change is challenging and complex, with no one proven effective method to guide successful implementation. Nursing experts identify several essential components to the successful translation of an evidence-based practice. These components include understanding the complexity of the intervention, completing a comprehensive assessment of adopters, and a well-designed implementation and communication plan.11-15 In addition, researchers stress the importance of evaluating the process and outcomes of translating an evidence-based practice change.15,16 It is important to identify measurable, sensitive outcomes that will evaluate the success of the initiative being implemented, in this case, hourly rounding.15 Much of the literature details the benefits of implementing hourly rounding, but little is written about how to identify barriers to implementation at the unit level.2-8,10

METHODS

This study was reviewed by the health network's institutional review board and approved as a quality improvement study. Two inpatient units where hourly rounding was not consistently practiced were chosen for further study because of their similar patient demographics, campus location, and physical work environment. Unit 1 was a neurological and surgical unit, and Unit 2 was a transitional trauma and surgical unit. Both units had 35 beds in semiprivate rooms and were located in the largest of the network's 3 hospitals. Staffing ratios were similar on both units. Unit leaders on both of these units embraced the study and were eager to understand the reasons for ineffective hourly rounding practice on their units.

Ethnography was the theoretical and data collection methodology used for this study. Ethnographic methods allowed the study team to listen to what people on the study units said, understand their perceptions, and see what the staff were doing.17-22 Ethnography enabled descriptive, focused observations regarding how unit staff was performing hourly rounding.18-22 The study team, consisting of 4 nurses working in a research department, was trained in ethnographic observation and interviewing by the study leader, a doctoral-level nurse-anthropologist experienced in ethnographic research.

As a first step, interviews were conducted with 13 stakeholders, including nursing administrators, unit managers, and those involved in developing and implementing the hourly rounding initiative. These interviews were conducted prior to the observational component of the study and provided background information about the hourly rounding initiative. Interviews were audio recorded with permission and were downloaded to a secure folder on the study team's computer.

Next, the team reviewed existing documents and presentations about the hourly rounding process that were prepared by the nursing administration. These materials provided insights into how hourly rounding was explained to frontline staff and unit managers, including how the process was to be carried out on patient care units.

After analysis of the background interviews and documents, the study team conducted ethnographic observations and interviews on the 2 study units for 1 month in spring 2010. Two team members were assigned to observe and interview staff on each study unit, individually observing for 2 to 3 hours at a time, and also to conduct impromptu interviews with available unit staff. A total of 40 hours of observations were conducted on each unit during all shifts, including weekends. The study leader also conducted observations on both units to cross-check the observational data.

Registered nurses (RNs) and technical partners (TPs; unlicensed nursing support staff) from each unit and shift spoke with researchers when not performing patient care tasks. A total of 48 staff members (29 RNs and 19 TPs) from the 2 units were interviewed. Staff interviews were not audio recorded to ensure confidentiality for respondents. Interview questions focused on topics including process, purpose, implementation, documentation, accountability, and successful measurement of hourly rounding. Interviews continued until data saturation occurred and a representative sample had been achieved. The "lived experience" insights from unit staff about the practice of the hourly rounding process on their units were essential to this study. Photographs provided useful information about the context of the study setting.

Data analysis

Interview notes and observation field notes were transcribed and imported into an NVivo 7 (QSR International 2001) database for coding and analysis. The study team members individually read through all the notes and transcripts to identify themes such as staff perspectives and comments about process dissemination, purpose of hourly rounding, process of hourly rounding, staff accountability, and other topics. A second round of coding involved collapsing the initial themes into 6 thematic categories as agreed to by team consensus. Results provided insights about whether hourly rounding was being practiced effectively on the 2 study units as well as staff members' thoughts about problems with the initial rollout of the hourly rounding initiative by nursing administration.

RESULTS

Themes identified from the ethnographic observations and interviews included (1) dissemination, (2) purpose of hourly rounding, (3) rounding process/workflow, (4) accountability, (5) staff attitudes about hourly rounding, and (6) patient safety. The themes are discussed in aggregate below because they were consistent between the 2 units.

Dissemination

From an examination of hourly rounding implementation materials and administrator and unit leadership interviews, it was clear that these leaders believed unit level staff had received adequate education about the purpose and process of hourly rounding. However, there were few details about how to do hourly rounding in the staff education materials examined by the study team. Nursing leaders were aware of unit-level problems with the hourly rounding process, including issues with staff responsibility and documentation of hourly rounding. Still, they believed their staff had received sufficient education on rounding and should understand how to perform the hourly rounding process.

Purpose of hourly rounding

Nursing leaders were able to clearly articulate the purpose of hourly rounding as improving patient outcomes and patient and staff satisfaction. However, they could not identify specific quality indicators that could be used to evaluate the success of this initiative. Leadership stressed the need for staff to become proactive in anticipating and identifying patient needs, instead of waiting for patient call bells and alarms. In contrast, most staff members from both units were unable to verbalize the purpose or logic behind hourly rounding.

Hourly rounding process and workflow

As defined by the current hourly rounding process materials at the network, RNs and TPs were to perform hourly rounding using specific steps to address patient needs and the room environment. Staff members were to initial an hourly rounding log sheet hung on the patient room door each time rounding had been completed. Although observations on both study units confirmed that nurses and TPs were in and out of patient rooms frequently, trips into a patient room were usually the result of a call bell alert and involved performance of a specific task. Before leaving the room, the staff member usually asked the patient if they needed anything. Few staff members were observed signing the hourly rounding logs as they exited patient rooms.

Staff from both units identified several problems that made it difficult for them to integrate hourly rounding into their patient care work. First, most of the staff respondents were unable to list the steps of the hourly rounding process. Observations confirmed there were also no visible cues on the units that RNs and TPs could view to reinforce the steps included in the hourly rounding process. Second, RNs and TPs were expected to share the responsibility for completing hourly rounding but, having received little guidance from leadership, were unsure how to divide up the rounding responsibility with each other for their shifts. Staff from both units indicated that while unit leadership should set expectations for the performance and tracking of hourly rounds, leadership also have a responsibility to educate and work with staff to identify how hourly rounding should be integrated into their current workflow. Also, respondents from both units indicated that it would have been helpful to have had a unit-based champion or rounding expert available to help them learn to integrate rounding into their workflow.

Accountability

Unit leaders reported that accountability for hourly rounding was monitored by reviewing the hourly rounding logs, which were to be signed each hour by the staff, as they completed hourly rounds. Leaders from both units said they reviewed the rounding logs periodically and addressed compliance problems or discrepancies with individual staff members. The logs, not part of the medical record, were not retained more than a few months. Information from the logs, which indicated completion of patient care activities such as toileting, was not recorded in any kind of central database for tracking purposes.

Nurses and TPs on both study units reported that performing hourly rounding was not an option, but an expectation of their unit leadership. However, staff expressed concerns about having to sign a log every hour. They also indicated that not performing rounds or completing the rounding logs would be reflected in their yearly performance evaluations. Observations confirmed that documentation on the rounding log sheets often was not performed hourly. Rather, staff members were often seen completing all of their log sheet entries at the end of their shifts.

Staff attitudes

Registered nurses and TPs from both study units overwhelmingly viewed hourly rounding as more work instead of a proactive process that might have benefits for them and their patients. However, some staff members did feel that hourly rounding was a good idea but difficult to accomplish because of competing priorities and tasks. Some of these respondents also said that they did not feel a sense of ownership of the hourly rounding process and reported that hourly rounding was a top-down process imposed on them. These staff members were interested in knowing the origins of and logic behind hourly rounding and desired proof that the hourly rounding process would be effective and provide benefits for their patients.

Patient safety

One stated goal of the hourly rounding initiative was to improve patient safety. However, neither administrators nor staff could point to specific patient safety outcome indicators that might have improved with implementation of hourly rounding. There were also no variables on the log sheets that leaders or staff could point to as outcome measures that could be tracked for improvement as a result of hourly rounding.

Staff members on both units took patient safety seriously and easily verbalized safety measures, such as assessing pressure ulcers or taking appropriate measures on the basis of fall risk. Staff also stated that they addressed the patient's room environment to remove hazards and emphasized that it was important to make sure the patients always had their call bell within reach so they could alert staff if they needed assistance. However, no staff respondents were able to link hourly rounding with patient safety.

DISCUSSION

Despite a well thought out hourly rounding communication and dissemination plan similar to those that had worked with past patient care process changes, the implementation of hourly rounding did not translate well, especially at the 2 studied units within our health network. There appeared to be a gap in understanding of the benefits of hourly rounding between administrators and frontline staff on the study units, as well as lack of clarity about how to implement hourly rounding into the patient care workflow.

Communication and documentation

Clear communication and education about a new process being implemented on a patient care unit are essential because staff members need to know why they are being asked to perform a new task and what the new process means for patient care.23-25 Communication and documentation of the new evidence-based workflow process for hourly rounding could have been improved. Staff members needed to understand what hourly rounding was and how to perform it.

Staff accountability for hourly rounding seemed to be focused on documentation rather than on the staff's ability to carry out the standard process for hourly rounding. The current hourly rounding log sheets did not reinforce the steps of hourly rounding but rather contained checklists of tasks, for example, toileting, or statements such as "needs met" that did not clearly link hourly rounding with patient outcomes such as a reduction in pressure ulcers or patient falls.

Unit-level educational support, including checklists and behavior prompts, are important in embedding new processes into unit workflow.16 Staff from both units wanted to know how to do hourly rounding, but after the initial education, no educational support or other information about the step-by-step hourly rounding process was provided. Such educational materials might have enabled staff to review and reinforce the process for themselves. Furthermore, neither of the 2 study units had unit-level champions who could have modeled how to do hourly rounding for their peers and reinforced the benefits of it.24,25

Process implementation

Implementation of hourly rounding as described in this study could have been improved in several ways. Areas for improvement of the process rollout included the need for increased clarity about the purpose of hourly rounding, better instructions about how rounding should be performed and documented, and clearly defined measures of staff accountability for process performance. Also, well-chosen, sensitive outcome measures to evaluate the initiative should be defined and measured. Results of these evaluation measures should be provided back to unit staff to show them the results of hourly rounding.16,24,25

Process evaluation

Evaluation is another important component of successful translation of evidence into practice.16,23,25 The hourly rounding implementation at this hospital network would have benefited from the use of a quality improvement framework such as plan do study act (PDSA). Use of a framework would have prompted administrators to identify outcome variables they could use to study the implementation of hourly rounding as well as the effectiveness of hourly rounding in improving patient care quality.16,23

One challenge to evaluating the translation of hourly rounding into practice is finding meaningful outcomes that are easily measured to show that hourly rounding is making a difference in patient care.16,23,25 While patient satisfaction and other quality outcomes such as fall and pressure ulcer rates are routinely tracked on the units, fluctuations in these measures could not be attributed directly to hourly rounding. No measures were tracked specifically to evaluate hourly rounding as many of the outcomes suggested by the literature3-10 were too difficult to measure in the setting, for example, tracking call bells. Information collected on the log sheets could not be used to track the value of hourly rounding in improving patient care because it did not relate directly to variables that could be used to evaluate the impact of hourly rounding. Therefore, the link between hourly rounding and quality care did not exist for staff, and subsequently there was not a high value given to the hourly rounding process.

Regarding patient satisfaction, the most common outcome measure cited in the literature,2-8,10,16 no additional satisfaction assessments were undertaken at the hospital network other than the commercially administered survey that patients receive by mail after discharge. Patient satisfaction as measured by this survey did not change appreciably on the study units after implementation of rounding, possibly because it was already fairly high and hourly rounding was not practiced effectively.

Currently there is little information in the translation literature about how to evaluate step by step why a practice change has not been successful.16,23,25 This study illustrates how to use qualitative methods to assess the effectiveness of patient care processes such as hourly rounding at the unit level. Similarly the results show the importance of frontline nurses as valuable sources of information for process improvement studies.

Next steps

The next step is to translate the findings from this study into a meaningful redesign of the hourly rounding process. Recommendations for the hourly rounding redesign group will include the following: (1) a more extensive assessment of adopters, particularly early adopters who can champion the process for unit staff; (2) use of the network's leadership development model to help train unit-level champions to lead this implementation effort; (3) inclusion of unit-level staff at all phases of the redesign; (4) establishment of a more robust communication and education plan; (5) use of a project management and/or a quality improvement process such as PDSA to enhance the strength of the redesign; and (6) identification of meaningful outcome indicators, such as falls or pressure ulcers, that can be used to evaluate the effectiveness of hourly rounding.

CONCLUSIONS

Results from this study indicate that translating complex evidence-based interventions into clinical practice can be fraught with challenges and unintended results. Implementation must be carefully planned and carried out with the needs of frontline staff as a major consideration. Also, a strong evaluation plan with meaningful outcomes is essential to document for staff that the intervention is working.

This study provides an example of how to evaluate problems with the implementation of evidence-based practices at the unit level. Nurses and nurse managers at other hospitals should be able to replicate this work to continue the understanding of issues related to problems with the translation and implementation of evidence-based practices.

REFERENCES