Benefits of Intentional Nurse Leader Rounding in the ICU

Abstract

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Table of Contents

Abstract

List of Tables

Table 1: Project Plan

Table 2: Matrix of Evidence

Table 3: XXXXX

List of Figures

Figure 1: Flow Chart

Figure 2: Detail of an Experimental Lab

Figure 3: Diagram of Classroom

Chapter I: Introduction

Identify the Issue

Importance of the Project

Project Purpose or Goal

Criteria for Evaluation

Chapter II: Literature Review

Introduction

Body of Evidence

State of Science

Summary

Chapter III: Implementation

Introduction

Procedures

Results

Artifacts

Chapter IV: Evaluation

Introduction

Conclusions

Recommendations

References

Appendix A: Title here

Appendix B: Title here

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Chapter I: Introduction

Healthcare organizations are progressively more focused on enhancing the experience that patients have when they interact with various parts of the organization. Nurse leader rounding is an evidence-based strategy to effectively improve the patient experience. In order to make informed decisions, leaders must know what is occurring on the frontlines of their organizations. Nurse leader rounding provides leaders with the opportunity to gather actionable information for process improvement initiatives. With direct observation and active listening of patient feedback areas can be identified to enhance the patient experience. Additionally, nurse leader rounds help to develop increased levels of trust by demonstrating to patients that the organization’s leaders are paying attention to the day-to-day processes and quality of work being performed at the bedside. Utilizing nurse leader rounding as a strategy to identify opportunities for improvement and receive real time feedback assists in improving care coordination, comfort and safety of the patients they care for. In this assignment the evidence-based strategy of nurse leader rounding is reviewed, implemented and data interpreted to improve care coordination outcomes of a small acute care ICU unit.

Statement of the Problem

The problem addressed in this evidence-based practicum (EBP) is that there is currently no formal leadership rounding process resulting in inconsistent knowledge of patient, family and staff concerns. Knowledge gaps related to the patient care provided at the unit level create the opportunity for safety concerns, poor patient outcomes and legal action.

Importance of the Project

Many challenges are faced by todays nurse leaders, one of which is to ensure a safe quality care experience for hospitalized patients. The patient experience is recognized as on of the highest priorities among leadership though many leaders struggle to balance the numerous elements that impact the patient experience while providing outstanding care. Nurse leaders are in a position to foster the changes necessary within their departments that impact patient experience and ensure consistency and quality in the delivery of care on a continual basis. Changing the communication patterns within the healthcare delivery team and expectations surrounding dissemination information related to patient concerns involves the nurse leader’s commitment to purposeful and consistent rounding with patients.

Recent feedback received from a patient’s family on a poor patient outcome prompted organizational leadership to implement a strategy to improve communication between patients and nurse leaders on the unit. Implementation of intentional nurse leader rounding is expected to improve collaboration with the healthcare team and engage the patient and their families in the care process. Additionally, the first-hand knowledge gathered through the rounding process provides invaluable opportunities to monitor, identify and make clinical care improvements. Being at the bedside, communicating and listening to patients and families puts leaders in a position to receive ideas for improvements that may not filter up to them otherwise. Furthermore, implementation of nurse leader rounding provides the opportunity for leaders to observe whether current internal monitoring and data collection systems that impact patient satisfaction and quality of care are effective and whether the conclusions they are drawn from these processes are accurate.

Improving communication through the implementation of daily nurse leader rounding requires engagement from organizational leadership. Both the director and nurse manager in the ICU have recognized the need to implement change. Barriers to successful and consistent implementation include the time necessary to complete the rounding process. Sherman (2012) suggests that nurse leaders plan on 60-90 minutes each day at a time when they are least likely to interrupt care or treatment routines. When meeting with ICU leadership they also voiced the use of travel nurses related to unstable staffing and inability to hire qualified nurses as a concern with care quality. These economic concerns have the potential to impact the results of the study.               Patients being treated in the ICU may also lack capacity to verbalize and participate in the rounding process. Socially the patients often do not have family support and engagement in the rounding process. Cultural differences, literacy and language barriers can also impact the participation of patients and families in nurse leader rounding and completion of the HCAHPS survey post discharge. Recent technological changes in the hospitals EMR to EPIC may influence the current staff’s competency and comfort level leading to unfavorable feedback and highlighting areas for improvement in care coordination. Legally, the nurse leader must be aware of being compliant with HIPPA when rounding on patients. Ensuring that the patients private patient information is not released to unauthorized individuals and conversations with patients are held in a quiet and private space is important.

While many barriers to successful implementation have been recognized the strengths and benefits of implementing nurse leader rounding are far more valuable. According to Tappen, Wolf, Rahemi, Engstrom, Rojido, Shutes, & Ouslander (2017) there are six areas that facilitate change: organization-wide involvement, leadership support, use of administrative authority, adequate training, persistence and oversight on the part of the champion and unfolding positive results. The implementation of intentional nurse leader rounding currently has the support of organizational leadership and education has been provided to the nurse leaders completing the rounding process.

Using Lewin’s change theory to transform the patient experience in the ICU the nurse leaders can implement and sustain intentional nurse leader rounding. The first stage of change (unfreezing) involves preparing the organization to accept that change is necessary, which involves breaking down the existing status quo before you can build up a new way of operating (Hussain, Lei, Akram, Haider, Hussain & Ali, 2018). As the nurse leaders in the ICU begin to embrace the new transition to intentional nurse leader rounding shift from the unfreezing stage to change will begin. In order to accept the change in process and contribute to making it successful, organizational leaders need to understand how it will benefit and impact organizational outcomes. This is where adequate training on the rounding process will be crucial. In Lewin’s change theory the last phase (refreezing) requires intentional nurse leader rounding to be incorporated into everyday business. Establishing a set time frame for nurse leader rounding creates a routine surrounding the process and engrains it into the organizations culture. With a new sense of stability, the nurse leaders will then feel confident and comfortable with the rounding process and recognize the value and benefits.

Project Purpose or Goal

The purpose of the EBP is to improve HCAHPs in areas of care coordination from 65.2% to 90% within 10 weeks by implementing nurse leader rounding. Specifically, “During this hospital stay, how often was there good communication between the different doctors and nurses. With the implementation of nurse leader rounds, improvement in the patient’s perception of care, communication and patient safety will be recognized in the daily rounding logs. The purpose of implementing nurse leader rounding with patients is to ensure that the organization is providing safe, high-quality care to the patient; collect positive feedback for recognition of staff; and distinguish trends and opportunities for process improvement initiatives.

Criteria for Evaluation

Evaluation of the EBP will be highlighted by the improvement in HCAHPS data. The benefits of intentional nurse leader rounding will also be recognized in the feedback provided by patients and families. Through this communication, development of unit-based process improvement initiatives will improve patient safety, comfort and care coordination.

Conclusion

With no current policy for implementing and performing nurse leader rounding this EBP will focus on highlighting the benefits for future expansion of nurse leader rounds in the organization. Nurse leader rounding is the consistent practice of asking specific care related questions one-on-one with patients and families to obtain actionable information. Literature analysis of nurse leader rounding will further demonstrate the strengths, weaknesses and potential impact of nurse leader rounds and the resultant implementation of change that influences the patient experience.

Chapter II: Literature Review

For the purpose of this project electronic databases such as: Purdue University Global’s Online Library, PubMed, and The Cochrane Library were searched using the following keywords:

nursing, nurse leader, rounding, nurse leader rounds, patient satisfaction and leadership awareness

. Results within the databases were limited to full text, peer reviewed articles published within the last five years in an academic journal. The search found 126 articles in the databases. After careful review ten articles were included in the literature review. Several were excluded as they did not focus on leadership rounding but rather hourly rounding performed by bedside nursing staff. The literature review focuses on impact of patient satisfaction, leadership visibility, implementation of leadership rounding and the relationship with improvement in HCAHPS. To see a full layout of each study, refer to Table 2 in the list of tables.

Body of Evidence

Increasing leadership visibility at the unit level was identified in several of the studies reviewed. Kennedy (2016) suggests that leader involvement correlates to employee engagement. The benefits of nurse leaders that have quality relationships with frontline staff report higher levels of engagement and exhibit proactive behaviors to improve the organizational outcomes. The purpose of the study focused on identifying clinical nurses’ observations of executive leader visibility and offer advice for leader interaction to create an environment of improved patient care. Kennedy (2016) completed a descriptive study at a 461-bed suburban hospital. This study involved a survey that was distributed to 826 nurses via email. The survey included five open ended questions that focused on what empowers staff members to achieve goals and align themselves with the organization’s values. The completion rate for the surveys was 289 or 35% of those surveys distributed. In response to the survey questions, staff felt that 29% felt that leaders involved in clinical practice should be seen while other leaders’ visibility wasn’t essential. 61% of the respondents indicated that organizational leaders should be visible to clinical staff. Only 4% of staff felt as thought there was no need to see the leadership team. The small response rate reduces the reliability of the study and may not adequately reflect the opinions of the entire nursing population in the study. Kennedy (2016) found through staff feedback that visits during off shifts such as weekends and evening would improve staff connection to leadership. The feedback received through the employee engagement survey suggested that leadership communication, more recognition and greater respect of employees would assist in facilitating an environment of improved care. The value of leadership visibility is an important strategy to promote positive patient outcomes, ensure staff satisfaction and maximize efficiency in patient care.

One of the areas discussed in Reimer & Herbener (2014) is leadership visibility through rounds on the unit. The purpose of this study is to review the implementation of an assortment of rounding methods that improve patient safety and positively impact patient and staff satisfaction. Six types of rounds were implemented on 7C- a 26 bed hematology/oncology unit at Lehigh Valley Hospital. These rounds included hourly patient rounds, interdisciplinary collaborative rounds, daily clinical rounds by the nurse educator, daily patient rounds by the unit manager, quarterly rounds by senior nursing and monthly safety rounds by senior executives. Qualitative and Quantitative measures just that rounding strategies are tied patient satisfaction but no single rounding methodology can achieve patient/staff satisfaction and improved clinical outcomes. Through trending of data Reimer & Herbener (2014) found that with multiple rounding methodologies a reduction in patient falls from 1.5/1,000 patient days and reduction in development in pressure ulcers to 1/1,000 patient days. The rounding methodologies also improved employee satisfaction to 3.4. Reimer & Herbener (2014) suggest the implementation of multiple rounding methodologies to achieve attainment of an enhanced patient experience.

Patient satisfaction was measured through Press Ganey scores. Press Ganey is a valid data collection tool. This standardized instrument measures patient satisfaction. An upward trending of patient satisfaction was also seen in the data collected between 2009 and 2013 related to attention to personal needs and adequate precautions to protect patient safety. Commitment to consistent standardized rounding processes proved to be effective in creating a positive patient experience.

Similarly, Winter & Tjiong (2015) completed a descriptive correlation study at a 95-bed full service acute care hospital in Northern Texas. The purpose of the study was to implement purposeful leader rounding twice weekly on all inpatients and then evaluate the impact on patient satisfaction. It was estimated that approximately 2,506 patient rounds were completed during the study. HCAHPS surveys for patients were reviewed for all patients discharged between November 1, 2013 and April 30, 2014. The data was then compared to baseline data collected between October 2012 to October 2013. Measurement of data using the HCAHPS showed no correlation between how patients respond to specific HCAHPS questions and how patients respond to questions posed by the leader that rounded in the area. During the study, the first two months of compliance were low (35%) likely impacting initial HCAHPS data. Some patients were also not able to participate due to being out of their room or being unavailable. Overall, mean scores for hospital rating , response of hospital staff and pain management were lower during postimplementation in the acute care unit at the facility. Winter & Tjiong (2015) suggests that while this study didn’t show the expected results that leadership rounding is a proven tool to improve quality, safety, communication and patient experience.

Similarly, in another study by Cody (2018) there was also no statistically significant change in patient satisfaction scores after implementation of nurse leader rounding. In this retrospective descriptive study five inpatient units at a 210-bed acute care hospital in Virginia were selected to participate in the nurse leader rounding process. The purpose of the study was to determine if there was a variance in HCAHPS survey scores after the implementation of intentional nurse leader rounding. In all, 1,285 surveys were collected prior to the implementation and 1,102 were collected after the implementation of nurse leader rounds. To avoid a mix of surveys from patients that did not receive nursing leader rounds surveys were removed for patients from the month of and the month prior to training. The data reviewed compared HCAHPS surveys from pretraining dates of April 2014 to December 2014 and post training dates of April 2015 to December 2015. Limitations within the study included the fact that patients that transitioned to a rehabilitation facility did not have results recorded and that reported survey scores were for the discharging units. Therefore, anyone who transferred between units may not have accurately recorded patient experience. The small response rate reduces the reliability of the study and may not adequately reflect the experience of all patients. Another possible study to determine why patients don’t respond to study could assist in obtaining a larger sample of respondents. While this study also did not have impact on patient satisfaction scores the author felt that nurse leader rounding still provided nurse leaders with the opportunity to impact the patient experience by addressing care concerns while the patient was still in the hospital.

In a cross-sectional survey study completed by Sexton, Adair, Leonard, Frankel, Proulx, Watson & Frankel (2018) 31 hospitals through the Michigan Health and Hospital Association were given a routine safety culture and engagement assessment through a web-based survey. The purpose of the study was to evaluate associations between taking action on feedback as a result of walking leadership rounds and healthcare worker assessments of patient safety culture, employee engagement, burnout and work-life balance. Leadership WalkRounds are a form of observable leadership engagement in which leaders identify and resolve issues related to the safe delivery of patient care (Sexton, Adair, Leonard, Frankel Proulx, Watson & Frankel, 2018). Across 839 work settings, 23,853 surveys were distributed and 16,797 were completed. Surveys were completed by staff over a two-month period in 2015. Staff with an FTE of 0.5 or greater for at least four weeks prior to survey administration were able to participate. Staff includes in the survey were attending physicians, registered nurses, social workers, dieticians, therapists, environmental support staff, technicians and administrative support staff. Any staff that were working less than 0.5 FTE were not included in the survey data results. With the large sample of respondents, the likelihood for error in results in reduced. Internal reliability of all scales ranged from α= 0.82 to α= 0.94. With the implementation of leadership WalkRounds 10 of the 12 study domains showed improvement from the first quartile to the fourth quartile supporting the authors hypothesis. Domains included areas focused on Safety, Communication, Operational Reliability and Engagement. While this study supports a strong pattern of results to improve workforce engagement and lower staff burnout through leadership WalkRounds is does not demonstrate how patient safety or satisfaction is impacted. Additional review of correlating data from HCAHPS during the study period may demonstrate how WalkRounds improves the patient care experience.

Tan & Lang (2015) completed a systematic review in which three descriptive cross-sectional studies using online questionnaires were reviewed. The objective of this review was to synthesize evidence on the effectiveness of nurse leader rounding and post discharge telephone calls. In the systematic review, two reviewers used the Joanna Briggs Institute’s standardized critical appraisal instrument. Studies included in the review included adult patients age 18 or older that had been admitted to the hospital and had interventions of nurse leader rounding and post discharge telephone calls. Studies undertaken in outpatient settings were excluded from the systematic review. The reliability of the study is limited due to the small sample size. Pooling for results were not possible due to the descriptive nature of the studies included for review. The narrative synthesis of data revealed that post discharge telephone calls can be used to reinforce discharge teaching. Additionally, the review suggests that nurse leader rounding provides the organization with the ability to gather feedback on nursing services through identifying and addressing issues with standards of care before the patient is discharged home. The evidence generated from this review is to weak to suggest that nurse leader rounding and post discharge telephone calls had increased patient satisfaction. An RCT is needed to further determine the effect of nurse leader rounding and post discharge telephone calls on patient satisfaction.

Two studies completed used HCAHPS data to validate how nurse leader rounding improved the patient’s perception of care. In the study completed by Kennedy, Craig, Wetsel, Reimels & Wright (2013) a retrospective descriptive research method was used to investigate the effects of nurse manager rounding, post discharge telephone follow up and improved discharge teaching on a 28 bed surgical unit in South Carolina. In all, 288 HCAHP surveys were completed by discharged patients between July 2010 and December 2011. Postimplementation surveys demonstrated that HCAHP scores improved from 28.6% to 73.7% in the 18 months following implementation of nurse manger rounding, post discharge phone follow up and improved discharge teaching. While the reliability of this study is impacted by a less than 50% response rate on the HCAHPS survey continued successive measurement of HCAHP scores would improve reliability of results. Nurse leader rounding was not discussed individually in this study but in correlation with post discharge telephone calls and improved discharge teaching it is proven to improve patient satisfaction.

In the second study completed by Morton, Brekhus, Reynolds & Dykes (2014) a restrospective descriptive design was used to examine the impact of implementing nurse leader rounds on the patient’s perception of care received in the hospital. The study was completed across Providence Health and Services organization. This reviewed data from Press Ganey and HCAHPS results from 51,785 patient surveys from five states and 32 hospitals. Patients that were discharged from inpatient units from April 2008 and September 2013 were included in the study results. However, if the patient did not answer the nurse leader rounding question that was included in the survey, the survey was excluded from analysis of the data. This large sample size of respondents reduces the likelihood for error in the results. Education to nurse leaders on the rounding process prior to nurse leader rounding implementation also reduces variances in the rounding process and enhancing reliability of results. The study is demonstrating external validity due to the large sample size representing patient surveys from 5 states and 32 hospitals. Overall, the organizations HCAHPS scores for overall rating rose from 64.6% in 2008 to 72.4% in 2012 following the implementation of nurse leader rounds. This study establishes a solid association that nurse leader rounding improves the patient’s perception of care.

State of Science

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1. What consistencies did you find in the evidence?
2. What inconsistencies did you find in the evidence?
3. What are possible explanations for the inconsistencies?
4. What gaps or holes in the evidence base justify the need for continued work in the area?
5. How does the evidence you have found support a practice change?

Conclusion

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Chapter III: Implementation

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Procedures/Methods

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Results

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Artifacts

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Conclusion

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Chapter IV: Evaluation

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Discussion of the Results

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Recommendations

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Conclusion

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References

• Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Conceptual paper: Kurt Lewin’s change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation & Knowledge, 3, 123–127.
  
  https://doi.org/10.1016/j.jik.2016.07.002
  
• Sherman, R. (2012, November 18). Five Steps to Make Your Nurse Leadership Rounding More Purposeful. Retrieved from https://www.emergingrnleader.com/nurse-leader-rounding/
• Tappen, R., Wolf, D., Rahemi, Z., Engstrom, G., Rojido, C., Shutes, J., & Ouslander, J. (2017). Barriers and Facilitators to Implementing a Change Initiative in Long-Term Care Using the INTERACT® Quality Improvement Program. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/?term=Barriers and Facilitators to Implementing a Change Initiative in Long-Term Care Using the INTERACT® Quality Improvement Program

Appendix A: Title here

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Appendix B: Title here

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