NUR 699 Grand Canyon University Week 6 EBP Proposal Section G Evaluation of Process

Course Code NUR-699 Class Code NUR-699-O500 Criteria Content Percentage 85.0% Evaluation Plan 30.0% Rationale for Methods 30.0% Implications for Future Research 25.0% Organization and Effectiveness 5.0% Mechanics of Writing (includes spelling, punctuation, grammar, language use) 5.0% Format 10.0% Paper Format (Use of appropriate style for the major and assignment) 5.0% Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) 5.0% Total Weightage 100% Assignment Title Evidence-Based Practice Proposal: Section G: Evaluation of Process 1: Unsatisfactory (0.00%) Evaluation plan presents the method used in the measurement of the outcomes but does not align the project objectives and/or evidence. The rationale is missing. Modification strategies as well as the impact to future research may or may not be present with minimal details. Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used. Documentation format is rarely followed correctly. Sources are not documented. Total Points 60.0 2: Less Than Satisfactory (80.00%) Evaluation plan presents the methods used in the measurement of the outcomes according to the project objectives and/or evidence. The rationale is missing. The information presented is ambiguous. Modification strategies as well as the impact to future research may or may not be present with minimal details. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied. Lack of control with formatting is apparent. Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors. 3: Satisfactory (88.00%) Evaluation plan presents the rationale for and the methods used in the measurement of the outcomes according to the project objectives and evidence. NUR 699 Grand Canyon University Week 6 EBP Proposal Section G Evaluation of Process

The rationale presented may lack cohesiveness and details. Possible project modifications when outcomes do not provide expected results are listed. The implications for practice and future research are broadly described. Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed. Formatting is correct, although some minor errors may be present. Sources are documented, as appropriate to assignment and style, although some formatting errors may be present. 4: Good (92.00%) Evaluation plan presents the rationale for and the methods used in the measurement of the outcomes according to the project objectives and evidence. The rationale is present. Validity, reliability, and applicability are briefly addressed. Strategies for project modification when outcomes do not provide expected results are outlined. Implications for practice and future research are broadly described. Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech. There are virtually no errors in formatting style. Sources are documented, as appropriate to assignment and style, and format is mostly correct. 5: Excellent (100.00%) Evaluation plan presents the rationale and the methods used in the measurement of the outcomes according to the project objectives and evidence. The rationale presented is aligned, comprehensive, and addresses validity, reliability, and applicability. The plan formulates clear and precise strategies for project modification when outcomes do not provide expected results. An informed position on the implications for practice and future research is developed and explained. Writer is clearly in command of standard, written, academic English. All format elements are correct. Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error. Comments Points Earned © Oncology Nursing Society. Unauthorized reproduction, in part or in whole, is strictly prohibited. For permission to photocopy, post online, reprint, adapt, or otherwise reuse any or all content from this article, e-mail pubpermissions@ons.org. To purchase high-quality reprints, e-mail reprints@ons.org. n Journal Club Article Round and Round We Go: Rounding Strategies to Impact Exemplary Professional Practice Nicole Reimer, BSN, RN, OCN®, and Laura Herbener, BSN, RN, OCN® The literature demonstrates that diverse rounding methods have been shown to positively impact a wide variety of quality and safety outcomes, as well as patient and staff satisfaction. Rather than adopting one or two of these strategies, the concepts and recommendations from the literature associated with rounding have formed the foundation for an academic, community, Magnet® hospital to implement a compendium of rounding efforts: patient rounds, interdisciplinary collaborative rounds, daily clinical rounds by the unit educator and daily rounds by the unit manager, quarterly unit rounds by senior nursing managers, and safety rounds by senior executives. This article details each of these methodologies as implemented on a 26-bed hematology/oncology unit. Positive © Fuse/Thinkstock outcomes perceived to be associated with the rounds have been achieved for patient, employee, and physician satisfaction, as well as clinical quality indicators. Nicole Reimer, BSN, RN, OCN®, is a director of patient care services and Laura Herbener, BSN, RN, OCN®, is a patient care specialist, both at Lehigh Valley Health Network in Allentown, PA. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the authors, planners, independent peer reviewers, or editorial staff. Reimer can be reached at nicole.reimer@lvh.com, with copy to editor at CJONEditor@ons.org. (Submitted January 2014. Revision submitted March 2014. Accepted for publication March 15, 2014.) Key words: rounding; collaborative rounds; patient rounds; executive rounds; safety rounds; lean methods Digital Object Identifier: 10.1188/14.CJON.18-06AP A variety of rounding methods have been increasingly implemented in healthcare settings to improve patient safety and positively impact patient and staff satisfaction. At Lehigh Valley Hospital (LVH), an academic, community Magnet® hospital, six types of rounds were implemented within the inpatient, emergency, and ambulatory patient care areas (see Table 1). This article details each rounding methodology, including its purpose, structure, and outcomes, emphasizing implementation on the 26-bed hematology/oncology inpatient 7C unit at LVH. Literature Review Most of the literature associated with rounding methods relates to hourly patient rounds by healthcare personnel in an inpatient setting; however, the seminal article on this subject is the quasi-experimental research by Studer, Robinson, and Cook (2010). The study demonstrated that a protocol incorporating specific actions into patient rounds can reduce the frequency of patients’ call-light use, increase their satisfaction with nursing care, and reduce falls (Meade, Bursell, & Ketelsen, 2006). 654 Other research reported that patient satisfaction was the most common outcome, with statistically significant improvements noted (Bourgault et al., 2008; Culley, 2008; Ford, 2010; Gardner, Woollett, Daly, & Richardson, 2009; Meade et al., 2006; Tea, Ellison, & Feghali, 2008; Weisgram & Raymond, 2008). Studies also focused on call-light use, finding reductions in use after implementing hourly rounds (Bourgault et al., 2008; Meade et al., 2006; Weisgram & Raymond, 2008). A third variable positively impacted by hourly rounds was staff satisfaction (Bourgault et al., 2008; Gardner et al., 2009; Leighty, 2007). Collaborative rounding has long been supported in the literature and continues to be a mainstay in rounding methodologies. According to Edwards (2008), team rounding reduces the likelihood of error, thus increasing patient safety. In addition, Vazirani, Hays, Shapiro and Cowan (2005) reported increased collaboration among members of the healthcare team, particularly between nurses and nurse practitioners. Teaching rounds performed by a unit-based nurse educator have been found to be conducive to staff development, particularly regarding the cultivation of critical-thinking skills (Segal & December 2014 • NUR 699 Grand Canyon University Week 6 EBP Proposal Section G Evaluation of Process

Volume 18, Number 6 • Clinical Journal of Oncology Nursing Mason, 1998). This professional development strategy prompts multiple outcomes, such as documentation compliance, patient and staff satisfaction, and quality clinical care. Senior executive rounding is another methodology reported in the literature. Termed “walk rounds,” the focus of a study by Frankel et al. (2008) was to improve the safety climate and the staff perception of patient safety through open dialogue and collaboration. Staff perceived that the walk rounds had a positive impact on the facility’s safety climate and patient safety. Campbell and Thompson (2007) corroborated those results in their retrospective study of patient safety rounds. Through rounding, Studer et al. (2010) described how nurse leaders can reinforce care delivery to patients, verify nursing actions, and recognize their employees. Studer et al. (2010) noted that this is “one of the most important actions . . . to improve patient perception of courtesy and respect and of nurse communication as a whole” (p. 46). The literature demonstrates that various rounding methods have been shown to positively impact quality and safety outcomes, as well as patient and staff satisfaction. Rather than adopting one or two of these strategies, the concepts and recommendations from the literature associated with rounding formed the foundation for the current article’s authors to devise, implement, and evaluate a compendium of rounding efforts. Rounding Methods Hourly Patient Rounds Hourly patient rounds are intended to increase patient safety and satisfaction of patients, family members, and staff. The aim is to anticipate and address patient needs. Rounds are completed by an RN or unlicensed assistive personnel every hour from 6 am to midnight and every two hours from midnight to 6 am. For ease of memory and standardization, the authors focused on pain, positioning, and personal needs. A standardized electronic tool, the Patient Rounding Log, was used to monitor completion. The tool is a part of the permanent medical record and has proven useful when investigating quality issues. Standardization is a key component in the hourly rounding process within the hematology/oncology inpatient unit and throughout the hospital (see Table 2). Patients and families were notified that hourly rounding occurred in a standardized manner, no matter the point of entry or unit placement. However, because the oncology population demonstrates a heightened need for uninterrupted rest, based on their condition and needs, patients would be offered a customized rounding schedule. Interdisciplinary Collaborative Rounds Interdisciplinary collaborative rounds are conducted in a variety of ways, and several factors determined the methods used, such as ideal times for family involvement, optimum times for physicians and other members of the interdisciplinary team, and patient diagnosis. Despite the use of various methods, the common purpose of collaborative rounds is to review the current plan of care, determine care priorities, and resolve patient care issues. Rounds always include the patient and family. On the inpatient oncology unit, the interdisciplinary team may include the patient’s primary nurse, attending physician, oncology medical fellow, medical resident, advanced practice nurse, physician assistant, pharmacist, and case manager. Rounds are completed daily for every patient and twice daily for patients who require reevaluation because of the acuity of their illness or who have complex discharge planning issues. TABLE 1. Rounding Strategies in Use at Lehigh Valley Hospital Strategy Purpose or Focus Participants Frequency Script Hourly patient rounds Increase patient safety and the satisfaction of patients, family members, and staff. Anticipate and address the patients’ needs. Patients, RN, technical partner Hourly Yes Interdisciplinary collaborative rounds Review the current plan of care, determine the care priorities, and resolve patient care issues. Patient, physicians, nurse practitioner, physician assistant, RN, pharmacist, case manager Daily No Daily clinical rounds by unit educator Offer support to staff from a clinical expert to facilitate critical thinking related to care delivery; promote patient safety, collaboration of team members, and quality patient care; and positively impact nurse sensitive clinical indicators and regulatory standards. RN, patient or family, patient care specialist, technical partner Daily Audit tool Daily patient rounds by unit manager Ensure patient and family are satisfied with their care, build relationships, and be proactive to resolve patient issues. Patient or family, RN Monday through Friday Yes Quarterly unit rounds by senior nursing Recognize staff’s hard work and dedication to patient care, and encourage discussion regarding nursing sensitive quality outcome metrics. NUR 699 Grand Canyon University Week 6 EBP Proposal Section G Evaluation of Process

Patient or family, RN, technical partner Quarterly No Safety rounds by senior executives Demonstrate to frontline staff that senior executives care about and are invested in resolution of staff safety concerns. Enlighten executives about depth of frontline staff concerns. All unit staff, patient safety officer, senior vice president of quality and safety, representative of the senior hospital executive team Monthly Yes Clinical Journal of Oncology Nursing • Volume 18, Number 6 • Rounding Strategies for Exemplary Practice 655 TABLE 2. Lehigh Valley Health Network Patient Rounding Standard Work Action Knock on door Script and Accompanying Work – Introduce self “Hi, I’m Kim Smith. I am your RN today.” Explain “A staff member will be coming around every hour from 6 am through midnight and every two hours from midnight to 6 am” Ask “Can I get you anything for pain? Do you need to go to the bathroom? Can I help you get repositioned? Is there anything I can do to help you get comfortable?” Scan the room Check if call bell, telephone, and bedside table are in reach; cords are safely positioned to prevent trip hazards; and the pathway to the bathroom is free of clutter and fall hazards. Is there anything else that needs to be cleaned up? Plan for future “We will round again in about an hour to check on you, but if you need something or you need assistance to get up, please use your call bell.” Two types of physicians complete rounds on the unit, gynecologic oncologists (starting at 7 am) and hematologic oncologists (starting at 9 am). The consistent times promote participation by all attendees and ensure that a nurse does not have more than one physician rounding at the same time. Buyin for all disciplines to participate was driven from the onset because each discipline quickly saw the value through gained efficiencies and resultant patient and staff satisfaction. Interdisciplinary collaborative rounds begin with a presentation of an earlier assessment by one of the aforementioned team members. All members of the collaborative team, inclusive of the patient and family, then discuss and agree on the plan of care. Efforts are made to ensure that every participant offers input. For example, the physician normally ends the discussion by inquiring if there are any questions or if anyone has anything else to add. Special emphasis also is made to encourage questions from patients and family and then to ensure understanding of responses. This normally is the responsibility of the primary nurse. Based on her established relationship with the patient and family, she is aware of their issues and concerns and makes certain, using strategies such as Teach Back, that these have been addressed. This rounding approach is organized, efficient, and predictable. For example, collaborative rounds for a patient with acute leukemia focus on such things as determination of the appropriate chemotherapy regimen, anticipated nadir, patient and family preference for managing anticipated treatment side effects, and discharge needs. Group dialogue through rounds can identify various outcomes. In some instances, rounds identify that a consultation is needed with an ancillary team member, such as a dietitian, spiritual counselor, and/or pain management specialist. Clinical practice guidelines and other care standards are found to require development or revision at other times. 656 Daily Clinical Rounds by the Unit Educator LVH has a unit-based educator role, termed a patient care specialist (PCS). The role requires a master’s degree in nursing, and most units have 1.0 full-time equivalent in the position. The PCS participates in identifying, planning, and implementing educational programs within specialty areas for hospital healthcare providers, patients, families, and/or community groups. NUR 699 Grand Canyon University Week 6 EBP Proposal Section G Evaluation of Process

The PCS conducts daily clinical rounds with staff regarding their patients. The rounds began because bedside nurses expressed a need for support by a clinical expert to facilitate critical thinking related to their care delivery. As a result, the rounds promote patient safety, collaboration of team members, and quality patient care. The rounding process fosters a learning environment, promoting critical thinking and patient care planning. A more specific focus within the rounds is to positively impact nursing-sensitive clinical outcomes and regulatory standards. The PCSs within the medical-surgical division, working collaboratively with the Nursing Quality Department staff, developed a comprehensive 125-indicator tool to guide the rounding process and collect data. This template, referred to as the Quality Bundle Tool, includes prioritized content in the format of a quality checklist. Examples include documentation of fall and pressure ulcer assessment scores and associated interventions in the plan of care. The PCS conducts rounds from Monday–Friday, with one nurse daily, and rotates to all shifts. Patients are selected by the PCS for a variety of reasons, including complexity of care, patient and family knowledge deficits, high risk for falls and pressure ulcers, request for follow-up by unit manager, and the bedside nurse’s identified learning needs. The PCS considers the patient’s history, plan of care, and current assessment and engages the bedside nurse through focused questioning to critically think through the care. For example, a PCS noted a fungal toenail in a febrile and profoundly neutropenic patient. She led the nurse through discussion to critically examine implications of the toenail to the immunocompromised patient. Following rounds, the PCS communicates significant findings to the entire healthcare team, as well as to patients and families. That transparency for the neutropenic patient prompted notification to an infectious disease consultant and a podiatry consultation. In short, the educator rounds prompt opportunities for improvement and risk reduction. Daily Rounds by the Unit Manager All managers reserve 8–11 am from Monday–Friday for responsibilities, including patient and staff rounds. The goal is to interact with all patients and staff; however, realistically, .