Giving nursing staff the flexibility to determine how hourly rounding will work best on their units is key to success, says Barbara Edwards, MSN, CMSRN, CNL, clinical nurse leader, at Florida-based St. Lucie Medical Center.
It has taken more than three years, two failures, and an epiphany about how to make change stick. But nurse leaders at St. Lucie Medical Center are enthusiastically calling hourly rounding a success seven months after piloting the much-talked about patient safety strategy for the third time on St. Lucie’s med-surg unit.
The unit recently attained the hospital’s highest score for patient satisfaction—a difficult-to-attain accomplishment for any med-surg unit. Plus, patient falls have decreased and call bells are ringing less often.
Another sign of success from an operational perspective: Hourly rounding has now successfully spread to two other units at St. Lucie—and nurses from across the hospital are clamoring to implement the strategy in their areas, too.
This is music to the ears of Barbara Edwards, the clinical nurse leader who spearheaded the initiative. That’s because she has learned by trial and error why St. Lucie—and she believes, many other hospitals—often have difficulty making hourly rounding stick.
Few, if any, nurses would argue that hourly rounding is not good thing to do from a patient safety perspective. But nursing leaders also need to consider the impact that rounding has on their nurses’ workflow. Mandates from nursing leaders as to how rounding should be conducted may not be received well by staff nurses—and may ultimately fail.
A better approach, and one taken by St. Lucie: “Give the unit nurses some flexibility as to how rounding will work,” says Edwards. “When they have input, they will find some way to make it work.” That’s how St. Lucie came up with a
successful version of hourly rounding that is all their own.
What Didn’t Work
The first time medical-surgical nurses at St. Lucie Medical Center gave hourly rounding a try, it was a major success—for a brief window of time. The unit followed a typical hourly rounding approach: At the top of every hour, nurses would check in on all of their patients to ensure their safety and that their needs were being met.
At the end of the pilot, the 43-bed med-surg unit documented several key improvements—as predicted by evidenced-based research on hourly rounding. Call bells decreased, pressure ulcer rates decreased, and patient satisfaction increased.
But the celebration was short-lived. As soon as the initiative fell off the radar of senior nursing leaders, hourly rounding fell by the wayside.
“From the nurses viewpoint, they saw hourly rounding as in interruption to their workflow rather than a helpful strategy,” says Edwards. “Nurses were expected to stop whatever they were doing at the top of every hour and visit their patients—even if they had just visited a certain patient 10 minutes before.”
In a second attempt at hourly rounding, Edwards tried having the certified nursing assistants (CNAs) handle the hourly rounding if they were less busy than the RNs. “But that didn’t work either. It didn’t foster teamwork. If nurses were busy, they wondered why the CNAs weren’t busy.”
The Epiphany
Not one to give up easily, Edwards went looking for ideas on how she might get her nurses to enthusiastically embrace hourly rounding. She found the input she needed at the Institute for Healthcare Improvement’s (www.ihi.org) annual conference last December.
“I got some good ideas on how different hospitals accomplish culture change,” she says. “I realized that sometimes the biggest hurdle is getting people to buy into what we want to change.”
Edwards learned another key lesson: Start small. “Sometimes you need to start as small as one nurse,” she says. So I started with just myself.”
On January 12 of this year, Edwards started making hourly rounds on her own every day—trying to visit all the patients on the 43-bed medical-surgical unit. She wanted to see for herself how much time and effort was involved.
To paraphrase the popular saying, curiosity eventually caught some nurses: “Soon some nurses started asking me what I was doing, so I told them,” says Edwards. “Then some of the nurses said they wanted to help me. This kept growing. Eventually, we picked one side of one hallway to start hourly rounds on. Then, our numbers grew to half the unit. And then the other half of the unit asked why they couldn’t be involved.”
By mid-February, Edwards had enlisted all the nursing staff on the unit into giving hourly rounding another try—just one month after she started her one-nurse brigade for patient safety.
“All the nurses were very involved spreading the change. I put it forth as a patient safety initiative, and then I gave the nurses the authority and power to make this work for our patients.”
What Has Finally Succeeded
The med-surg nurses essentially threw out the traditional hourly rounding model where each nurse or CNA rounds on her own assigned patients. This approach didn’t give staff the uninterrupted time they needed to devote to medication reconciliation, documentation, or patient education.
Instead, all unit RNs, charge nurses, and clinical nurse leaders now sign up for just one hour a day (e.g., from 9 a.m. to 10 a.m.) to round. During low census times, this increases to two hours per day. The nursing assistants also participate, signing up for two hours of rounding per day.
The catch: Nursing staff do not just see their own patients during this period of time—they visit about 20 to 23 patients on the unit, depending on the census. “We split the unit in half. So one nurse or nursing assistant rounds on one half of the unit; the other rounds on the other half.”
The day and night shifts have also set specific hours for regular rounding, taking into account when rounding is unnecessary. For example, there’s no rounding at 7 a.m. or 8 a.m. because staff are in patient rooms a lot during these times for bedside shift reports, patient assessments, and medication dispensing.
Tender Loving Care
When speaking with patients, nurses at St. Lucie describe the hourly rounds as “TLC rounds”—with TLC standing for tender, loving care. “We make sure staff are asking patients about their comfort and care,” says Edwards.
For nursing staff, TLC also represents patient safety items to check for when rounding:
T = Turn the patient, if need be, and ask “May I help you to the bathroom?”
L = Listen to any concerns or questions, look at the environment for safety issues, make sure the patient’s personal items are in reach.
C = Comfort, care, and communication (e.g., assess for pain, temperature, repositioning, unit noise that is bothersome)
The rounding nurse tries to fulfill any needs she or he can—while still meeting the goal of rounding on 20 some patients in an hour. Nurses immediately identified this as a challenge—and suggested solutions. Now, CNAs are called in to help with bathroom trips, etc. Also, if the patient has a major request (for example, pain medication adjustment), then the rounding nurse calls the primary nurse to see if he or she can address the issue.
Celebrating Successes
Edwards stresses the importance of continually showing nurses why rounding is important. Every week during the rounding pilot, Edwards posted patient satisfaction scores and patient fall data so unit nurses could see the dramatic improvements. “It really helps staff to visualize and see how patient care is improving based on actions they are taking,” she says.
Interviewed for this article:
Barbara Edwards, MSN, CMSRN, CNL, clinical nurse leader, Port St. Lucie, Fl (Barbara.Edwards@HCAHealthcare.com).