Clinical Question
The clinical question of interest is: In an acute care setting, can purposeful hourly rounding by nurses and interdisciplinary team members help decrease falls during a patient’s hospital stay compared to not hourly rounding at all?
- P: Nurses and members of the interdisciplinary team
- I: Purposeful hourly rounding
- C: Not hourly rounding at all
- O: Decrease falls
- T: During a patient’s hospital stay
Research into this study area is inspired by the relatively high number of falls in acute care hospitals, which goes as high as 13 per 1000 patient days (Di Massimo et al., 2022). These incidents also frustrate patients, clinicians, and the healthcare system. Besides, the falls apart from negatively impacting patient safety, they also lead to increased costs and length of stay, and in worse cases, they may translate to severe injuries and even death.
With this being a global healthcare issue, there is limited evidence and research that counteracts the risks posed through situation-specific fall prevention protocols. In this regard, purposely hourly rounding, which involves checking on patients hourly across the day and after 2 hours overnight, is a solution to this issue as it not only ensures proactive addressing of patient needs but also ensures that checks and balances are in play to prevent falls from arising through structured monitoring. Thus, the research paper looks at two qualitative and one quantitative article to provide evidence to support the clinical question.
Database Used
The database used to source the two desirable articles is PubMed. It was developed in 1996 and is under the maintenance of the National Center for Biotechnology Information (NCBI). PubMed is a free resource that supports the retrieval and research of life sciences and biomedical literature focusing on global and personal health improvement. It has over 34 million citations and abstracts and provides links to full-text articles. The sources within the database are drawn primarily from online books, MEDLINE, and life science journals. Thus, it offers valid and reliable studies relevant to the clinical question and contributes significant evidence to the research question.
Evidence-Based Quantitative Article
The Article
With the search in the database limited to randomized controlled trials and articles published within the last five years, only five articles were found. With evidence and the clinical question used as a guide, the research was narrowed down to one piece. The article is titled Intentional Rounding versus Standard of Care for Patients Hospitalized in Internal Medicine Wards: Results from a Cluster-Randomized Nation-Based Study, and it is authored by Di Massimo et al.
Summary
The selected study focuses on the effects of intentional rounding and proactive regular-based patient monitoring on pressure ulcers and falls. This alone is directly relevant to the clinical question as it answers it now. The authors start by acknowledging the growing dynamism experienced in a healthcare setting and the need for healthcare professionals to assess and investigate new strategies that ensure healthcare quality is heightened while connecting these with evidence in line with meeting patient needs and ensuring time-cost efficiency and patient satisfaction (Di Massimo et al., 2022). The authors then shift their attention to those hospitalized with chronic or acute illnesses, holding that such patients, depending on disease severity levels, often require total concentration on their conditions.
Guided by the 2013 Francis Report, the authors note that in the recent past, there has been a blatant disregard for care fundamentals. They conducted their study within care framework fundamentals with influential contextual factors on patient satisfaction. A recommendation is thus made in the literature that nurses should focus on exteriorizing their contribution to care through the creation of positive relationships. They note that proactivity and intention are critical to purposeful rounding structuring. This has been the subject of interest in the past decade as issues such as patient falls escalate (Di Massimo et al., 2022).
However, the authors note that the various studies are generalized with fragmented results and little evidence of their position and applicability in healthcare systems. The authors also note that implementation is an issue from these studies, and these form the basis of the current research as the authors focused on analyzing intentional rounding’s effects in clinical practice with close attention to internal medicine wards, basic settings, and required care approach that is both emotionally centered but also clinical.
Study Approach, Sample Size, and Population Studied
Study Approach
The study, named FADOI-INTENTO, was a cluster-randomized controlled study. The cluster, in this case, was a hospital ward embodied by the Italian Scientific Society of Internal Medicine in association with the National Association of Nurses of Medicine (Di Massimo et al., 2022). As such, the intentional rounding study was delivered in the preliminary and active phases.
In the first phase, special training was offered to assist the parties involved in ensuring they were familiar with the procedures involved, including completing an IR log. This was pivotal in assembling data on healthcare professionals’ signatures, round time, and the activities engaged in. through the help of an expert. The training took place in four-hour interactive sessions with a minimum target attendance of nursing assistants and nurses of no less than 65%.
Throughout 24 hours, intentional rounding was structured with 2-hour rounds with performance executed by nurses or their assistants at the site of focus. It was based on the “4Ps” of possession, pain, positioning, and personal needs. In line with these, healthcare professionals were tasked with first introducing themselves to the respective patients and their families, followed by activities in line with individual care plans, and eventually performing these assessments. During night shifts, the intentional rounding focused only on visual safety checks. Upon the training completion, the professionals had to pilot the learned procedures for a week, during which the supervisor would do sample checks on the IR log with feedback provided.
Through this approach, the study’s primary outcome was the fall’s cumulative incidence and also that of pressure ulcers. The latter were to be graded based on the classification provided per NPUAP/EPUAP (Di Massimo et al., 2022). Secondary outcomes focused on bell calls amounts, nurses’ critical thinking ability, and patient satisfaction quantification based on care received. However, in their approach, the authors noted that it was pretty challenging due to enrollment challenges posed by the COVID-19 pandemic.
Sample Size
Twenty-eight hospital wards were essentially selected to represent the care level intensity in Italy and geographical distribution. The 28 were then randomly assigned based on a 1:1 ratio to intentional rounding or intervention (n=14) or standard care (n=14) through a predefined list and study center selection (Di Massimo et al., 2022). However, local authorities raised specific issues that rendered two sites allocated to usual care unable to participate. With this sample size, calculation estimates were drawn based on the pilot study done at a coordination center.
A two-tailed test established that with 485 subjects for both groups, 80% power would be detected with an assumed incidence rate of 20 events per 1000 person-days and an exposure period of 5 days in both groups at 0.05 significance level 1.0 conservative estimate. In this regard, between October 2019 and March 2020, 1822 patients were enrolled across 26 sites (Di Massimo et al., 2022). Only 779 were included in the Modified intention-to-treat population, with 400 under the intentional rounding arm and 379 under standard care.
Population Studied
The selected sites were a representation of internal medicine wards. All patients who were 18 and above formed the subject of the study, and those admitted consecutively into internal medicine wards were eligible (Di Massimo et al., 2022). However, no specific exclusion criteria were applied apart from express refusal through consent, as all the subjects were expressly informed of the study procedures through written permission.
Application of Evidence
The evidence provided herein is critical in applying intentional rounding to ensure a reduction in the rate of falls in acute care settings. This is because the evidence asserts that purposeful rounding addresses care fundamentals in vulnerable and complex patient populations. The evidence herein thus remains critical as the significant effect maintains that the reduction of falls favors intentional rounding adoption and patient safety (Di Massimo et al., 2022). Besides, from the review, it is clear that with purposeful rounding, nurses are more satisfied with their roles and responsibilities, significantly reducing burnout and job dissatisfaction.
Outcomes Evaluation
Primarily, the study established that there was about a 50% reduction in composite endpoint incidence, including falls, for the proactive intentional rounding method compared to standard care. There was an observed relative risk reduction at relatively elevated levels, with estimates of up to 80% (Di Massimo et al., 2022). It is also noteworthy that such a high reduction was attained despite those in the intentional rounding group being vulnerable to falling compared to the control group. These results were significant as they represented the essence of deliberate rounding on patient safety and its economic impact. It reduced the length of stay damage compensation requests, as well as additional treatments and examinations. Intentional rounding had relatively similar effects on pressure ulcers.
Validity
These outcomes remain valid primarily because they are presented in a peer-reviewed journal article. Besides, the results represent accurate findings drawn from similar individuals who did not participate in the said study. This is seen by how randomization was done highly, ensuring there was no sample bias. Moreover, there was a control group where results from the subject group could be compared directly to lead to the desired meaningful and trustworthy conclusions.
Reliability
The study and its findings are also highly reliable. Primarily, the results herein have been achieved by other studies using the same methodology, meaning that the findings are replicable. Besides, the study’s outcomes are precise and devoid of vagueness, which is critical in their reproducibility in other similar instances. There is also objectivity in the works based on their aims and how the findings are presented, which leads to elevated success in the study and its resulting results. In this regard, the data and information provided herein best fit the clinical question of concern. They can assist in establishing clear conditions and a basis for future research.
Study Biases
Primarily, bias was identified in the outcome. This essentially emerges from the fact that pressure ulcers were more frequent, yet sensitivity to intentional rounding was relatively lower than falls. As such, the lower results were, to an extent, shelved. Another bias in the study is attrition bias, which is based on the researchers’ use of the modified population for its assessment. There were also some differences in the baseline characteristics of the two groups involved, which could be attributed to selection bias, potentially affecting the final results associated with possible relations discomfort. Besides, blinding was not done, contributing to performance and detection bias.
Level of Evidence
The level of evidence presented from the study is level I in the hierarchy of evidence. This is because the investigation is a sizeable randomized control trial done in multiple sites. Besides, the randomization in the study is also of a high quality, which reflects the quality of results and the eventual outcomes obtained from the study. It thus shows the authority that the outcomes provided by this study pose while also assuring its replicability and its utilization in future research with the integration of the various factors.
Evidence-Based Qualitative Article
The Article
The qualitative evidence selected is titled Nurses’ Experiences and Perceptions of Hourly Rounding: A Private Australian Catholic Hospital Single Case Study. It was written by Francis et al. and was also drawn from the PubMed database.
Summary
The article begins by acknowledging nurses’ role as caregivers and ensuring that patients are safe with proper diagnoses in line with health status and the prevention deterioration interventions. In this regard, the authors provide information to facilitate and promote the essential role of nurses. There is a need for increased interactions between nurses and patients.
The nurses should always initiate this as part of their responsibilities. This is what the authors define as hourly rounding, which they believe, by extension, involves the identification of potential hazards, patients’ surveillance, patient health status monitoring, and immediate environment interactions (Francis et al., 2019). In this regard, the study is motivated by evidence that suggests that structured nursing rounds lead to positive patient outcomes as patients feel safer while leading to reduced adverse events such as falls with patient deterioration and medication errors also avoided.
However, the authors also acknowledge the existence of various barriers to the implementation of hourly rounding. This is attributable to competing priorities and tasks, heavy workloads, and limited time. The documentation associated with intentional rounding is also viewed as a significant concern coupled with reduced staff engagement and inadequate staff education. The authors also acknowledge the existence of the burden of time as reported by nurses. In line with this, the study aimed to comprehend the experiences that nurses have and their perceptions of rounding implementation, drawing from a 2014 study conducted on rounding practices targeting to enhance patient experience while reducing patient fall risk.
Study Approach, Sample Size, and Population Studied
Study Approach
The study approach was a qualitative exploratory, descriptive single case study design. In this regard, confidential individual interviews were conducted through a Heideggerian hermeneutic phenomenological interview. The questions herein were supplemented with probing for the sake of clarity or exploring the responses presented by the participants further. All the interviews were transcribed verbatim and digitally recorded using thematic and content analysis techniques to analyze textual data from the interviews (Francis et al., 2019). From these, the key phrases were then distilled and coded with explicit and implicit ideas embedded within the isolated texts. This enabled the explicated phenomenon of interest concerning nurses’ perceptions and experiences.
Sample Size
A total of fifteen nurses were involved in the study. Out of these, only one was interviewed on the phone for logistical reasons, while the rest were interviewed on-site and face-to-face at the hospital (Francis et al., 2019). Additionally, seven interviews were linked to a single researcher, while two researchers undertook the remaining eight.
Population Studied
The population of interest involved all enrolled and registered nurses who were, at the time of the study, contracted to the Catholic private acute care regional hospital in Victoria, Australia of interest. These were all the nurses who, at the time, were also engaged in implementing a 12-month intentional rounding period (Francis et al., 2019). However, participation was voluntary and based on consent, and another factor was the release time from the accommodated study. Out of all those who passed the criteria, only 40% participated.
Application of Evidence
The study presents nurses’ evaluations based on their perceptions and experiences of hourly rounding. Qualitative research is relevant as it offers a different dynamic to implementing intentional rounding in the case of falls. Furthermore, it provides critical and valid information on what can be done to make the technique more accommodative and more applicable in the case of the nurses based on creating a compromise between nurses, the tool, and the patients, which is pivotal (Francis et al., 2019). Moreover, it draws the reviews’ attention to the downside of intentional rounding, which makes it quite comprehensive, ensuring that it focuses on both the positive and negative sides.
Outcomes Evaluation
The findings assert that rounding is perceived as critical as nurses support it and its operationalizing protocol of practice. Further still, the study identified the model of care and ward activities as barriers that pushed nurses to modify their hourly rounding. Another obstacle was the intentional rounding of log documentation positioning outside wards, which the professionals felt barred them from completing the required paperwork (Francis et al., 2019). In this regard, the authors recommended a move to feedback and regular authentic consultation as a top feature of patient care and nurses’ health in line with their compatibility with intentional rounding.
Validity
The outcomes of this study are valid based on the extent to which the interviews were accurately recorded with transcriptions. Besides, each of the transcripts was read severally to ensure familiarity and a top distillation of the key phrases and, consequently, the results obtained. Additionally, the findings are interpretative and descriptive, meaning they are easily understood with comprehensive data.
Reliability
The study findings are also reliable as there is stability in how the multiple responses from the participants are coded. Besides, the devices used for recording also enhance reliability. Again, the findings are credible and transferable and can be quickly confirmed and verified.
Study Biases
Primarily, selection bias is evident as only nurses from a single ward were engaged. This, to an extent, limits the study considering that the hospital of focus was also a private hospital. Additionally, the interviews were also limited to a single time point. In this regard, if these perceptions were to be measured at different times, different perceptions would have been revealed and even further insights on rounding practices.
Level of Evidence
The article, in this case, is classified as level VI evidence. This is because; it presents evidence from a single qualitative study. This type of evidence is quite limited as it is based on opinion, which varies from time to time and is held differently by different people. Nonetheless, they present evidence directly from those affected without posing any form of arm or limitations, as people can express themselves as they wish.
References
Di Massimo, D. S., Catania, G., Crespi, A., Fontanella, A., Manfellotto, D., La Regina, M., De Carli, S., Rasero, L., Gatta, C., Pentella, G., Bordin, G., Croso, A., Bagnasco, A., Gussoni, G., Campani, D., Busca, E., Azzolina, D., & Dal Molin, A. (2022). Intentional rounding versus standard of care for patients hospitalized in internal medicine wards: Results from a cluster-randomized nation-based study. Journal of Clinical Medicine, 11(14), 3976. Web.
Francis, K., Kurtsev, A., Walter, D., Steele, C., & Staines, C. (2019). Nurses’ experiences and perceptions of hourly rounding: A private Australian Catholic Hospital Single Case Study. International Archives of Nursing and Health Care, 5(2). Web.
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