A Quality Improvement Initiative to Achieve High Nursing Presence During Patient- and Family-Centered Rounds

Study Design

CHW is a 296-bed tertiary care hospital. The PHM teaching service includes residents, medical students, and attending physicians. Each team is primarily ward based but may cover patients in >1 unit. Rounding order is based on patient acuity, readiness for discharge, and resident availability. The current study was performed on a 16-bed acute care medical unit within the hospital. On this unit, the typical patient-to-nurse ratio is 3 to 4 patients per nurse.

The improvement team (ie, the Family-Centered Rounds Taskforce) included hospital administrators, PHM physicians, staff nurses, and nursing leaders.

Planning the Intervention

A 10-question electronic needs assessment survey was administered to daytime nursing staff on the study unit. The questions were formulated based on information gathered from available literature regarding nursing presence on PFCR and discussion with PHM physicians and nursing leaders. This survey was conducted to better understand nursing attitudes toward PFCR at our institution and to help determine what interventions would be helpful in increasing nursing presence on PFCR. Using a 5-point Likert scale, the survey queried current nursing practices and attitudes regarding PFCR, local barriers to nursing attendance on PFCR, and techniques used by nurses and physicians to promote active nursing participation on PFCR. Five questions addressed current nursing practice and perception regarding PFCR; 1 multifaceted question addressed local barriers to nursing attendance on PFCR; and 4 questions addressed nursing and team techniques to facilitate nursing participation on PFCR.

Interventions

Two Plan-Do-Study Act cycles were conducted. The first intervention was a workshop designed to educate nurses about the importance of PFCR, to encourage interest in PFCR, and to promote the development of skills for effective nursing participation on PFCR. This intervention was chosen to promote and encourage interest in PFCR. The sessions were facilitated by 3 PHM physicians during 4 sessions with 6 to 10 nurses in attendance per session. The sessions were inclusive of the entire nursing unit staff consisting of 34 nurses, including both the daytime and nighttime nursing personnel. Each session lasted ∼60 minutes. During the workshop, the results of the needs assessment survey were reviewed in a didactic session. Key themes for effective nursing participation were introduced and discussed within the group. These themes included support for families, clarification of current patient status, feasibility of the daily plan, and ongoing assistance with discharge planning. These themes were formulated by using content themes derived from structured group interviews of PHM physicians and needs assessment survey of the nurses. They were reinforced by using a team-based, rounds simulation role-playing exercise based on previous successful workshops for physician team members.⁹

The second intervention was the development of a strategy to contact nurses by using a commercially available hands-free communication device. This nursing contact strategy was chosen in response to the barriers identified on the survey. The hands-free communication device was chosen specifically because it was already being used on the study unit for nursing communication. The unit staff and medical teams were provided education about the process for the nursing contact strategy by 1 of the study team members. Before rounds, the unit administrative staff printed out a sheet containing patient names, room numbers, and nursing assignments. A member of the medical team (typically the medical student) would then use this assignment sheet to contact each nurse 5 to 10 minutes before each patient encounter. The medical team member used the hands-free communication device to contact the nurse, who would become aware of the call with the speaker’s recorded voice stating there was a call from the rounding team. If the nurse accepted the call, the team member could then speak to the nurse, alerting him or her to rounds initiation on his or her patient. This team member then marked whether the nurse was present on rounds. Data were collected 7 days per week and included all of the patients who were seen by PHM physicians. The resident team also manages patients who are not seen by PHM physicians, and these patients were not included in the study. The order of patient encounters was not altered based on nursing patient assignment; each nurse was therefore contacted before each patient encounter.

Project Outcome

The primary process measure was the completion rate of the daily contact summary form. The primary outcome measure was the average percentage of patient encounters with a nurse present on PFCR.

Data Collection

Data were obtained via daily tracking of nursing presence on rounds by a member of the physician team over a 7-month period (April 2011–October 2011). The average was calculated weekly throughout the 7-month study period. A p-chart was generated to display the weekly average percentage of nursing attendance on PFCR. Weeks that contained <2 days of data collection were excluded from the analysis. This study was approved as exempt by the CHW institutional review board.