NURS 4151 Week 8 Recommendation Synthesis Example

Hourly Rounding and Falls in High-Risk Inpatients: A Synthesis of the Evidence and a Practice Recommendation

Student Name

College of Nursing, Walden University

NURS 4151: Nursing Research and Evidence-Based Practice

Instructor Name

Month Day, Year

Hourly Rounding and Falls in High-Risk Inpatients: A Synthesis of the Evidence and a Practice Recommendation

PICOT question: Among adults scored at high fall risk on medical-surgical floors (P), does rounding every hour with set purposes (I), set against rounding on request (C), change falls per 1,000 patient days (O) across six months (T)?

Six studies were retained and leveled in earlier weeks (Appendix A). This synthesis reads them by theme rather than one at a time. It asks three questions: whether rounding is associated with fewer falls, under what conditions it worked, and what stands in the way of doing it consistently. It then offers one recommendation, worded no more strongly than the evidence allows.

Effect on Fall Rates

The studies agree on direction. A systematic review of scheduled rounding found moderate-strength evidence that rounding programs reduce patient falls (Mitchell et al., 2014), and the multisite study by Meade et al. (2006), along with the single-site evaluations by Tucker et al. (2012), Goldsack et al. (2015) and Brosey and March (2015), each reported fewer falls during rounding than before it. No study in the set reported more falls with rounding.

That agreement needs to be qualified by level and quality. The review is the strongest source, but its authors could not pool results because outcomes were measured inconsistently, and they called for controlled trials to settle which approach works best (Mitchell et al., 2014). The primary studies sit at Level II or below, and none had a randomly assigned control group. Fall definitions and denominators also differed. Tucker et al. (2012) reported falls per 1,000 hospital days, Goldsack et al. (2015) per 1,000 patient days, and Meade et al. (2006) measured falls over a much shorter period across many units. Observation windows ranged from about a month to a year. The consistent direction is therefore meaningful, but the size of the effect cannot be stated with confidence.

One further limit matters for the PICOT question. The studies generally reported falls for all patients on the units studied rather than for high-risk patients alone, so applying the evidence to high-risk patients specifically is an inference. One finding complicates that inference: Tucker et al. (2012) reported that the patients who fell during their study were not the ones with the highest risk scores. Targeting rounding to high-risk patients may therefore miss some of the falls it is meant to prevent, a point the pilot design should take into account.

Conditions Under Which Rounding Worked

Where rounding reduced falls, it tended to be structured and supported. Meade et al. (2006) used a protocol with specific actions at each visit, and found benefit whether rounds were hourly or every two hours, which suggests that what nurses do in the room may matter more than the exact interval. Goldsack et al. (2015) offers the clearest contrast in the set: the unit whose leaders and a staff champion helped design the program saw a significant fall in its rate, while a unit that received the same program with only brief training shortly before the start saw no change. Brosey and March (2015) similarly described a structured program implemented on a single unit with defined expectations.

Sustained support appears to matter as much as initial design. In the study by Tucker et al. (2012), falls dropped during a 12-week intervention on two orthopedic units but drifted back toward baseline a year later, as adherence to the rounding protocol became variable. Read together, these studies suggest rounding is not a stand-alone intervention but a practice whose effect depends on structure, staff ownership and ongoing reinforcement.

Barriers to Consistent Rounding

The qualitative and review evidence explains why rounding is hard to sustain. Deitrick et al. (2012) used ethnographic methods on two inpatient units and found that implementation faltered without careful planning, communication and follow-up evaluation. Nurses in the study by Tucker et al. (2012) described the rounds as an imposition and their documentation as a burden. A systematic review of barriers to hourly rounding identified the same themes across 20 articles: workload, burdensome rounding logs, missing staff buy-in, patient acuity, inadequate education and lack of sustainability (Toole et al., 2016).

Two of these barriers bear directly on my unit. The log that started this project is exactly the kind of documentation the literature identifies as a burden, and it may consume the time and goodwill that rounding itself needs. Staff buy-in, meanwhile, is the factor that most clearly separated success from failure in Goldsack et al. (2015).

Contradictions

One result in the set does not fit the pattern: the second unit in Goldsack et al. (2015), where rounding produced no change in the fall rate. Two explanations are grounded in the study's design. First, that unit's staff were trained just before the pilot began and had no part in shaping the program, so the intervention may never have been delivered as intended; the study did not measure adherence, so this cannot be confirmed. Second, the unit's baseline rate was lower than that of the unit that improved, 2.6 against 3.9 falls per 1,000 patient days, leaving less room for change in a 30-day window. The drift toward baseline reported by Tucker et al. (2012) is a related contradiction over time rather than between units, and it points to the same issue of fidelity.

Recommendation

On medical-surgical units with a meaningful fall rate, structured hourly rounding should be piloted, with staff involved in its design and with adherence measured, rather than adopted unit-wide as a standing policy.

Strength of evidence: moderate for the direction of effect, weak for its size. The recommendation rests on consistent Level II findings, a systematic review rated moderate, and qualitative and review evidence on implementation. It is phrased as a pilot because no study in the set was randomized and because the effect appears to depend heavily on how rounding is introduced.

What would change it: a randomized or well-controlled trial showing no effect on falls would argue against rounding altogether, while a controlled study showing benefit sustained beyond a year would support adopting it as policy. Evidence that rounding every two hours works as well as hourly rounding would also change the recommendation's design, since it would reduce the burden that the barrier literature identifies.

Appendix A: Leveled Evidence

Table 1

Retained Studies by Level and Quality (Johns Hopkins Hierarchy)

Levels and quality ratings follow Dang et al. (2022). The full leveling table with sample, intervention, outcome and limitation columns was submitted in Week 7.

References

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

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

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