Running head: HOURLY ROUNDING 1

Hourly Rounding

Megan Dickson

Bon Secours Memorial College of Nursing

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Identifying a Problem

Time management is an imperative skill to have in the health care profession. To get all

appropriate tasks and duties completed in a timely fashion, nurses and staff must take the time to

organize how they go about their shift. This time management also helps the patients understand

that the health care team will promptly respond to their needs, as well as attempting to anticipate

them. Hourly rounding is thought to give structure to how often nurses and staff will go into the

patients rooms to check on the condition of the patient and their room. Rounding has both

positive and negative consequences that need to be weighed and challenged to determine how

and when they should be done and by whom. From a nurse manager point of view, this is how

hourly rounding could be implemented keeping the four domains of leadership in mind: the

heart, the head, the hands, and the habits. The five exemplary leadership practices will also be

utilized to ensure the best outcomes of this implementation.

The Heart

The first, and possibly most important, domain of leadership is the heart. This domain has

two paths: motivation by self-interest or by the benefit of those you are leading (Blanchard &

Hodges, 2005). Implementation of hourly rounding is motivated purely to benefit others. Firstly,

the safety of the patients is the utmost importance and hourly rounding should improve the

quality of care given by the health care professionals (Fabry, 2015). Overall improved patient

outcomes and improved staff time management are other potential outcomes (Shepard, 2013).

Bragg (2016) says that patient satisfaction can be improved with hourly rounding, in addition to

management of pain and the patients understanding of the pain medicine schedule. Finally, as

with any business, money is an aspect in executing a new process (Bragg, 2016). This could be

considered both self-interest as well as benefiting others. Hospitals can receive money from
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payment programs when their patient satisfaction and outcomes are good (Fabry, 2015).

However, they can also be penalized for never events which are preventable hospital acquired

conditions that should never occur, such as falls with injury or hospital-acquire pressure ulcers

(Fabry, 2015). Like any business, hospitals want to receive extra money for accomplishing goals

and do not want to pay penalties for performing poorly.

As a nurse manager, the two populations of interest are the patients and the staff. The

patients need to be well taken care of with their nurses anticipating their needs and seeing they

are punctual about fixing any problems. However, implementing a new process can only be done

if it also benefits the ones that are carrying it out. The nurses and staff need to feel like this

assists them in the duties, rather than feeling like another chore from management they need to

complete. By putting the financial aspect of this process aside, and assessing numbers later,

management can look at the procedure itself. Management should help show the staff that this

could help them and in turn help their patients.

The Head

Following the heart is the head, which examines your beliefs and theories about leading

and motivating people (Blanchard & Hodges, 2005). There are two parts of this domain, a

visionary role which sets the course and an implementation role, with the intent of doing things

the right way (Blanchard & Hodges, 2005). Setting the course in an important part of planning

for any kind of anticipated change. By laying down the plan of how and why things should be

done, it allows those who are directly affected by the change, the nurses and staff, to have more

understanding of the process itself. In Deitrick, Baker, Paxton, Flores, and Swavelys (2012)

study, there was not much instruction on how to perform the task itself, even during education

sessions. In that same study, most nurses and staff could not articulate the reason for hourly
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rounding (Deitrick et al., 2012). In contrast, Toole et al. (2016) found that staff thought hourly

rounding was a bright idea but were unsure of the execution of adding it into the existing

workload. The literature showed that staff support the principles of hourly rounding, but

struggle with ways to adapt it to make it practical (Toole et al., 2016). In addition, Deitrick et al.

(2012) found that the staff, understood what was expected of them but felt little to no guidance

from management on how to adapt their workflow to a new required task. Staff felt that unit

leadership should also be held responsible for the education of staff and to work with them on

integration, not just for setting expectations and tracking performance (Deitrick et al., 2012).

It is imperative to know the best way to explain how and why a process is being

implemented. As a manager, this needs to be determined before taking it to the staff, and

questions should be anticipated. Educational sessions should be held at times that are convenient

for all shifts and staff members affected. This can be done by holding multiple sessions during a

time frame that is not too late for morning staff and not too early for night staff. Allowing for

these time frames would show that management appreciates the time of both morning and night

staff members. After this, the management team should be ready to answer questions from the

staff members and to seriously consider the suggestions given by the staff. Many times, a

flawless plan thought up behind a desk is an imperfect plan in the field. Management should take

the time to adjust the plan of action before implementing it, to refine it to what will work best.

Finally, the nurse manager can work on executing the plan.

The Hands

Once intent is set and the beliefs are known, the hands get to work. With the hands at

work, the nurse manager should act as a performance coach (Blanchard & Hodges, 2005). This

means the management team must stay involved in the process. Per Blanchard and Hodges,
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(2005), there are three parts of being a performance coach: performance planning, day-to-day

coaching, and performance evaluation. Shepard (2013) says that continuous evaluation and

subsequent revisions are necessary. Along with this, it is important to ensure that

documentation of hourly rounding does not become a tick-box exercise for nursing staff that

takes up valuable time without leading to benefits for patients (Harris, Sims, Levenson, et al.,

2017). Day-to-day coaching will help nurses and staff to adapt to the process itself as well as

adding it into their current workload. Each unit will likely need their own ways of performing

hourly rounds since the acuity of each patient will be different. Toole et al. (2016) found that

there could be lack of staff buy-in if rounding frequency is not at the staff discretion because of

the low acuity of some patients and potentially their autonomy of activities of daily living.

Deitrick et al., (2012) suggests that having a rounding expert or a unit champion on the floor

during implementation of hourly rounding will help staff to integrate the new process into their

work.

As a nurse manager, it is important to evaluate the effectiveness of a new process.

Weekly evaluations, including staff input and audits of documentation, would be extremely

beneficial for this investigation. The nurse manager should be readily available for constructive

criticism or praise about the process. It is just as helpful to hear what is not working as it is to

hear what is working. A rounding expert or a unit champion would be extremely beneficial for

day-to-day coaching. Someone who does not have other obligations to tend to that can put the

brunt of their energy into helping the staff with this change. This person will also be able to

report to the nurse manager to express what problems the staff is having, if there are staff

members that are struggling, and to point out staff that excel at rounding that could act as a

mentor for staff that continues to struggle and any new staff members.
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The Habits

Involvement of supportive relationships is one of the habits that help leaders succeed

(Blanchard & Hodges, 2005). This means that management and leaders for this project must stay

involved throughout the extent of the process. When all levels of management work together for

the greater good, a lot of solid work can be done. Fabry (2015) says, Hospital leaders in

conjunction with the front-line nursing staff need to determine if hourly rounding is the right fit

for the nursing staff and patient population. By doing this it allows for the nurses to have more

autonomy and promotes a shared governance (Toole et al., 2016). In not including staff in

decision-making, Toole et al. (2016) found there was less staff buy-in as well as success. Lack of

leadership was one of the main barriers found in Toole et al.s (2016) systematic review, leading

to inconsistencies and challenges that may have been prevented.

Staff needs to know that management at every level respects their opinions and will listen

to what they want to say. This also means that management knows that staff will have an open

mind and will attempt to integrate the new idea into their shift (Fabry, 2015). There needs to be a

continuum of support throughout the system. By working together, the entire system can find a

way to implement hourly rounding that is conducive and beneficial. The nurse manager can act

as a liaison between upper and lower staff, passing the messages along to each set of employees.

From this, the staff should understand that the nurse manager is listening to their concerns and

investigating what can be done as well as hearing input from upper-level leaders and attempting

to execute their requests.

Model the Way

Setting an example is vital when attempting to successfully accomplish a change in a

workplace. Modeling the way is truly the leaders responsibility. Upper-level management as
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well as the nurse manager should be able to articulate the way to perform hourly rounding and to

educate the staff on how to best adapt it into their workflow. A top-down approach is usually a

difficult way to go about change. Deitrick et al., (2012) found that many nurses could not find

ownership while performing hourly rounds and felt it was one more chore upper-level

management wanted done every day. Nurses need to have some evidence that hourly rounding is

for their benefit as well, not solely to make the hospital look better. Education is another

important factor when modeling the way. By educating the staff with proof of success and ways

to adapt to the change, there will more staff buy-in and a higher chance of accomplishment.

Inspire a Shared Vision

After setting the bar for how to perform hourly rounds, its important to show the staff

how this also involves them. Show them that with their help, this process will run smoother and

could potentially help them with their jobs. There are a lot of nurses that have been working for

years that have a lot of wisdom and experience in nursing that can be known to get set in their

ways. These veteran nurses are who the nurse manager should focus their energy on. The

experienced nurses will have the most influence on the less experienced nurses. Shepard (2013)

articulates the importance of getting buy-in from formal and informal nurse leaders to quickly

get hourly rounding into practice. Showing that the front-line staff will be included for

determining if this process of hourly rounding is a good fit and will have a say in delivery of care

will promote a sense of unity among the system (Fabry, 2015).

Challenge the Process

There are many barriers to implementing a new practice. Both during and after

implementation, the nurse manager should continue to search for innovation and improve what

has already been established. One barrier to overcome relates to the workload of the nurse (Toole
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et al., 2016). Interrupting the regular workflow that a nurse has already grown accustomed to can

be a major stressor. The nurse manager should help the nurses find a way to adapt their current

work pattern into one that allows for hourly rounding. Another problem is having to document

the rounding. There are many ways to document this rounding, including having a paper in the

patients room that staff initials, having a white board that is to be updated during rounds, or

computer documentation. In the study conducted by Toole et al. (2016), it was found that staff

thought of the rounding documentation as irrelevant, a waste of time, and were completed before

or after shifts, rather than completing rounding. Overall, this review of the literature identifies

that nurses think rounding logs are a non-value added task (Toole et al., 2016). In addition to

interruptions and extra documentation, it is difficult to implement a universal process for patients

that do not have universal needs. The nurse manager should work with the staff to allow for them

to determine the importance of hourly rounding for each patient individually, allowing for

autonomy for the staff. A prescriptive rounding process diminishes a nurses sense of

professional autonomy (Toole et al., 2016).

Enable Others to Act

Fostering collaboration and strengthening the staff will promote them to implement

hourly rounding into their workflow. Again, autonomy amongst the staff is important if

management wants to succeed. The Magnet model identifies the importance of empowering

nurses to act on their own autonomous decisions and promotes a transformational leadership

style that encourages shared governance structures to effectively implement change in practice

(Toole et al., 2016). Without supporting the nursing staff in their ability to make decisions, the

process will fail as nurses become resentful about being forced to implement a plan that is not

conducive for their work (Shepard, 2013). It is also important that the brunt of the work of this
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change not fall onto specifically nurses. Other staff that cares for the patients are fully capable of

performing hourly rounds and can help alleviate some of the burden on the nurses (Shepard,

2013). The nurse manager should motivate the nurses and staff to work and communicate

together to help each other.

Encourage the Heart

Finally, to make a change last, it is important to make sure the staffs efforts are

recognized and valued. In Toole, Meluskey, and Halls (2016) review, a study was found that

pointed out that staff did not feel valued and did not receive enough recognition, which

contributed to a lack of success of hourly rounding. The nurse manager should frequently

express their gratitude to the staff for being willing to make the change during the

implementation process and for their hard work throughout. It is important to make the staff

aware that their efforts are appreciated and not forgotten, even if hourly rounding will not be

continued as a required task. Showing the staff audits of how well they are doing shows how the

staff is doing. If appropriate, the nurse manager could have monthly recognition for the staff

members who have the best rounding records that month, giving staff members something to

work towards.

Professional Practice Implications

One suggestion on rounding would be to focus on the purpose and quality of rounding as

opposed to the frequency of the rounds (Toole et al., 2016). Putting time frequency limitations

on this process removes the critical thinking and individualized nursing care which is at the heart

of the nursing profession (Toole et al., 2016). This will promote autonomy of the staff and

allow for the nurses to assess which patients need more frequent rounding and whether the nurse

or the tech should perform most the rounds. If a patient only needs some supplies or assistance
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with ambulation, surely the tech can perform this round. However, if a patient has a higher

acuity, cannot care for themselves, or needs more education on their diagnosis or medications, a

nurse would be more appropriate for this round. Finally, this promotes teamwork and

communication throughout the staff and can lead to better patient outcomes.

Another implication would be to have an adequate number of education sessions at

convenient times to properly instruct the staff on the best way to incorporate rounding into their

work (Toole et al., 2016). Fabry (2015) suggests having these sessions between 1900 hours and

0100 hours because it demonstrates to the night shift staff that they are appreciated and valued,

which can help improve morale and retention of information. Another factor in the education of

the purpose and process of rounding is to make sure the education methods are conducive to the

staff (Fabry, 2015). As with teaching a patient information, the instructor should have multiple

modalities to teach from. The nurse manager should work with the staff to accomplish effective

implementation of this process and monitor the performance of these rounds.

Outcomes Evaluation

By working with the nurse and staff as a team, focusing on their needs, allowing for

autonomy of the staff, and ensuring proper education, staff were consistently involved and

willing to work towards a common goal aside upper-level management. This improved staff

satisfaction and communication across the board. Rounding that was adapted to the units needs

also resulted in improved patient outcomes. Patients felt that their needs were being addressed

before having to call out, hit the call bell less often, and felt the staff was working as team to give

them the best care possible. Finally, because patients were more satisfied and were safer, there

were less injurious incidents which meant the hospital had less penalties to pay and received

money from money payment programs because the patients were so happy with their care.
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References

Blanchard, K., & Hodges, P. (2005). Lead like Jesus: Lessons from the greatest leadership role

model of all times. Nashville, TN: Thomas Nelson

Bragg, L. (2016). Team Concepts. How do patients perceive hourly rounding?. Nursing

Management, 47(11), 11-13. doi:10.1097/01.NUMA.0000502807.60295.c5

Deitrick, L., Baker, K., Paxton, H., Flores, M., & Swavely, D. (2012). Hourly rounding:

Challenges with implementation of an evidence-based process. Journal of Nursing Care

Quality, 27(1), 13-19. doi:10.1097/NCQ.0b013e318227d7dd

Fabry, D. (2015). Hourly rounding: perspectives and perceptions of the frontline nursing staff.

Journal of Nursing Management, 23(2), 200-210. doi:10.1111/jonm.12114

Harris, R., Sims, S., Levenson R., et al. (2017). What aspects of intentional rounding work in

hospital wards, for whom and in what circumstances? A realist evaluation protocol. BMJ

Open 2017;7;e014776. doi:10.1136/bmjopen-2016-014776

Shepard, L. (2013). Stop going in circles! Break the barriers to hourly rounding. Nursing

Management, 44(2), 13-15. doi:10.1097/01.NUMA.0000426147.98903.ae

Toole, N., Meluskey, T., & Hall, N. (2016). A systematic review: Barriers to hourly rounding.

Journal of Nursing Management, 24(3), 283-290. doi:10.1111/jonm.12332