NURS 4151 Week 10 EBP Project Example

Purposeful Hourly Rounding to Reduce Falls on a Medical-Surgical Unit: An Evidence-Based Practice Project

Student Name

College of Nursing, Walden University

NURS 4151: Nursing Research and Evidence-Based Practice

Instructor Name

Month Day, Year

Purposeful Hourly Rounding to Reduce Falls on a Medical-Surgical Unit: An Evidence-Based Practice Project

Falls are one of the most common harms hospitals cause, and nurses are expected to prevent them. The Agency for Healthcare Research and Quality estimates that between 700,000 and 1,000,000 people fall in United States hospitals each year, and its prevention toolkit treats falls as largely preventable through reliable, unit-level practices (Agency for Healthcare Research and Quality [AHRQ], 2013). Scheduled nursing rounds are one such practice, and many hospitals have adopted them. This project asks whether the evidence supports hourly rounding on one composite medical-surgical unit, and if so, in what form.

Background and Problem

The setting is an adult medical-surgical floor of 30 beds in a community hospital. Many of its patients are older adults admitted with infections, heart failure or complications of diabetes, and a large proportion are rated high risk by the Morse Fall Scale when admitted. Falls are reported monthly on the unit's quality board, and the unit's rate has been above the hospital's target for most of the past year. Exact figures are held by the hospital's quality department and are not reproduced here.

For several years the unit has required hourly rounding documented on a paper log at each patient door. The log records a set of checks: pain, position, toileting and whether the call light and personal items are within reach. In practice, the log is signed every hour and rarely reviewed. The policy requiring it cites no evidence and has not been revised since it was written. This project began with a simple question about that habit: whether it was doing what it was meant to do, and whether there was a better way to do it.

Clinical Question

The question was framed in PICOT format so that it could guide a search and later an evaluation (Stillwell et al., 2010): for adults at high risk of falling on medical-surgical units (P), what is the effect of purposeful rounding every hour (I), set beside rounding only in response to call lights and routine care (C), on the number of falls for every 1,000 patient days (O) during a six-month period (T)?

The question went through two revisions. The first draft asked about all inpatients and about safety in general, which was too broad to search or measure. Limiting the population to high-risk patients focused the question on the group rounding is designed to protect, and expressing falls against patient days made the outcome comparable across months with different census levels. A six-month time frame was chosen to capture more than a brief improvement, since short projects sometimes report gains that fade.

Methods

CINAHL Complete and PubMed were searched through the university library. Search strings combined subject headings and keywords for three concepts: nursing rounds, including the terms hourly, purposeful and intentional rounding; accidental falls; and inpatient or acute care settings. Results were limited to English-language reports published from 2005 onward. The two databases together returned 185 records, and 124 remained after duplicates were removed. Title and abstract screening excluded 98, mainly because they were not about rounding or did not report falls. Of 26 full texts read, 20 were excluded, most often because rounding was bundled with several other interventions whose effects could not be separated. Six studies remained. The screening flow and full search log appear in Appendix A. The reference list of the one systematic review was also checked by hand, which yielded no additional studies.

Each study was appraised with a structured worksheet and assigned a level and quality rating using the Johns Hopkins model (Dang et al., 2022). The leveled studies are summarized in Appendix B.

Appraisal of the Evidence

The strongest source is a systematic review of hourly rounding programs, which judged the case for fewer falls under rounding to be of moderate strength while noting that outcomes had been measured too differently across studies to combine them (Mitchell et al., 2014). It was rated Level II, quality B.

Four primary studies measured falls. Meade et al. (2006) compared rounding at one-hour and two-hour intervals across 27 units in 14 hospitals using a nonequivalent groups design. Tucker et al. (2012) followed two orthopedic units before, during and one year after a 12-week rounding intervention and added focus groups with nurses. Goldsack et al. (2015) evaluated a 30-day rounding pilot on two units of one hospital against each unit's previous year. Brosey and March (2015) reported a program evaluation on a single medical-surgical unit. The first three were rated Level II, with quality B for Meade and Tucker and C for Goldsack because of its short observation period and inconsistent results between units. Brosey and March was rated Level V, quality C, because it was designed as an improvement report rather than as research.

The sixth study, by Deitrick et al. (2012), observed, ethnographically, the introduction of hourly rounding on two inpatient units. It was rated Level III, quality B. Its value lies less in its level than in the question it answers: why rounding programs struggle once they leave the planning stage.

Two weaknesses run through the set. None of the studies randomly assigned units or patients, so none can establish that rounding itself caused the changes observed. And the studies defined and counted falls differently, over periods ranging from a month to a year, so their effect sizes cannot be compared directly.

Synthesis

Read together, the studies point in the same direction. Every study that counted falls reported fewer during rounding than before it, and none reported an increase (Brosey & March, 2015; Goldsack et al., 2015; Meade et al., 2006; Tucker et al., 2012). The systematic review reached the same conclusion at moderate strength (Mitchell et al., 2014). Consistency across designs, settings and hospitals gives this direction some weight, even though no single study is strong.

The studies also suggest that rounding succeeds under particular conditions. Meade et al. (2006) found benefit at both one-hour and two-hour intervals when rounds followed a protocol of specific actions, suggesting that the content of each visit matters at least as much as its frequency. In the pilot by Goldsack et al. (2015), the unit whose staff and leaders shaped the program improved, while a second unit introduced to it at the last minute did not. Tucker et al. (2012) found that falls declined during their intervention but had largely returned toward their starting level twelve months on, by which time adherence had become uneven.

The implementation evidence explains that drift. The orthopedic nurses interviewed by Tucker et al. (2012) experienced the rounds and their documentation as an imposition. Deitrick et al. (2012) found that rounding took hold only with deliberate planning, communication and evaluation. A review of barriers found the same obstacles recurring across hospitals: heavy workloads, burdensome logs, patient acuity, thin staff education, weak buy-in and poor sustainability (Toole et al., 2016).

One further finding bears on the population in the clinical question. Among the orthopedic patients studied by Tucker et al. (2012), those who fell were not the ones carrying the highest risk scores. Restricting rounding to high-risk patients could therefore miss some falls, and the pilot described below applies rounding to all patients on the unit while measuring outcomes for the high-risk group as the primary result.

Recommendation

The evidence supports a structured, staff-designed pilot of purposeful hourly rounding on the unit, with adherence measured, before any decision to adopt it as permanent policy. The strength of evidence is moderate for the direction of effect and weak for its size. Mid-level evidence supports a trial, not a mandate. The recommendation would change if a controlled study found no effect on falls, or if evidence showed that two-hourly rounding performs as well as hourly rounding with less burden on staff.

Implementation Plan

The plan follows the Iowa Model, which asks teams to form a group, design and pilot the change, evaluate process and outcome data, and only then decide whether to adopt it more widely (Iowa Model Collaborative, 2017).

Stakeholders. The unit manager sponsors the pilot and protects time for planning. A design group of four staff nurses from day and night shifts, two nursing assistants and the unit educator shapes the rounding protocol. The hospital's fall prevention committee reviews the plan, and the quality department supplies monthly fall data. Float pool leadership is included from the start because float staff cover a large share of night shifts.

Design choices. The paper log at each door is retired, since the literature identifies burdensome documentation as a barrier and the current log has no known use. Rounding visits address pain, position, toileting and possessions within reach, and nurses and assistants alternate hours so that each has a manageable number of visits. During the busiest hours, rounding is combined with medication administration rather than scheduled separately.

Education. All unit staff complete a 20-minute session during the month before launch, covering the evidence summary, the protocol and how adherence will be checked. Float staff receive a one-page protocol card with each assignment to the unit, and the charge nurse reviews rounding expectations at the start of each shift.

Timeline. Month 1: design group meets weekly and finalizes the protocol. Month 2: education and a two-week trial run. Months 3 through 8: six-month pilot, matching the time element of the clinical question. Month 9: evaluation and a decision on adoption, revision or discontinuation.

Evaluation Plan

The primary outcome is the one named in the clinical question: falls per 1,000 patient days among patients scored as high fall risk, compared with the same six calendar months of the previous year to account for seasonal variation in admissions. Falls among all patients on the unit are reported as a secondary outcome, along with falls with injury.

The process measure is rounding adherence. Twice a week, on randomly chosen shifts, the educator or a design group member asks five randomly chosen patients whether a staff member checked on them within the past hour and observes whether the call light and personal items are within reach. The target is 85% of checks met. Adherence data are reviewed monthly alongside fall data, so that a failed pilot can be distinguished from a pilot that was not delivered. Staff views are gathered at months 3 and 6 through a brief survey asking whether rounding is feasible and whether it feels like care or paperwork.

Limitations

The project has three main limitations. The evidence base contains no randomized trials, so the pilot tests a practice whose effect size is uncertain. A single-unit pilot compared with its own history cannot separate rounding from anything else that shifts during the same months, for instance new bed alarms or staffing patterns; the design group will record any such changes. Finally, a unit's monthly fall count is small, so six months may not be enough to show a statistically clear change even if rounding works. The evaluation will therefore weigh direction, adherence and staff experience together rather than relying on a single test.

Conclusion

The rounding log that prompted this project is a practice adopted without evidence and kept without review. The literature suggests that rounding itself has value, but mainly when it is structured, designed with the staff who carry it out and sustained over time. A pilot built on those conditions, with outcomes and adherence measured side by side, offers the unit a way to find out whether rounding can reduce its falls and to replace a habit with a practice it can defend.

Appendix A: Search and Screening Summary

Databases: CINAHL Complete and PubMed. Limits: English language, 2005 onward, peer-reviewed journals in CINAHL. Records identified: 185. After duplicate removal: 124. Excluded at title and abstract: 98. Full texts assessed: 26. Of the 20 full texts excluded, eight bundled rounding with other interventions, five did not give falls as a count or rate, four involved children or mixed ages, and three duplicated an included study. Included: 6. Search strings as run are recorded in the Week 4 search log.

Appendix B: Leveled Evidence

Rated Level II: the systematic review by Mitchell et al. (2014) and the studies by Meade et al. (2006) and Tucker et al. (2012), each at quality B, and the pilot by Goldsack et al. (2015) at quality C. Rated Level III: the ethnographic study by Deitrick et al. (2012), quality B. Rated Level V: the program evaluation by Brosey and March (2015), quality C.

References

Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ Publication No. 13-0015-EF). https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html

Brosey, L. A., & March, K. S. (2015). Effectiveness of structured hourly nurse rounding on patient satisfaction and clinical outcomes. Journal of Nursing Care Quality, 30(2), 153-159. https://doi.org/10.1097/NCQ.0000000000000086

Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International.

Deitrick, L. M., 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. https://doi.org/10.1097/NCQ.0b013e318227d7dd

Goldsack, J., Bergey, M., Mascioli, S., & Cunningham, J. (2015). Hourly rounding and patient falls: What factors boost success? Nursing, 45(2), 25-30. https://doi.org/10.1097/01.NURSE.0000459798.79840.95

Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223

Meade, C. M., Bursell, A. L., & Ketelsen, L. (2006). Effects of nursing rounds on patients' call light use, satisfaction, and safety. American Journal of Nursing, 106(9), 58-70. https://doi.org/10.1097/00000446-200609000-00029

Mitchell, M. D., Lavenberg, J. G., Trotta, R. L., & Umscheid, C. A. (2014). Hourly rounding to improve nursing responsiveness: A systematic review. Journal of Nursing Administration, 44(9), 462-472. https://doi.org/10.1097/NNA.0000000000000101

Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-based practice, step by step: Asking the clinical question: A key step in evidence-based practice. American Journal of Nursing, 110(3), 58-61. https://doi.org/10.1097/01.NAJ.0000368959.11129.79

Toole, N., Meluskey, T., & Hall, N. (2016). A systematic review: Barriers to hourly rounding. Journal of Nursing Management, 24(3), 283-290. https://doi.org/10.1111/jonm.12332

Tucker, S. J., Bieber, P. L., Attlesey-Pries, J. M., Olson, M. E., & Dierkhising, R. A. (2012). Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units. Worldviews on Evidence-Based Nursing, 9(1), 18-29. https://doi.org/10.1111/j.1741-6787.2011.00227.x