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J Nurs Care Qual

Vol. 30, No. 2, pp. 153159
c 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 

Effectiveness of Structured
Hourly Nurse Rounding on
Patient Satisfaction and Clinical
Outcomes
Lisa A. Brosey, DNP, RN, CPHQ;
Karen S. March, PhD, RN, ACNS-BC
Structured hourly nurse rounding is an effective method to improve patient satisfaction and clinical outcomes. This program evaluation describes outcomes related to the implementation of
hourly nurse rounding in one medical-surgical unit in a large community hospital. Overall Hospital
Consumer Assessment of Healthcare Providers and Systems domain scores increased with the exception of responsiveness of staff. Patient falls and hospital-acquired pressure ulcers decreased during the project period. Key words: accidental falls, evidence-based nursing/standards, hourly
rounding, PARiHS framework, patient satisfaction, pressure ulcer/prevention and control

CUTE CARE FACILITIES continue to evaluate cost-effectiveness methods to enhance patient satisfaction and improve patient
safety. A growing body of evidence describing the positive effects of structured nurse
rounding on patient satisfaction and clinical
outcomes has emerged within the past few
years.125 On the basis of this emerging evidence and the positive effects demonstrated,
many organizations in the United States and

Author Affiliations: Lancaster General Health,

Lancaster, Pennsylvania (Dr Brosey), and The
Stabler Department of Nursing, York College of
Pennsylvania, York (Dr March).
No funding was received for this work.
The authors declare no conflict of interest.
Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are
provided in the HTML and PDF versions of this article
on the journals Web site (www.jncqjournal.com).
Correspondence: Lisa A. Brosey, DNP, RN, CPHQ,
Lancaster General Health, Lancaster, PA 17604
(labrosey@lghealth.org).

the United Kingdom have instituted hourly

nurse rounding as a standard component of
nursing practice in an attempt to improve patient satisfaction and reduce patient harm.*
Hourly nurse rounding entails assessment of
3 to 12 elements on each patient every hour
between 6 AM to 10 PM and then every 2 hours
from 10 PM to 6 AM.1,6,9 Rounds are reduced
to every 2 hours during the night so that sleep
patterns are less disturbed and patients are not
awakened unnecessarily.
The most noted elements assessed during hourly nurse rounding include pain
level, need for toileting or elimination,
assessment of the environment including
room temperature, proximity of personal
items, safety hazards, and positioning of
the patient or need to change the patients
position.1,2,4,6,7,9,1121,2325 Studies on hourly
nurse rounding reveal that patients report higher patient satisfaction, fewer patient falls and hospital-acquired pressure
ulcers (HAPUs), and decreased call bell
activation.122,24,25 Evidence further suggests

Accepted for publication: July 19, 2014

Published online before print: September 18, 2014
DOI: 10.1097/NCQ.0000000000000086

*References 1,

3, 6, 7, 10-13, 16, 17, 20 -22 .

153

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that nursing care strongly contributes to

patients perceptions of overall satisfaction
and likelihood to recommend a facility to
others.2630 Supplemental Digital Content,
Table (available at: http://links.lww.com/
JNCQ/A126), provides a summary of studies
on the effects of structured nurse rounding on
patient satisfaction, patient falls, HAPU, and
call light usage.
LOCAL PROBLEM
The project facility adopted structured
hourly nurse rounding as a standard of nursing care in 2008; however, there was little
structure to and accountability for implementation of this practice. As a result, past efforts
with hourly nurse rounding were inconsistent
and ineffective. Discussions with the nursing
staff and observation of practice revealed minimal compliance with hourly nurse rounding
process or the intent to assess pain, elimination, environment, and position (PEEP)
proactively in the current day. Therefore, the
project leader met with nursing leadership
to present current evidence and benefits associated with this intervention and to garner support for implementation on one pilot
unit. The project unit was a 24-bed medicalsurgical nursing unit with private and semiprivate rooms. This unit was selected on the basis
of its need for improvement in patient satisfaction scores (lowest rating of medical-surgical
units in facility) as well as its higher incidence
of patient falls (2 times the national mean) and
HAPUs (higher than facility mean).
Intended improvement/study question
The purpose of this project was to implement a standardized structured hourly nurse
rounding process and to monitor the outcomes of patient satisfaction, patient falls, and
HAPUs over a 3-month time period.
METHODS
Setting
Promoting Action on Research Implementation in Health Services (PARiHS) framework was the translation model used for the

project.31 This framework is based on the

premise that successful implementation of evidence into practice is dependent on 3 factors: evidence, context or environment, and
facilitation. Each factor has equal importance
in the implementation process and is interrelated with other factors. For example, if the
evidence is strong and the environment is accessible to change, then the facilitation of the
change process will be less rigorous and demanding. In contrast, if the evidence is not
strong and the environment is not adaptive to
change, the facilitation process may require
a higher level of support and change management skills for successful implementation
to occur. The framework requires evaluation
and presentation of the supporting evidence,
evaluation and analysis of the context or environment (including support from management and the culture for change of the environment), and the use of facilitating techniques that are fluid and adaptive to the changing environment.
For this project, the level of evidence was
rated low (most of the evidence on hourly
nurse rounding included quality improvement program evaluations) whereas context
or environment was rated high (demonstrated
by the expressed attitudes and beliefs of
the majority of staff members and leadership
about the value of improving the care provided to patients and the desire to reduce
harm). Since the evidence component was
low and the context component was high,
the facilitation method suggested by the PARiHS framework was to enable and empower
the staff to take control of their learning and
change process needs through mentoring and
support of staff decisions.31 Discussions regarding current best practices and the positive effects of structured hourly nurse rounding practices were key elements in supporting
the staff to be active in the decision to move
forward with implementation. Institutional review boardexempt approval was obtained
for this evidence-based practice project.
Planning the intervention
A literature search was conducted using
CINAHL, PubMed, Cochrane Database of

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Effectiveness of Structured Hourly Nurse Rounding

Systematic Reviews, and Nursing & Allied
Health Collection. The search was limited to
published literature between 2008 and 2014.
Key search words used were patient satisfaction, patient fall prevention, pressure ulcer
prevention, and call light. Additional search
words of hospital and rounds were added to
the key word of patient satisfaction, and the
search word hospital was added to the key
words patient fall prevention and pressure
ulcer prevention. Peer-reviewed articles were
evaluated. Evaluation of titles and abstracts
was performed with the following inclusion
criteria: inpatients in an acute care facility, an
intervention consisting of structured nurse
rounding, and written in the English language.
Studies that included every hour or every
2 hours structured nurse rounding and reported outcomes were analyzed for strength
and quality of evidence based on the Johns
Hopkins Nursing Evidence-Based Practice
Model and Guidelines32 (see Supplemental
Digital Content, Table, available at: http://
links.lww.com/JNCQ/A126). Evidence was
classified into 1 of 5 (levels 1-5) hierarchical
levels dependent on the study design and then
a rating of quality (a, b, c) was assigned on
the basis of the overall study characteristics.
The process of implementation included
development of a structured approach to staff
education, historical data analysis, observations of staff workflow, evaluation of the current state of hourly nurse rounding, and development of guidelines for structured hourly
nurse rounding on the unit. First, a meeting
with the 8-member unit-based nursing governance council resulted in unanimous approval
for implementation of structured hourly nurse
rounding. A 20-minute education session that
included a review of evidence, working definition of structured hourly nurse rounding,
review of historical performance indicators,
and goals for improvement in the fiscal year
were provided to every staff member on the
unit through group staff meetings or one-onone sessions. A fact sheet was presented to
the staff for their reference.
Observations and shadowing of the staff
on all 3 shifts, on weekdays and weekends,

155

were performed for several weeks. These observations yielded information on workflow
patterns, usage and timeliness of response
to call lights, and length of time needed to
complete a structured round with and without need for toileting. Baseline data were collected on compliance with performing hourly
nurse rounding, patient satisfaction, fall rates,
and HAPU rates. Key stakeholders included
the nurse manager, registered nurses, patient care assistants, and unit secretaries, who
were instrumental in developing the timeline
for implementation and were empowered to
make decisions throughout the project, and
the patients. Guidelines and principles outlining the accountabilities for performing the
nurse rounding were developed on the basis
of the published evidence, the observed time
needed for conducting nurse rounding, and
the workflow patterns of the staff.
Methods of evaluation
Baseline patient satisfaction scores on Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) surveys and
inpatient fall rates and HAPU rates through
the event report process were collected, analyzed, and presented prior to implementation of structured nurse rounding. Structured
hourly nurse rounding compliance was also
determined during a 7-day period of time just
prior to implementation. Monthly data collection and outcome reporting were provided
on the performance indicators. Monitoring of
7-consecutive-day rounding compliance was
assessed each month during the project implementation period. Continuous monitoring of
compliance of structured hourly rounds was
not performed since manual collection of the
data was perceived by the staff as adding burden to their other duties. Results were discussed monthly at staff meetings and were
graphically displayed in the staff lounge.
Analysis
Descriptive statistics were used to trend, organize, and describe the characteristics of the
data collected on hourly nurse rounding compliance, inpatient fall rates, and HAPU rates.

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A Cox-Stuart trend analysis was performed on

the historical inpatient fall data to effectively
illustrate that fall rates declined more consistently postimplementation. Frequency distribution analysis of the HCAHPS responses was
performed. Data were compared with appropriate benchmarks for patient satisfaction, inpatient fall, and HAPU rates.
RESULTS
Outcomes
An overall goal of more than 80% hourly
nurse rounding compliance was set after the
baseline assessment and prior to the implementation of hourly nurse rounding. Preintervention baseline hourly nurse rounding
compliance was 48.4%. Additional monthly
compliance reviews were performed for
7-consecutive-day periods revealing compliance rates of 69.4%, 44.3%, and 59.2%. Overall
compliance was calculated by the total number of rounds completed divided by the total number of possible events. Hourly nurse
rounding was considered to have been performed when a staff member entered the patients room, evaluated the patient for PEEP,
and documented the activity on designated
flow sheets.

The project unit discharged 582 eligible

patients during the project period. Eighty-one
HCAHPS surveys were returned. Percentage
of always declined slightly in the HCAHPS
composite domain score of responsiveness
of staff to 48.6% (n = 81) from patients
discharged postimplementation as compared
with a result of 49.3% (n = 35) preimplementation. However, the other domain responses
all increased 6.1% to 30.9% postintervention
when compared with preintervention. The
Table displays the comparisons.
A patient fall was counted anytime a patient descended to the floor with or without
assistance from the hospital staff. A patient
fall rate was calculated by the total number
of falls reported divided by the total number
of patient-days multiplied by 1000. A rate of
7.02 patient falls per 1000 patient-days was
noted in the prior year (November 2011 to
February 2012) and a rate of 3.18 resulted following implementation (November 15, 2012,
to February 14, 2013). This reflected a 57.7%
reduction from the previous year during similar time periods.
Patient fall rates had decreased on the
project unit prior to implementation of
structured hourly nurse rounding. A CoxStuart trend analysis was performed on data
from the preceding 12 months prior to

Table. Percentage of Always, Yes, and 9 or 10 Reponses in each HCAHPS Domain

Composite Results Pre- and Postimplementation of Hourly Nurse Rounding

HCAHPS Domain
Overall satisfaction
Communication with nurses
Responsiveness of hospital staff
Communication with doctors
Hospital environment
Pain management
Communication about medicines
Discharge information
Likelihood to recommend

Pre %
(n = 35)

Post %
(n = 81)

1 y After Project
Implementation
(n = 472)

48.6
70.5
49.3
69.2
49.1
58.3
50.8
72.7
60.0

72.3
76.6
48.6
76.7
61.8
69.8
81.7
86.3
74.7

72.2
78.8
57.6
75.7
59.8
70.1
59.1
85.8
76.6

Abbreviation: HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems.

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Effectiveness of Structured Hourly Nurse Rounding

implementation. This analysis revealed a
statistically significant (P = .015) reduction in
the rate of falls in the preceding 12 months.
Therefore, the likelihood that the downward
trend continued because of random chance
was only 1.5%. A Cox-Stuart trend analysis
was also performed on data from 3 additional
years, which did not demonstrate any similar
downward trend during the corresponding
data periods. In addition, data patterns
revealed that the October to December
quarter historically had the highest rate in
the preceding 3 years. That pattern was not
seen following the project implementation.
The units improved patient fall rate of 3.18
falls per 1000 patient-days remained higher
than database comparisons but demonstrated
a major improvement in reduction of patient harm (Figure). Lower patient fall rates
were sustained as demonstrated by a 2.19
patient fall rate per 1000 patient-days 1 year
postimplementation.
A HAPU rate was calculated by the total
number of HAPUs divided by the total number of patient-days multiplied by 1000. Available information demonstrated that 4 HAPUs
were reported preimplementation compared
with zero during the project implementation

157

period, and only 1 HAPU was reported in the

12 months postimplementation. The ultimate
goal of zero HAPU continues to be a focus for
the facility and is in alignment with national
benchmarks.
DISCUSSION
Summary
The initial increase in compliance with
hourly nurse rounding to 69.4% in December
from baseline was not sustained in subsequent
months. The goal of compliance (>80%) was
not met in any of the implementation phase
monitoring periods. When asked, the staff reported that they believed they were conducting the hourly PEEP rounds but thought they
were not always documenting the events.
Some suggest that manual monitoring of this
indicator may be ineffective due to the reliance on humans to remember to record their
actions, which is often not completed.27 Incorporating hourly nurse rounding into the
normal workflow for staff lessens the perception that an additional task was being
requested.
For the HCAHPS domain of responsiveness
of staff, the percentage of always responses

Figure. Project unit inpatient fall incidence: Rate per 1000 patient-days.

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was the only domain in which the score

was lower postimplementation than preimplementation. The other domain percentages
all increased. All but one HCAHPS domain
demonstrated increases in the percentage of
always, yes, and 9 and 10 responses during the project period, which was consistent
with the evidence.
The rate of patient falls on the project unit
decreased prior to implementation of structured hourly nurse rounding possibly due to
a reemphasis on the Fall Prevention Program
in the nursing department. When comparing
falls rates from similar time periods, it appeared there was a decline in fall rates, although the trend began to decline prior to
project implementation. Historically, fall rates
had been highest in the October to December
time period. That usual pattern did not recur
during the project implementation (Figure).
A reduction of 11 fall incidences between the
pre- and postimplementation period reflected
a cost avoidance of $46 563 ($4322 11) for
the project implementation period.33
The reduction in the rate of patient falls,
when comparing analogous yearly time
periods, was similar to reports from other
projects and studies documented in the
literature. While the decline in fall rates during implementation was modest compared
with preceding quarters, it was clinically
significant for the winter quarter especially
considering historic data and case-mix indices. Both Bourgault et al13 and Krepper
et al16 noted no effect in patient falls with
implementation of rounding following preexisting robust fall prevention programs and low
rates of patient falls prior to implementation.
HAPU rates per 1000 patient-days had also
declined in the 6 months prior to implementation on the project unit. However, a reduction of 4 HAPUs comparing pre- and postimplementation resulted in a cost avoidance of

$172 720 ($43 180 4).33 This reduction in

HAPU rate was similar to results reported by
Ellis,14 Sherrod et al,18 and the Studer Group.2
Limitations
This project was implemented on 1
medical-surgical unit in 1 hospital. In addition,
3 months is a short period of time to evaluate a
change in nursing workflow or cultural adoption of this intervention for sustainability.
CONCLUSIONS
Change management strategies were used
to influence the culture of nursing practice, so
changes were not be perceived as simply additional tasks to complete. Recommendations
for project sustainability include incorporating unit-based rounding champions to continue to stimulate enthusiasm and prioritize
discussions so that the initial improvement
changes do not drift. Periodic monitoring and
public display of the data stimulate continual
focus on the results of this intervention.
Evidence indicates that structured hourly
nurse rounds are safe, efficient, and useful
in todays practice. Performing hourly nurse
rounding may be cost-effective as an intervention because it promotes cost avoidance by
reducing injuries related to patient falls and
pressure ulcer formation, both of which may
extend hospital length of stays. The corpus
of evidence suggested that structured nurse
rounding demonstrated favorable trends in
improving patient satisfaction and reducing
patient falls, HAPUs, and call light usage. This
project demonstrated overall improvement in
patient satisfaction indicators and decreased
patient harm through lower patient fall
and HAPU rates. Reduced patient harm
contributed more than $200 000 in cost
avoidance of care that is not reimbursed to
organizations.

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