“Effects of Nursing Rounds on Patients’ Call Light Use, Satisfaction, and Safety”: Article Critique

Plan

In the introduction part, I will point out that this study is a critique of a journal article written by the above-mentioned authors and was subsequently submitted for publication to the American Journal of Nursing. The said article was published in time for the September 2006 issue of the journal. The overview of the article will be tackled in the introductory part of the paper and then I will conduct a breakdown of the article by focusing on key concepts as presented by the authors.

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Aside from that, there will also be a discussion on the significance of the study in health care. This means that an overview of health and safety issues related to nurses taking their daily rounds in the hospital will be included in the discussion. It will be shown how making the rounds will reduce the use of the call light. The call light is a device common in modern hospitals. There is a need to provide an overview of the technology involved in the use of call light as well as an explanation about its specific usage in hospitals.

Since the article is not only limited to the impact of nursing rounds in the use of call light there is a need to provide an overview of the other hospital issues that will be impacted by introducing a more systematic way of doing nursing rounds. Thus, aside from analyzing the effect on the call light, the proponent of this paper will also look at the effect of nursing rounds on safety, specifically regarding the rate of patient falls. In other words, patient falls is the technical term for patients falling from their beds and the frequency of nurses’ rounding was expected to reduce this problem.

In the main body of the paper, the proponent will take a closer look at the design of the experiment, why it was devised that way and the specific outcomes that were expected from the study. There will be a general overview with regards to the age-old technique of nurses doing rounds to check on their patients and how it has provided comfort to those who are suffering pain and other forms of mental and physical discomfort.

There will also be an explanation regarding the rationale of the study which was to address problems in healthcare such as low satisfaction ratings given by patients when it comes to the performance of health workers. This has an opposite effect which is the low job satisfaction of health workers which more often than not resulted in burnout and job turnovers. The paper will also explain how the researchers were able to find out that the common denominator between these two issues is the use of the call light and reducing its usage will enable nursing staff to hit two birds with one stone.

After discussing the importance of nursing rounds there is a need to take a more detailed analysis with regards to the scientific aspect of the research design. For instance, nursing rounds were not simply inserted into the study and then sitting back to observe what will happen. The paper will explain why there was such a thing as a one-hour rounding as well as a two-hour rounding.

The proponent of this paper will take a closer look at the rounding protocols developed by the researchers. By taking an in-depth analysis of the protocol there will be a clear understanding of how it will affect nursing rounds. For instance, there will be a discussion of why specific steps were incorporated into the protocol such as making sure that the TV remote is within easy reach by the patient.

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In the latter part of the study, the results of the experiment will be analyzed. The proponent of the paper will provide an explanation as to why the research design was able to show the effect of nursing rounds on patient’s reduced use of call light, increase in the level of satisfaction as well a significant reduction in patient fall rate.

On the other hand, there will also be an in-depth analysis of the limitations of the research. There will be a focus on the limitations of adopting a quasi-experimental design. There will be an explanation as to why the researchers were forced to use that method of acquiring data. But at the same time, it will be pointed out that the quasi-experimental design could seriously influence the results of the experiment. For instance, hospital units assigned to both control and experimental groups were chosen nonrandomly.

Finally, there will be a discussion regarding how to improve the research design. At the end, there will also be a discussion with regards to the future directions of the research and what must be done to increase the accuracy of the data gathering method. Moreover, there will be a discussion as to why it is imperative to why there is a need to increase the duration of the experiment from a six-week period to a six-month period.

There are two major reasons why healthcare is such a hot topic in the United States and the rest of the world. First of all, healthcare is costly and would reduce a patient to penury in the blink of an eye, especially when he or she has no insurance. Secondly, there is a shortage of health workers. There can be many solutions to the problem of rising healthcare costs and shortage in healthcare. But the most practical solution is to maintain a high level of job satisfaction so that health workers will not quit and change professions.

The attempt to arrest is this trend is just one of the reasons why Meade, Bursell, and Ketelsen designed a study to reduce call light use in the hopes of reducing fatigue in the workplace and in the process increase job satisfaction in hospitals. What the study was hoping to find out is the effects of nursing rounds in call light use, satisfaction, and safety.

Background

There were two problems that the study hoped to address. The first one is about the need to increase the satisfaction of patients with regard to healthcare. Since the patients are paying premium money for healthcare then they deserve to have quality care. Secondly, there is a need to reduce burnout in the nursing department because if this trend is not arrested then more and more nurses will quit further exacerbating the already burgeoning problem of staff shortage in healthcare.

In trying to hit two birds with one stone the researchers were able to determine that the root of the problem is in the frequency of the call light use and the circumstances surrounding the use of the call light system. The call light is the evolution of the nurse’s bell or whatever form of communication was used in the olden times when a patient needed to call the attention of the nurse because patients and residents must have a way of communicating with the healthcare staff (Carter, 2005). The call light system consists of a call light control which can be as simple as a cord that can be pulled by the patient but in most instances, it is a hand-held button device (Carter, 2005). When the patient pushes the button the nurse in the hallway is alerted.

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Now here is the significance of the call light with regards to the study. The call light can be abused and misused. Patients usually do not have a clear understanding of how staffing works in a hospital. If there is a severe shortage of health workers such as nurses and nursing assistants, the patients would not know about it. Therefore, if they use the call light they would like to see a nurse pronto. Patients can be inconsiderate at times and it is understandable why they sometimes can be so difficult. But regardless the nursing staff can be stretched to the breaking point.

By putting oneself in the shoes of the patient one will realize that changes can be made with regards to the use of the call light system. The first thing that must be done is to determine why patients use the call light system in the first place. It was determined that patients use it to help them with self-care tasks such as the need to use the toilet, ambulating, eating, etc. The researchers also found out that the frequency of using the call light stems from not maximizing the use of nursing rounds.

From all these inputs coming from the two weeks’ observation and the gathering of baseline measurement, the researchers were able to come up with a design that tackles the two aforementioned problems. They will create a system that will maximize the use of nursing rounds by laying down a specific to-do list for nurses every time that they check on the patient. They will make sure that everything is within reach; that all the patients’ needs are addressed before leaving the room and to assure them that another nurse is coming to check on them after one hour or two hours at the most.

Methodology

The researchers knew that they could not simply create an experiment out of thin air. In order to determine the framework for their study, they used two weeks’ worth of observation as their baseline measurement of call light frequency and the reason for call light use. They were also getting inputs from a review of the literature and finally they drew from their own clinical experience in shaping the said experiment.

They decided to use a quasi-experimental design because the study requires data from actual events and not from a highly controlled laboratory exercise. The main reason for doing so is that researchers could not manipulate humans in the same way that other scientists can manipulate laboratory animals. Thus, they have to observe the patients in real-time working along with the 24-hour operation of the hospitals as well as the ever-changing shifting of the nurses.

Due to the fact that they decided to use a quasi-experimental design, there were many things that they could not control. Since they went with the flow of a regular hospital they could not disrupt the staffing and they could not order the nurses to change their shifts etc. As a result, there was a nonrandom assignment of nurses and hospital units to the control and experimental groups. The researchers were at the mercy of the nursing officers and nurse managers at every participating hospital. They can only hope that the decision of the nursing officers and the nurse managers will not significantly affect the experiment.

In order to assure the accuracy of data and at the same time to determine the exact impact of nursing rounds, the researchers decided to use twenty two hospitals with 46 units. In order to eliminate the effect of demographics the hospitals were chosen from 14 states representing urban and rural populations and the number of beds ranging from 25 to more than 600. Aside from that the researchers required every participating hospital to have at least one unit n the experimental group and one unit with similar types of patients in the control group.

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The rounding protocol that needed to be strictly followed in the whole duration of the experiment can be summarized as follows:

  1. Assess patient pain levels using a pain-assessment scale.
  2. Put medication as needed on RN’s to-do list and offer the dose when due.
  3. Offer toileting assistance
  4. Assess the patient’s position and position comfort: ask if patient needs to be repositioned and is comfortable.
  5. Make sure the call light is within the patient’s reach.
  6. Put the telephone within the patient’s reach.
  7. Put the TV remote control and bed light switch within the patient’s reach.
  8. Put the bedside table next to the bed.
  9. Put the Kleenex box and water within the patient’s reach
  10. Put the garbage can next to the bed.
  11. Prior to leaving the room, ask, “Is there anything I can do for you before I leave? I have time while I am here in the room.”
  12. Tell the patient that a member of the nursing staff (use names on white board) will be back in the room in an hour (or two hours) to round again.

It is important to list down the details of the rounding protocol. This will allow for a quick reference with regards to the framework of the experiment. Moreover, a quick glance at the list will reveal that the effects of the nursing rounds is not only due to the increased levels of human interaction as well as the psychological and social factors that resulted in having a health worker, knowledgeable about the medical condition of the patient, doing the rounds and asking if the patient is well. If there will be a positive impact in the use of nursing rounds then it can also be attributed to the way the protocol was carefully designed to maximize the time spent in rounding as well as addressing different types of needs per round.

In step number 3 of the list, the health worker is effectively dealing with one of the major reason for call light use and it is the need for assistance in using the toilet. If this protocol will be followed in every round then the nurses can effectively distribute the workload and at the same time effectively reduce the use of the call light. But there is more. In steps 5 to 10 the nurse doing the rounds is making sure that elderly patients or those that have ambulatory problems need not have to call the nurse if they need items – such as the TV remote or Kleenex – that could have been moved closer to the patient so that it is within reach.

But it can be said that the most significant part of the protocol, the one that could arguably impact the dynamic between nurses and patient can be found in the last two steps of the nursing rounds. In asking, “Is there anything I can do for you before I leave?” the nurse doing the rounds is effectively ensuring that the patient’s immediate needs are all taken cared of. This is followed up by the assurance that the patient should take time in answering that query because as long as the nurse is in the room he or she will do whatever is necessary to ensure safety and comfort.

After giving the patient ample time to go through his or her mental list of things that needed assistance or needed complaining about, the nurse doing that particular round is eliminating any problems that would have prompted the patient to reach out for the call light. But the last step in the protocol puts icing on the cake so to speak. By informing the patient that another nurse is coming soon to do another rounding, it will give assurance to the patient that their comfort and safety is the number one concern of the hospital. But

It must also be said that the researchers went a little further by not only instructing the nurse to tell that a nurse is doing the rounds soon but also to specifically inform the patient of the name of the nurse doing the next rounding as well as the time that the nurse is expected to arrive. This is an effective strategy for it will inform the patient how long they had to wait before using that call light knowing that a nurse is coming soon to help them. Secondly, it communicates to the patient that the administration is on top of things because aside from a regular schedule of nursing rounds the hospital is even very specific to know the name of the nurse that will do the rounds every hour or every two hours.

Results and Discussion

Data on 108, 882 instances of call light use were collected from 14 hospitals (27) units over a six-week period. There was a significant reduction in the call light use for the one-hour rounding period as well as the two-hour rounding period. Both groups showed significant increases in patient satisfaction scores. But when it comes to safety, specifically in reducing patient falls, significant reductions was only observed in one-hour rounding.

It seems that the strategy did work. The systematic way of maximizing the use of nursing rounds increased the satisfaction of the patients while at the same time reducing the incidence of patient falls. The increased satisfaction is the result of having a system that effectively addresses the needs of the patients. The specific to-do list that was used by nurses during every round allowed them not to miss anything. As a result the patients need not use the call light more often.

One nurse manager testified to the effectiveness of using additional rounds in reducing call light use. But according to the manger there were more benefits including increased patient satisfaction, decrease in patient fall rate, fewer pressure ulcers, less skin breakdown. On top of that there were fewer distractions, a quieter work environment and better organization. The said manager is recommending the use of the same strategy to increase satisfaction and safety inside medical facilities.

With regards to the effectiveness of the one-hour rounding in reducing patient falls one can surmise that the relative short interval between rounds allowed the nurses to check on the patients more often. The only problem with this approach is that it is more rigorous and would increase the workload of an already overworked staff. The above-mentioned results will be helpful in designing a strategy that will improve the use of nursing rounds as well as in designing an experiment that will provide more accurate data.

The researchers suggested the use of random selection of hospital units when assigning the same to control and experimental groups. They are also suggesting that the scope of the study must be increased to include more states and effectively making it into a nationwide study. They also pointed out the need to increase the duration of the study from a mere six weeks to six months. It is easy to understand why they wanted a longer duration. They wanted to find out if the nurses can sustain such workloads.

Limitations

There were many steps taken to assure the accuracy of the data. This was made evident in the preceding discussion concerning the methodology of the experiment. But it can be argued that accurate data would have been impossible considering the quasi-experimental design of the experiment. A quasi-experimental design means that the subjects were never controlled in the same way that guinea pigs are being manipulated in a classic experiment design.

As many would know it is perfectly normal to use animals in laboratory testing but in human beings this is impossible. This implies that in the use of lab animals one can has a greater degree of assurance regarding the accuracy of the data. But in a quasi-experimental design there is no guarantee that human nature did not intervene to influence the outcome of the experiment in ways that were never intended by the researcher.

For instance no one knows how each hospital decided in assigning nurses to work in the control, one-hour, or two-hour rounding groups. It is even possible that the hospitals unwittingly attempted to raise the level of patient satisfaction on some specific units by assigning them to a rounding protocol. If this experiment will be replicated then there is a need to create a system where nurses are randomly assigned to different units.

Another problematic aspect of the quasi-experimental design is the fact that hospitals operate 24/7 with a great number of people working round the clock. The human interaction between health workers as well as health workers to patients may have influenced the outcome of the survey. There is also no way to determine if all the nurses followed the rounding protocol and record data correctly during patient interaction. Based on experience there are so many things that goes on inside the head of nurses that when they interact with patients the to-do list keeps on popping-up and the nurse can be distracted to the point that he or she forgets that there is an ongoing experiment.

On the other hand the realization that there is an ongoing experiment can move into an unexpected direction. The nurses may have behaved out of the ordinary during the duration of the study. It is possible that since they are well aware that their behavior is being monitored then they will put their best foot forward. Meade, Bursell, and Ketelsen call this phenomenon the Hawthorne Effect. This will be expounded in the following pages.

The Hawthorne Effect was discovered in the 1920s by a group researchers from Harvard University. In the Hawthorne Works Plant of the Western Electric Company, Elton Mayo and his group wanted to know the effect of manipulating lighting conditions in the factory. They first increased the level of illumination inside the factory and found out that productivity levels did increase. So they continued with their experiment and the next logical step is to lower the illumination so that they can conclude that productivity will decrease. But they were surprised to find out that when they indeed lower the level of illumination in the factory, productivity rose even higher.

So they continued to lower the level of illumination until workers were working in virtual darkness. To their amazement the productivity was maintained at high levels (Pohlman & Gardiner, 2000). The researchers learned later that the employees were excited to be taking part in the experiment and felt glad that they received friendly attention from the experimenters (Pohlman & Gardiner, 2000). The same can be applied in the study on the effects of nursing rounds.

If the Hawthorne Effect applies to this experiment then data generated by the study becomes suspect. The social and psychological factors involved in the study may have influenced the results. The nurses may have been more enthusiastic in doing their jobs. They may have a more cheerful disposition as compared to in the past when no one was looking. This will significantly impact the experiment.

Conclusion

Barring all limitations identified in the study there is a good reason why the there was significant reduction in call light use and decrease in the rate of patient falls. The researchers were able to correctly identify the reason for high rate of call light use while at the same time creating an atmosphere where patients are always complaining about the lack of quality care. It was implied that administrators can do something to remedy the situation. It is now time to stop the complaining and try to find a solution to the problem at hand.

It was pointed out early on that the issue concerning low satisfaction rating given by patients in assessing healthcare is related to the low job satisfaction rating given by nurses when it comes to evaluating their assessment of the work environment and the type of work needed to be performed in hospitals. The surprisingly common denominator is the use of the call light system.

The researchers were able to determine that the call light system is not simply a device to call the attention of the nurses. The call light system is a lifeline that effectively communicates the state of mind of the patient. This means that frequent use of call light is an indicator of a problem that is hidden from plain view. For instance a increase in the use of call light can mean that pain medication is not working and that doctors will have to do something about it.

Focusing on the usage and effects of the call light system in hospitals also revealed a significant piece of information – the call light can effectively alter the working environment in a negative way. The use of call light can result in burnout, it can also result in creating too much distractions that the nurses running to and fro from nursing station to patients bedside is rendering them ineffective to perform other tasks.

One of the significant results of the experiment is to demonstrate that a minor adjustment of the use of nursing rounds can greatly improve the working environment. The insight regarding the effective use of nursing rounds can be achieved by paying close attention to the 12-step protocol created by the researchers. It is obvious that the researchers are not simply adding more work to an already overburdened staff but they were actually giving them pointers how to maximize the time spent on nursing rounds.

Unnecessary problems were eliminated by simply asking questions about the needs of the patients. But the breakthrough in the design can be found in the last two steps where the nurses gave ample time for the patient to think of their needs and giving them the opportunity to ask assistance while the nurse is still inside the room. The second major breakthrough is in telling the patient that someone is coming back after one hour or two hours to come and check on him or her again. This provides an assurance that the patient is not left on her own devices. If the patient is in need of more than medication, requiring more human contact to ease the pain then the last step in the protocol will go along way in increasing patient satisfaction.

The limitations of the research design must be addressed. If the research will be replicated there is a need to create a system where there would be a random assignment of hospital units to both control and experimental groups. The same should be done in assigning nursing staff to work in both control and experimental groups. There must be ample time given to the nursing staff to learn and master the 12-step protocol. As one will notice in the methodology section of the research there were nurses who were unable to attend the presentation and demonstration of how to do the rounds according to the specifications of the study. They learned the intricacies of the protocol through a video recording of the presentation. This could affect their understanding of the protocol and could have influenced the way they took down data and follow the procedures.

There is also a need to increase the scope of the research and create nation-wide study to determine if social factors are not affecting the results of the experiment. There is also a need to increase the duration of the experiment to find out if nurses can sustain one the added workload of having additional workloads. There is also a need to conduct the experiment in facilities that handle long-term care where patients needed to stay in hospitals for a prolonged period of time.

References

Carter, P. (2005). Lippincott’s Textbook for Nursing Assistants: A Humanistic Approach to Caregiving. PA: Lippincott Williams and Wilkins.

Hitt, E. (2006). “Frequent Nursing Rounds Decrease Call-Light Use.” Medscape Medical News. Web.

Mauk, K. (2006). Gerontological Nursing: Competencies for Care. MA: Jones and Bartlett Publishers.

Meade, C., A. Bursell, & L. Ketelsen. (2006). Effects of nursing rounds on patient’s call light use, satisfaction, and safety. American Journal of Nursing. 106(9), 58-70.

Morse, J. (1997). Preventing Patient Falls. CA: Sage Publications, Inc.

Pohlman, R. & G. Gardiner. (2000). Value Driven Management: How to Create and Maximize Value Over Time for Organizational Success. New York: AMACOM.

Stokowski, L. (2008). “Ring the Nurse: Improving Call Ligth Management.” Medscape. Web.

Weinberg, D. (2003). Code Green: Money-Driven Hospitals and the Dismantling of Nursing. New York: Cornell University Press.

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