A group of Southern California nurses has found that collaboration is the key to making hourly rounding work. What started as a friendly chat among friends in 2006 has turned into a formal collaboration among disparate facilities to improve patients’ clinical outcomes by implementing hourly nursing rounds on all inpatient units.
Hourly rounding is the nursing practice of regularly checking on patients’ needs using the four Ps — positioning, pottying or personal needs, pain, and proximity of personal items such as the call light — with the promise to return in an hour. Researchers have found the practice has helped improve patient satisfaction and safety, while decreasing call light use. Hourly rounding was originally presented in an article by Christine M. Meade, PhD, Amy L. Bursell, PhD, and Lyn Ketelsen, RN, MBA, in the September 2006 American Journal of Nursing.
It’s not so much just taking the research article and implementing it; it’s really figuring out how to change [hourly rounding] and massage it so that it fits the needs of the individual organizations and the individual institutions, says Alicia Puppione, RN, MSN, APRN-BS, one of the original members of the Southern California nurse group that implemented hourly rounding. Puppione is also the John Douglas French Alzheimer’s Foundation gerontological clinical nurse specialist at Saint John’s Health Center in Santa Monica.
Additionally, the group has included representatives from Glendale Adventist Medical Center, Childrens Hospital Los Angeles, San Joaquin Community Hospital in Bakersfield, and several Kaiser facilities, including Kaiser Permanente Los Angeles Medical Center.
The group began sharing tools, tips, and stories from the front line via monthly teleconferences, with occasional in-person gatherings. As the focus shifted from implementing hourly rounding to sustaining the practice, teleconferences have decreased to every other month.
Learning from each otherThe 7 Center/7 West Shared Governance Council, pioneers in hourly rounding at Kaiser Permanente Los Angeles Medical Center. Back row: Red L. Ganzon, RN, Simon Flores, RN, Josefina Pastor, RN, Riza Uayan, CNA, Emily Annan, RN, and Maria Aparicio, RN. Front row: Connie Johnson, RN, Marietta E. Caguco, RN, and Minh Merideth, RN.
I think [the collaboration has] been successful in helping us make something happen that we all anticipated was going to be kind of tricky, says Margaret Ecker, RN, MS, director of nursing quality at Kaiser Los Angeles Medical Center. I’m positive that it saved us time and ensured the success at the various hospitals.
That time savings has come not only from trading written material, but by gleaning knowledge from shared stories of what has worked and what has not.
Frequently, staff nurses attend the meetings and share their tales. One memorable account involved a small test at a facility with a patient who had been hospitalized on the unit frequently and was particularly distressed. Nurses conscientiously rounded with her every hour, helping her anticipate needs and dealing with issues proactively, rather than reactively. The results were impressive — the patient seemed less agitated, and her needs were met without frequent call light requests.
By doing one relatively simple thing like coordinating care as far as hourly rounding goes, the nursing staff felt like they were able to make a difference, Puppione says. We all have clinical stories like that.
The stories about difficulties with implementation have helped as well. We all heard about those roadblocks, so we didn’t have to make that same mistake, Ecker adds.
A common challenge has included building will among staff nurses to embrace and drive the change. Convincing a single staff nurse to try hourly rounding, consequently adjusting the practice to fit the setting, and then sharing results with co-workers has helped overcome common objections such as, This is just one more thing management expects from us, or I’m already in there every hour anyway.
Establishing a work day design that actually makes hourly rounding possible was another widespread difficulty.
That challenge was common, but the solution was different from facility to facility, Ecker says. Some hospitals began using a kind of log system. Some people use signs in the room. Some people were already computerized [using electronic medical records] and used that to help them. Other people use these decorative clocks that are on every door.
From the heart
Other discussions have centered on making rounding an authentic interaction with patients, rather than just robotically marking things off on a checklist. [Rounding] has to come from your heart, says Punnoose Varghese, RN, MS, CCRN, director of the telemetry/step-down services at Glendale Adventist Medical Center. A lot of us feel we went into nursing school to make a difference in somebody’s life. With all the things we have to do nowadays, you don’t always have the time [or] energy to do that. But a least with this [hourly rounding], it gives them [the RNs and CNAs who alternate the rounding] a good start. You see the relationship between patients and the nurses growing.
Ecker considers this collaboration one of the recent highlights of her career. It is exciting to me to be working in this out-of-the-box way, she says. It took us away from an institutional way of doing things and exposed us to all of these incredible ideas, other ways of doing things. It was this unusually transparent and cooperative way of finding out what’s working and what’s not working. Sharing across boundaries was exhilarating.