Use of EBP as a Problem Solving Approach to Improve Patient Satisfaction, while Overcoming the COVID Pandemic Barrier
Background: The Centers for Medicare & Medicaid Services requires hospitals to meet rigorous patient satisfaction requirements for reimbursement. One metric used for patient satisfaction is call light responsiveness within a unit. Aims: To meet target call light responsiveness benchmarks at a 45- bed telemetry, medical– surgical nursing unit within a Magnet® designated hospital. Methods: An evidence- based practice (EBP) project model was utilized. The chief nursing officer worked with an EBP nurse mentor. A PICOT (Population, Intervention, Comparison, Outcome, and Time) question was developed to guide the literature search. Literature was critically appraised, and a resulting intervention was established. Nurse educators taught the unit nurses how to perform the intervention, and intervention integration was assessed via direct observation. Call light responsiveness data were collected to assess whether targets were met. Results: Five articles were deemed as applicable to the PICOT question, and the best evidence determined that using the 4Ps (pain, presence, “potty,” and positioning) during structured registered nurse (RN) care rounding every 2 hours improved patient outcomes. After RN education and implementation, hospital call light responsiveness began to improve. Linking Evidence to Action: Rounding without intention increases RN workload and does not result in improved patient outcomes or a satisfied patient. RN rounding every 2 h is effective and efficient when done with intention (i.e., adhering to the 4Ps). RN patient rounds had done every 2 hours with intention improved patient satisfaction and other patient outcomes such as a decrease in call light usage.
Worldviews on Evidence Based Nursing Publication Submission
Implementation of Evidence-based Practice: Evidence-based Practice change implementation projects
Background: Hospitals in the United States must meet rigorous patient satisfaction metrics to satisfy the Centers for Medicare and Medicaid (CMS) requirements. In one Magnet® hospital in our large health system, one of our 45-bed nursing units was challenged with meeting their target call light responsiveness benchmarks (Table 1). The Chief Nursing Officer contacted the System’s evidence based practice support (EBP nurse mentor) to help find a solution to this dilemma. The nursing unit setting is a stepdown- telemetry, renal nursing unit that recently hired a large number of new RNs. Their current practice was that the nursing leadership completed patient purposeful rounding 90% of the time. This nursing leadership rounds included toileting and pain assessment twice a day at 5am and 5pm to decrease call light usage at shift change. However, the nurse response to call light statistics continued to decline. The staff nurses were generally in the patient rooms at a minimum of every two hours, but no structured patient care rounding was noted. The system’s nursing strategic plan values every nurse is a leader, and has a clear commitment to use evidence based practices to improve the health of those they serve. The nursing leadership strategic plan states and supports that problem-solving is done best when it is closest to and completed with the patient.
| Pre- NOV 19 | Pre-Dec 19 | Pre-Jan 20 | Pre-May 2020 (COVID delay) | |
|---|---|---|---|---|
| Pre- NOV 19 | Pre-Dec 19 | Pre-Jan 20 | Pre-May 2020 (COVID delay) | Pre-Intervention |
| Call light | 75.80% | 75% | 71.90% | 65.90% |
| Responsiveness | 75.80% | 75% | 71.90% | 65.90% |
Table 1: Pre EBP uptake data.
PICOT: In hospitalized patients (P), how does hourly rounding (I), compared to bi-hourly rounding (C), affect patient satisfaction (O)?
Search Strategy
Search terms included (Hospitalized patients OR inpatients OR patients OR admitted) AND (hourly rounding OR hourly checks OR rounds) AND (bi-hourly OR routine OR every two hours) AND (patient satisfaction OR patient experiences OR patient perceptions OR patient attitudes), CINAHL full text, MEDLINE full text.
Health source: Consumer Edition databases were utilized which resulted in 208 articles returned; filters included peer-reviewed: 66, date limited to 2009-2019: 52 articles; English only: 52 articles; United States: 23 articles. Four were found relevant and three were applicable from this search based upon the setting and patient population identified. Then, a review of the Cochrane database resulted in zero articles and a review of the PubMed database resulted in 46 articles returned. Filters for PubMed included free full text: 19 articles; date limited to 2009-2019: 17 articles. Three were found relevant and two were noted as applicable based upon the setting and patient population identified.
Critical Appraisal of the Evidence
The relevant articles were critically appraised using rapid critical appraisal tools (RCAs) to determine quality and level of evidence. The adapted RCA tools used are from The Helene Fuld Health Trust National Institute for Evidence- based Practice in Nursing and Healthcare [1]. The synthesis of the body of literature revealed that while every 2-3 hour registered nurse (RN), purposeful/intentional rounding is significant, the team discovered that what occurs during the rounding, and how patients perceive the presence of the nurse doing the rounding interventions matters just as much [2]. The body of literature revealed that the uptake of the structured use of the 4Ps (Woodward, pain, presence, “potty,” and positioning) [3] by the RN every 2-hours improves patient outcomes. The patient outcomes that were impacted includes an increase in patient satisfaction scores, improvement in the patient’s perception of quality nursing care, and responsiveness of staff, pain management, and a decrease in call light use and falls.
Integration of the Evidence with Clinical Expertise and Patient Preferences
Key stakeholders included the system EBP nurse mentor, nursing leadership, clinical nurse leads, a nurse educator, staff registered nurses, and patient care assistants.
The nursing leadership on the unit completed 16-direct observations audits of RN rounding on both day and night shift to determine current practice. The key stakeholders planned implementation strategies to promote the uptake of the every 2-hour RN rounds. These rounds focused on the 4Ps; pain, presence, “potty,” and positioning [3]. The stakeholders used simulation to teach these best practices since simulation is commonly used as a teaching method and the staff has a convenient, permanent space for simulated learning on the unit. These logistics allow this teaching strategy to be effective because it permits nurses to attend the simulation at their convenience therefore100% compliance with the education was achieved.
The nurse educator used the Knowledge to Action Framework in a simulated environment to promote the knowledge, skills and attitudes needed for successful practice change [4]. The nurse leaders used a variety of evidence-based implementation strategies to support the change in rounding behaviors. These leaders shared data and EBP progress daily on the unit’s Key Process Indicator (KPI) board [5]. Progress was also discussed at staff meetings and in huddles on all shifts. Lastly, nurse leaders posted flyers in strategic locations on the nursing unit to keep the care goals in front of the team. When the nurse leaders made rounds, they used just-in-time coaching techniques to assess the nurse’s understanding and uptake of the 4Ps intervention Coaching was also used as an opportunity to role model the implementation of 4Ps and improve patient outcomes in real time.
Outcomes
In June 2020, rounding using the 4Ps began and as reported in the literature, call light responsiveness began to improve (Table 2). Leaders celebrated with the staff by distributing Hershey® Kisses and Hugs® drinks to signify a job well done while honoring COVID-19 restrictions on the nursing unit (Table 2). Ongoing sustainability strategies for this best practice include strategic communication between the nurse leaders and staff RNs.
| Pre-Intervention | Pre-Intervention | Post-Intervention | Post | Post | Post | Post | |
|---|---|---|---|---|---|---|---|
| Press GANEY | 19-Nov | May 2020 (COVID delay) | 20-Jun | 20-Jul | 20-Aug | Sept. 20 | 20-Oct |
| Call light | 75.80% | 65.90% | 77.10% | 81.80% | 100% | 81.30% | 82.40% |
| Responsiveness | 75.80% | 65.90% | 77.10% | 81.80% | 100% | 81.30% | 82.40% |
Table 2: Pre and Post EBP uptake data.
Dissemination
Plans are in place to highlight this EBP project at the local hospital Nursing Grand Rounds event. We will also present findings at the System Nurse Practice Advisory Council to encourage lateralization across the System’s care sites. An abstract and poster presentation was accepted to an upcoming Sigma Theta Tau International Rho-Nu-at-Large Chapter #419, in November 2020. Lastly, the organization is considering showcasing this EBP project at an upcoming Magnet® Conference.
References
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Key stakeholders included the system EBP nurse mentor, nursing leadership, clinical nurse leads, a nurse educator, staff registered nurses, and patient care assistants. The nursing leadership on the unit completed 16-direct observations audits of RN rounding on both day and night shift to determine current practice. The key stakeholders planned implementation strategies to promote the uptake of the every 2-hour RN rounds. These rounds focused on the 4Ps; pain, presence, “potty,” and positioning [3]. The stakeholders used simulation to teach these best practices since simulation is commonly used as a teaching method and the staff has a convenient, permanent space for simulated learning on the unit. These logistics allow this teaching strategy to be effective because it permits nurses to attend the simulation at their convenience therefore100% compliance with the education was achieved. The nurse educator used the Knowledge to Action Framework in a simulated environment to promote the knowledge, skills and attitudes needed for successful practice change [4]. The nurse leaders used a variety of evidence-based implementation strategies to support the change in rounding behaviors. These leaders shared data and EBP progress daily on the unit’s Key Process Indicator (KPI) board [5]. Progress was also discussed at staff meetings and in huddles on all shifts. Lastly, nurse leaders posted flyers in strategic locations on the nursing unit to keep the care goals in front of the team. When the nurse leaders made rounds, they used just-in-time coaching techniques to assess the nurse’s understanding and uptake of the 4Ps intervention Coaching was also used as an opportunity to role model the implementation of 4Ps and improve patient outcomes in real time.
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