By Sara A. Lowe

Alice is a new nurse employee on a busy medical/surgical unit at General Hospital. During her first week, she noticed how frequently she heard call lights beeping. The unit was noisy from all the call lights, and the nurses seemed to be constantly scurrying around in and out of patient rooms. She asked Anne, her preceptor, why they weren’t doing hourly rounds. Anne said she was unfamiliar with hourly rounding. Alice explained that where she had worked before, nurses had rounded hourly on their patients. As a result, the unit was quiet, patients weren’t ringing their call lights, the number of patient falls had been reduced by half, and nurses had more time to get their work done since they weren’t constantly interrupted to go in and out of patient rooms. Anne was intrigued by what Alice was telling her and wanted to learn more about rounding and whether it would work on their unit at General Hospital.

Hourly rounding is a systematic, proactive, nurse-driven evidence-based process designed to anticipate and address needs of hospital patients.1-4 Rounding has been shown to increase patient satisfaction with their hospital experience as a result of regular attention from nurses. In addition, research indicates that on inpatient units where rounding has been “hardwired,” patient falls have decreased by 50%, skin breakdown has been reduced by 14%, and the number of patient calls via call lights has dropped by 38%.1,2,3,4

The concept of hourly rounding was developed in the late 1980s at a medical center in Birmingham, Ala. That hospital introduced the role of a unit “hostess,” who rounded on every patient four times each shift. The hostess answered call lights within five minutes and addressed all patient requests that did not require a licensed staff member. Tasks that the hostess took care of included adjusting room temperatures and providing patients with juice, water or pillows. The change brought about by the hostess was dramatic: Within two weeks there was a noticeable decline in patient and physician complaints together with many positive comments about the hostess from nurses. Nurses appreciated having someone available to answer call bells quickly, and patients felt that their needs were being met promptly.5 Hourly rounding developed from these roots.

Patient Satisfaction

One of the key drivers of hourly rounding is patient satisfaction. The unit hostess role described above indicates that patient satisfaction can be affected by things such as prompt response to call lights and attention to other patient needs and concerns. Patient satisfaction can be defined as “the consumer’s fulfillment response; the degree to which the level of fulfillment is pleasant or unpleasant.”6 One author suggests that “satisfaction is a short-term attitude that is encounter specific.” He adds that “service quality is often judged by patients based on their perceptions of performance relative to expectations.”7 These perceptions about a patient’s hospital experience are measured by the Hospital Consumer Assessment of Healthcare Providers and Systems survey. The HCAHPS survey measures experiences of patients during their hospital stays and is used by hospitals throughout the United States.8

Hospital patients often need help with basic tasks, such as using the restroom, eating, bathing and ambulating. Nurses’ responsiveness to their needs is a key factor patients often consider when making judgments about the quality of their care. Other factors that can influence opinions about satisfaction can include patient and family perceptions of things like prompt response to call lights, timely assistance to the restroom, timeliness and appropriateness of pain control, friendliness of the nurses and effective exchange of information with nurses. When a patient’s need for assistance isn’t met in a timely fashion, it can result in patient falls and increased pain, as well as complaints from patients and families.1-3,4,9,10 It should be noted that the HCAHPS survey includes questions about pain control and assistance to the restroom.8

As noted above, patients often measure their satisfaction with hospital care based on factors such as staff responsiveness to their needs and prompt answering of the call bell. The call bell is a “lifeline” for a hospital patient.10 It is how the patient summons the nurse for assistance or information. Patients expect that when they push the call bell, the nurse will come promptly. But busy caregivers may find it time-consuming to answer call bells. Also, every time a nurse tells a patient, “Call me if you need anything,” she or he seems to be giving up control of her time to the patient.10 Because of the expectations of patients for assistance and attention as well as the need for nurses to have some control over their activities, it became important to find a way to satisfy both patients and nurses while meeting the legitimate needs of both. Rounding fills this need in the inpatient setting. Rounding allows the nurse to focus on the needs of each patient so that each patient gets the full attention of the nurse. During the round, the nurse will address all patient needs, including pain, restroom, comfort and position, information, treatments, meds and other requests so that when the round is complete, all of the patient needs have been met.1

Purposeful Hourly Rounding

Hourly rounding means visiting patients every hour to proactively take care of their needs, with rounding modified to every two hours overnight.1 Often the word “purposeful” is used along with hourly rounding to indicate that rounding requires specific actions and words, or scripting, on the part of the nurse who is rounding. Rounding is different from just checking to see if a patient needs anything. Instead, rounding is purposeful. By asking the patient about specific things during each round, nurses can anticipate patient needs instead of reacting to patient needs by waiting for the patient to use the call bell.1-3,4,11-15

The tasks of rounding are organized using the letter P. The three basic Ps of rounding are pain, potty and position, which are the three basic needs common to most patients. These 3 Ps are universal and used in most hospitals that use hourly rounding as their patient care model. Other Ps can be added, based on the preferences of each hospital.11,12 Other Ps for rounding include “pump, periphery, plan of the day, possessions.” Using words beginning with P makes the tasks of rounding easy to remember.

When rounding, it is best to limit the number of Ps so that it is easier for staff to remember the tasks associated with rounding. Most hospitals choose four or five Ps as their focus for rounds and incorporate all patient care tasks, including med passes and treatments, into those Ps.11-15

Types of Rounding

There are three types of rounds during each shift: introductory (which can include bedside shift report), initial and hourly. Let’s examine each type.

The introductory round is just what it says, a round to introduce the oncoming nurse by the outgoing nurse. The process allows the oncoming nurse to be “managed up” by her colleague who is leaving and increases the patient’s confidence in the oncoming nurse. Managing up means that the outgoing nurse introduces the oncoming nurse by highlighting the nurse’s strengths. An example of this is: “Hello, Mrs. Jones, I’m going home now, but I wanted to introduce Kelly, who will be taking care of you today. She has worked here for three years and is an excellent nurse, one of our best. She will take very good care of you today.” A statement like this from the outgoing nurse sets up the oncoming nurse as competent and lets patients feel they are in good hands.11,15

The introductory round can be included as part of the bedside shift report or can take the form of the outgoing and incoming nurse visiting each patient together at change of shift for introductions and a quick check of the patient’s well-being. As part of the introductory round, the outgoing and oncoming nurse visit all their patients together at shift change and give a shift change report. The outgoing nurse can then leave, and the oncoming nurse can begin his or her initial rounds.11,12,15

The initial round is the first hourly round of each shift, and it is done after the outgoing and oncoming nurses complete the introductory rounds. The initial round includes all of the dialogue and actions that are part of a regular hourly round with the addition of two important elements. First, the initial round should include an explanation to the patient of what hourly rounding is. This way, the patient understands rounding and knows that it is purposeful. Second, during this initial round that the nurse should ask each patient, “What is the Most Important Thing that I can do for you today?” The MIT may be something as simple as making a phone call to check on the status of a patient’s pet or checking with the physician to see if the patient can have regular instead of decaf coffee. Asking for the MIT shows patients that their priorities are important and will be addressed along with their medical treatment. The MIT is usually written on the patient’s communication board so that the nurse can focus on ensuring that the MIT is carried out. Each oncoming nurse should ask about the MIT as part of the initial round, as the patient’s MIT likely will change shift to shift.11-15

The regular hourly round is done every hour for the remainder of the shift. The hourly round is performed in the same way at most hospitals although the Ps used may vary. The hourly round is performed every hour addressing the Ps from 0600 to 2200. At night, the nurse can set up the overnight expectation for rounding by telling the patient that she will round every two hours from 2200 until 0600. She will quietly come into rooms and check that patients are safe, but will not waken them if they are sleeping. She will sign the rounding log at each round so the patient can see that the round happened during the night. Rounds return to every hour beginning at 0600.11-15

Communication

An important part of every round is nurse-patient communication. One way to encourage this is with a communication board. At many hospitals where rounding is practiced, a glass dry-erase communication board is installed in patient rooms to help with communication. Typically these wall-mounted boards, often called white boards, contain basic information for the patient, including date, room number, room telephone number and names and phone numbers of nurse, nurse tech and nurse manager. A possible discharge date is also often included. Other information on white boards can include pain level, meds for pain and the schedule of the next dose, the MIT and information about the plan for the day, including tests and treatments. Information on these boards is updated at the start of each shift and communicated by the nurse to the patient so that the patient understands what is going to happen each day, who his or her care team is and what the goals for pain control are.15

Another communication tool often used with rounding is the in-room rounding log. This log is often paper and is posted on the wall inside the room. The log has spaces for each hour where the nurse can write his or her initials to note that the round was completed. These in-room rounding logs let patients know that rounding has occurred even if they were asleep.11-15

Rounding Process and Scripting

Hourly rounding is a formal process that requires key actions and words during each round. It is important to use key words at key times. For example, when entering a room for a round, the nurse should say, “I am here to do my hourly round” and explain hourly rounding and the Ps to the patient. When finishing the round, the nurse should say, “Is there anything else I can do for you before I leave? I have the time.” Then, when the nurse is ready to leave the room, he or she should say, “I’ll be back in an hour to round on you.” During the initial round, a key phrase the nurse should use is “What’s the most important thing I can do for you today?” These key words at key times help set up expectations for the round. Patients know that the nurse is there to do an hourly round and can expect that the nurse will address the Ps. By telling the patient what the Ps are, the nurse is letting them know that their basic needs are important and will be addressed every hour.11-15

OR Today Magazine | Continuing Education | No way around itNurses should also round using the concept of “nursing out loud,” or NOL. “Nursing out loud” means talking as you perform the round. For example, “I’m pulling the curtain for your privacy.” Or “Let me check your pitcher to be sure you have enough water and ice.” By talking through what they are doing, nurses let the patient know what they are doing and why, which allows for better communication between patient and nurse.15

Rounding helps nurses organize patient care so that all patient needs in areas of pain, restroom, position, information, room orderliness and patient requests can be addressed during the round. Once all these things are done for the patient during the round, the nurse can move on to round on the next patient and know that the patient is comfortable. Patients also know that the nurse will be in to round on them on a regular schedule, so they are less likely to use the call light.1-3,4,11-15

Into Action

Implementation of purposeful hourly rounding can be difficult. You must have the nursing leadership team’s support since you will need its help in getting rounding started on inpatient units. At the beginning of implementation, nurses may tend to view hourly rounding as more work for them instead of as a way of reorganizing their work and making their time in a patient’s room more purposeful. Also nurses often don’t understand that regular tasks, such as medication passing, can be integrated into the hourly rounding process, not done outside the round. Careful communication about the benefits of rounding for both nurses and patients should take place to help nurses understand the why of rounding. Communicating the why is essential in getting hourly rounding established on a patient care unit. Nurses want to do what’s best for their patients, and when they understand the benefits, such as a reduction in falls and skin breakdown, as well as time savings for them, they are more likely to willingly adopt the practice.2,3-4,11-15

Communicating the why and benefits to the nurse, such as reducing the interruptions of call lights, answers the “what’s in it for me?” question. Nurse leaders should clearly explain to nurses that purposeful hourly rounding seeks to reduce patient calls because nurses are anticipating patient needs and being proactive in addressing them.1-4,12-15

Staff training will be needed to demonstrate what rounding looks and sounds like. The training skills labs will need to be repeated quarterly until rounding is fully established on each unit. As noted above, part of rounding training includes scripting, or providing specific words that staff are to use when rounding. Rounding will need to be validated on each unit daily to ensure that staff are not only rounding, but doing it correctly.1,2,8-12

Rounding Verification

As rounding is being implemented, it is essential to verify that hourly rounding is being done purposefully and correctly. Nurse leaders can validate that nurses are rounding effectively through nurse leader rounding. Nurse leader rounding is done on every patient every day by the nurse manager. One of the key purposes of nurse leader rounding is for the nurse leader to visit each patient daily and ask whether the nursing staff are effectively addressing the tasks of rounding (pain, potty, position). Nurse leaders round using a rounding log that lists patients’ names and room numbers. The log includes columns with questions the nurse leader can ask patients about rounding behaviors, such as pain control, toileting, personal comfort, hygiene and call bell use.14,15

Answers to these questions can provide the nurse leader with information about how each nurse is practicing rounding and where coaching may be needed to improve rounding practice. The nurse leader also assesses the appearance of the patient room during the round. After nurse leader rounding is completed, the nurse leader can follow up with nurses and coach them as needed on their rounding based on the feedback from patients. Nurses who are rounding well can be praised. Nurse leader rounding is not done to “catch” nurses not performing hourly rounding, but rather to affirm that hourly rounding is being done in a purposeful way and is effectively addressing patient needs.14,15

Successful implementation of hourly rounding can be assessed by looking at scores on patient satisfaction surveys, such as HCAHPS.8 A nonstandard HCAHPS survey question, “Did the nurse visit you every hour?” is designed to provide information from a patient about whether rounding took place during his or her hospital stay. Some hospitals choose to add the above nonstandard question to their HCAHP survey to directly measure rounding. When used on the survey, this question is worded as above. This question is noted as nonstandard because it is not part of the required HCAHPS survey but an option that can be added.8 Tracking the “yes” responses will provide information about the implementation of rounding on a hospital unit and in the hospital overall. As rounding becomes hardwired on a unit, the number of “yes” answers to this questions should increase. Scores of 90% or more on “yes” responses on this HCAHPS question indicate that hourly rounding is being performed effectively on a patient care unit.11,15

Rounding Outcomes

Studies have shown that when purposeful hourly rounding is effectively implemented, the frequency of patient call lights should decrease by as much as 65%, patient falls by 65% and pressure ulcers and skin breakdown to almost none.1-4,11-15

Similarly, patient satisfaction at hospitals and on units with hourly rounding usually improves dramatically. Hospitals where hourly rounding is fully implemented have reported that their patient satisfaction scores have increased as much as 30 to 40 points and the increase has been maintained over time. Nurses also report satisfaction with rounding since they aren’t interrupted so often with call bells. Reduction in nurse fatigue has also been reported because nurses aren’t running around as much answering call bells. Staff overtime has also been reduced at some hospitals with rounding since nurses can better organize their work and manage their time.1-4,11-15

While the implementation of hourly rounding can be difficult at first, once it is fully hardwired, the benefits to both nurses and patients are well documented. Today’s nurses must be aware of the importance of hourly rounding given the proven impact of this nurse-driven intervention on patient satisfaction.

Lynn Deitrick, RN, PhD, is a nurse-anthropologist who has worked in the field of patient satisfaction and patient experience for more than 13 years. She has published more than 25 articles in peer-reviewed journals on topics including call bells, patient satisfaction and hourly rounding, and has presented on these topics at numerous professional conferences.

References

1. Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds on patients’ call light use, satisfaction and safety. Am J Nurs. 2006;106(9):58-70.

2. Deitrick L, Baker K, Paxton H, Flores M, Swavely D. Hourly rounding: challenges with implementation of an evidence-based process. J Nurs Care Qual. 2012;27(1):13-19. doi:10.1097/NCQ.0b013e318227d7dd.

3. Rondinelli J, Ecker M, Crawford C, Seelinger A, Omery A. Hourly rounding: a multisite description of structures, processes & outcomes. JONA. 2012:42(6):326-332.

4. Olrich T, Kalman M, Nigolian C. Hourly rounding: a replication study. MedSurgNurs. 2012;21(1):23-36.

5. Sheedy S. Responding to patients: the unit hostess. J Nurs Admin. 1989;19(4):31-33.

6. Oliver, RL. Satisfaction: A Behavioral Perspective on the Consumer. New York, NY: McGraw-Hill Cos;1997:28.

7. Taylor, SA. Distinguishing service quality from patient satisfaction in developing healthcare marketing strategies. Hosp Health Services Adm. 1994;39(2):232.

8. HCAHPS. HCAHPS Web site. http://www.hcahpsonline.org. Accessed March 27, 2014.

9. Deitrick L, Capuano TA, Paxton SS, Stern G, Dunleavy J, Miller WL. Becoming a leader in patient satisfaction: changing the culture of care in an academic community hospital. Health Mark Q. 2006; 23(3):31-57.

10. Deitrick L, Bokovoy J, Stern G, Panik A. Dance of the call bells: using ethnography to evaluate patient satisfaction with quality of care. J Nurs Care Qual. 2006;21(4):316-324.

11. Studer Group. Hourly Rounding Guide. Patient Care Strategies: Achieving Nursing and Patient Care Excellence. Gulf Breeze, FL: Fire Starter Publishing; 2006.

12. Proactive patient rounding reduces call light use and falls, eliminates pressure ulcers and enhances patient and staff satisfaction. Agency for Healthcare Research and Quality Web site. http://www.innovations.ahrq.gov/content.aspx?id=2504. Updated July 6, 2011. Accessed March 27, 2014.

13. Ford B. Hourly rounding: a strategy to improve patient satisfaction scores. Medsurg Nurs. 2010;19(3):188-191.

14. Best practice: making hourly rounding purposeful. Association for Patient Experience Web site. http://www.patient-experience.org/Education-Research/Article-Archive/Best-Practice-Making-Hourly-Rounding-Purposeful.aspx. Published April 11, 2011. Accessed March 27, 2014.

15. Studer Q, Robinson BC, Cook, K. The HCAHPS Handbook: Hardwire Your Hospital for Pay-for-Performance Success. Gulf Breeze, FL: FireStarter Publishing; 2010.