Design for Change, Capstone Project Example

Introduction

Adult patients in an acute care setting primarily rely on the call light to gain a nurse’s attention. However, a series of recent studies indicate that call light usage impose substantial strains on a nurse’s time (Meade, Bursell, & Ketelsen, 2006). In fact, the majority of the aforementioned studies indicate that the frequent use of call lights have an adverse effect on patient care management. Patient care is already compromised by nurse shortages, job dissatisfaction, and burnouts (p. 59). Nursing services are paramount to the quality of care a patient receives, and is therefore crucial to patient satisfaction. However, numerous studies indicate that patients who use call lights typically do so for non-life-threatening reasons. For instance, Olrich, Kalman & Nigolian (2012) found that the primary reasons for call light usage include bathroom/bedpan assistance, accidental call light usage, room door needs to be closed, and food or drink requests (p. 24). As such, many call light requests can be efficiently handled by certified nursing assistants (CNAs), instead of RNs or LPNs (Meade, Bursell, & Ketelsen, 2006). The primary purpose of this paper, therefore, is to determine the effect of hourly nursing rounding for adult patients in an acute care setting, with regards to patient safety, compared to the provision of scheduled treatments and responding to call lights. The author will provide ample evidence that the implementation of hourly rounds by nurses will significantly improve patient safety and satisfaction, and will simultaneously reduce the use of call lights, thereby improving nurse effectiveness and overall job satisfaction.

A Need for Change in Practice

The primary focus of this paper is to provide evidence that patient safety and satisfaction will improve if nurses implement hourly rounds, instead of providing scheduled treatments and responding to call lights. Rosswurm & Larrabee (1999) developed a model that will guide healthcare professionals through a methodical process for the change to evidence-based practice. The authors propose that systematic change can be deemed successful if patient outcomes improve as a direct result of change (p. 318). The Rosswurm & Larrabee model consists of six steps to successfully implement change. The first step is to assess the need for change (Rosswurm & Larrabee, 1999, p. 318). As stated before, current practice for adult patients in an acute care setting relies on scheduled treatments and call lights. In other words, nurses respond to a patient’s needs only if the patient requires scheduled medication or surveillance, or if the patient calls for a nurse through the use of a call light (Olrich, Kalman, & Nigolian, 2012, p. 23). Patients often require assistance with basic self-care tasks, such as going to the bathroom, or eating. In the event that a patient requires assistance, he or she will use a call light. However, with the current practices in place, patients have voiced their dissatisfaction with the quality of care provided. Because current practice requires the nurse to only visit a patient when he or she requires medication or specified treatments, the patient goes for prolonged periods of time without nurse interaction. If that patient experiences the need for a nurse during a period of no interaction, he or she is inclined to use the call light to gain a nurse’s attention. In nearly 60 percent of all call light usages, the patients simply needs bathroom or bedpan assistance, has comfort concerns (such as repositioning), or has other personal needs (p. 23).

Link the Problem, Interventions, and Outcomes

The second step of Rosswurm & Larrabee’s (1999) six-steps to designing change is to discuss the problem, identify potential interventions, and identify the desired outcomes as a result of the change. The problem with current practice is that patient safety and satisfaction is compromised. For instance, a nurse who is tending to another patient’s medication needs at a particular moment is obligated to tend to the patient who used the call light. In many instances the patient who used the call light cannot wait any longer to address his or her needs, such as using the bathroom, and attempts to do so without a nurse’s assistance. This often results in patient falls and subsequent injuries (Meade, Bursell, & Ketelsen, 2006). The lack of nurses to immediately respond to a patient’s needs therefore compromises the patient’s safety and promotes the likelihood that the patient will voice dissatisfaction with the quality of care. In addition, increased call light usage aids in fatigue and burnout effects among hospital staff (p. 59). A change in practice will improve patient safety and satisfaction, and consequently improve working conditions for nurses.

A solution to this problem is the implementation of hourly rounds. A variety of studies indicate that patient satisfaction is directly related to nursing practices (Ford, 2010). Factors such as trust, compassion, continuity of care, and service quality are all determinants in a patient’s assessment of care satisfaction. In addition, patient safety plays a key role in patient satisfaction (p. 188). Recent studies found that hourly patient rounding significantly reduces call light usage, improves patient safety, and increases patient satisfaction (Bourgault, King, Hart, Campbell, & Swartz, 2008). Hourly patient rounding is a method of organizing current work, and was developed by the Studer Group (Ford, 2010). The premise of this model is to assess patient needs on a routine basis and address them accordingly. The routine method of addressing patient needs have proven to improve patient safety (p. 189). This method of practice allows nurses to address problem before they arise and to gather patient information in a structured manner. It is therefore a proactive means to address patient needs. In essence, hourly patient rounding requires nurses to check on patients on an hourly basis with the intent to adequately address their personal needs and enhance patient safety.

Synthesize the Best Evidence

The third step of Rosswurm & Larrabee’s (1999) six-steps to designing change is to provide the important findings within reviewed literature and to identify at least six studies in peer-reviewed articles that support the need for change (p. 318).  As mentioned before, current practice makes it increasingly difficult to monitor patient safety. Nurses cannot tend to all patients at once and this becomes even more difficult with higher levels of nurse shortages (Meade, Bursell, & Ketelsen, 2006). As a result, patients do not interact with nurses as regularly as they would like. As such, patients utilize call lights to gain a nurse’s attention to assist with personal care tasks, such as going to the bathroom or becoming more comfortable. Meade, Bursell & Ketelsen (2006), Miller, E.T. et al., (1997), and Sheedy, S. (1989) found that CNAs could easily tend to patients who use call lights. This would alleviate some of the stress associated with call light responses from RNs and LPNs. However, a shortage in nursing staff, combined with nurse fatigue will not adequately address issues of patient safety and patient satisfaction. Other studies found that hourly patient rounding significantly reduced pressure ulcers among patients in the surgical ICU, increased operational efficiency among nurses, and improved overall job satisfaction among nurses (Halm, 2003; Castledine, 2002; Dutton, 2003).

Design Practice Change

The fourth step of Rosswurm and Larrabee’s (1999) six-steps to design change is to describe how the desired practice change will be designed. Hourly rounding allows nurses to tend to patient needs on an hourly basis. This practice will be easily implemented because it is not new to the nursing field. In fact, hourly rounding was common practice for many medical institutions during the 20^th century, but became less popular as the field of nursing became less occupied (Ford, 2010). The most appropriate means to implement hourly rounding is to design a systematic schedule among all involved staff. In other words, there should be a logical system in place, which allocates specified times and locations for all nurses (Ford, 2010). Secondly, nursing staff should explain to patients that a nurse will check on the patient on an hourly basis. The patient should be informed that the nurse will address his or her personal needs every hour. The patient should also be informed that such surveillance will enhance patient safety and improve patient satisfaction (p. 189).

Implement and Evaluate the Change in Practice

The fifth step of Rosswurm and Larrabee’s (1999) six-steps to design change is to implement and evaluate the process of change and its outcome. Meade, Bursell, & Ketelsen (2006) found an improvement in patient satisfaction and patient safety, and a reduction in patient falls and usage of call lights after one year of implementing hourly rounding in 22 separate hospitals (p. 67). In fact, after one year of changing from scheduled treatments and responding to call lights to hourly rounding, there was a 60 percent reduction in patient falls and an 80 percent improvement in patient satisfaction (p. 67). There was also a significant decrease in call light usage after the implementation of hourly rounding. However, the authors found little change in the incidence of patient falls and call light usage when hourly rounding occurred every two hours (p. 68). In other words, two hours were too long for patients to be without nurse interactions. Patients either became uncomfortable, had to use the bathroom, or had some other personal need within a two-hour period. Meade, Bursell, & Ketelsen (2006) therefore argues that hourly roundings should occur every hour, and not every two hours (p. 68).

Integrate and Maintain the Change in Practice

The last step of Rosswurm and Larrabee’s (1999) six-steps to design change is to discuss how the change will be maintained. Given the evidence presented in various studies, change is most easily maintained when staff members are willing to participate. In other words, the implementation of hourly rounding in acute adult care units will only be successful if the nurses are willing to support and participate in the change (Meade, Bursell, & Ketelsen, 2006). Given the benefits associated with the implementation of hourly rounding, it is likely that nurses will participate. Doing so will increase their overall job satisfaction, and reduce instances of fatigue and job burnout.

Summary

Adult patients in an acute care setting primarily rely on the call light to gain a nurse’s attention. Most of these ‘attention calls’ pertain to personal needs, such as obtaining a more comfortable sleeping or sitting position, or going to the bathroom. Because current practice does not require nurses to check in on patients on a regular basis, many patients have infrequent interactions with nurses. As a result, patients become impatient and attempt many of these personal needs tasks on their own and end up falling or injuring themselves. These effects often result in decreased patient satisfaction and patient safety. It also impedes on nurses’ time and can aid in nurse fatigue, or job burnout. Meade, Bursell, & Ketelsen (2006) conducted a one-year study in 22 hospitals and found that the implementation of hourly rounding significantly improves patient safety and patient satisfaction. Hourly nurse rounds refer to the practice of a nurse checking in on patients on an hourly basis to ensure the patient’s comfort and ease. The study found a 60 percent reduction in patient falls since the implementation of hourly rounds, and an 80 percent improvement in patient satisfaction with regards to overall care. In order to ensure a continued reduction in call light usage, it is pertinent that nurses are willing to implement change. The evidence presented in this paper support the argument that hourly nurse rounding are far more beneficial to patient safety, patient satisfaction, and nurse job satisfaction than scheduled treatments and responding to call lights.

References

Bourgault, A., King, M. M., Hart, P., Campbell, M., & Swartz, S. (2008). Circle of excellence. Nursing Management, 39(11), 18.

Castledine, G. (2002). Patient comfort rounds: A new initiative in nursing. British Journal of Nursing, 11(6), 407.

Dutton, R. (2003). Daily multidisciplinary rounds shorten lenght of stay for trauma patients. Journal of Trauma, 55(5), 913-919.

Ford, B. M. (2010). Hourly Rounding: A strategy to improve patient satisfaction scores. Medsurg Nursing, 19(3), 188-191.

Halm, M. (2003). Interdisciplinary rounds: Impact on patients, families, and staff. Clinical Nurse Specialist, 17(3), 133-142.

Meade, C. M., Bursell, A. L., & Ketelsen, L. (2006). Effects of Nursing Rounds on Patients’ Call Light Use, Satisfaction, and Safety. American Journal of Nursing, 106(9), 58-70.

Miller, E. (1997). Nurse call systems: impact on nursing performance. Journal of Nursing Care Quality, 11(3), 36-43.

Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly Rounding: A Replication Study. Medsurg Nursing, 21(1), 23-36.

Rosswurm, M. A., & Larrabee, J. H. (1999). A model for change to evidence-based practice. The Journal of Nursing Scholarship, 31(4), 317-322.

Sheedy, S. (1989). Responding to patients: The unit hostess. Journal of Nursing Administration, 19(4), 31-33.