Running head: THE EFFECTS OF INTENTIONAL NURSE ROUNDING ON
The Effects of Intentional Nurse Rounding on Patient Satisfaction and Call Bell Usage: An
Integrative Literature Review
Rachel Martinko
University of Central Florida
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THE EFFECTS OF INTENTIONAL NURSE ROUNDING ON
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Abstract
Providing quality patient care in the acute care setting is at the forefront of healthcare, as it
directly impacts hospital reimbursement. Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) is a survey tool used to measure patients’ perceptions of a
hospital stay post discharge. Intentional nurse rounding is a practice that is suggested to assist
nursing staff in providing superior patient care while in the hospital setting. Nursing staff
routinely rounds on patients, either in hour or two-hour intervals, assessing and anticipating
patient’s needs. An integrative literature review was performed to determine the effects
intentional nurse rounding had on patient outcomes, specifically patient satisfaction and call light
usage. A comprehensive electronic database search was completed using CINHAL, Cochrane
Database of Systematic Reviews, PubMed, OneSearch, and Academic Search Premier.
Quantitative research studies published after 2006 and in the English language were analyzed for
this review. It was concluded that intentional nurse rounds have a positive impact on patient
satisfaction and helped to decrease call light usage in the acute care setting. Recommendations
for future studies include determining effects routine rounding has on different patient outcomes,
such as patient safety, and rate of compliance nurses perform these rounds.
Keywords: nursing round, call bell, patient satisfaction, hourly round
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The Effects of Intentional Nurse Rounding on Patient Satisfaction and Call Bell Usage: An
Integrative Literature Review
Significance
The American healthcare reimbursement system is changing into one that emphasizes
quality patient care and positive outcomes. This focus is designed to ensure continuous
transformations are made to keep up with improvements within the system (American Hospital
Association [AHA], 2012). Under the Affordable Care Act, hospital reimbursement relies
heavily on performance scores from patient satisfaction surveys issued after a patient is
discharged from the facility. These questionnaires, known as the Hospital Consumer Assessment
of Healthcare Providers and Systems (HCAHPS), are designed to evaluate the quality of care
provided during an inpatient stay (Centers for Medicare & Medicaid Services [CMS], 2014). The
HCAHPS are part of the Value-Based Purchasing program, which incentivizes hospitals to
improve performance. In 2014, 1.25% of hospital reimbursement from Medicare was at stake,
and this percentage will increase each year. Hospitals must perform in the top 95th percentile of
the HCAHPS and core measure scores to ensure their full 1.25% in received (CMS, 2014).
Guaranteed full reimbursement from Medicare is no easy feat. Thus, leaders of
healthcare organizations are looking toward ways of improving the quality of care provided to
patients, while improving patient outcomes. Through this, they expect to increase customer
satisfaction, and ultimately HCAHP scores, to boost their national ranking and ensure proper
reimbursement for care provided (AHA, 2012).
An admission to the hospital can be a scary experience, as patients are forced to rely on
nursing staff to meet the simplest of needs, such as toileting or retrieving a personal item out of
reach. The call bell serves as a patient’s lifeline and primary way of communicating with the
THE EFFECTS OF INTENTIONAL NURSE ROUNDING ON
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nursing staff. However, answering call lights can become a tedious task for nursing staff, and
patients may have to wait several minutes for their needs to be met. This has a direct effect on
patient satisfaction, and the quality of care provided. A proactive approach to meeting patient’s
needs is called intentional rounding, also known as hourly rounding, and serves as the foundation
of providing excellent nursing care during a hospitalization (Levenson, 2013).
Intentional rounding focuses on patient-centered care, as nursing staff visits patient
rooms, addressing their needs on a routine basis. Rounds are typically completed on an hour or
two-hour schedule (Blakely, Kroth, & Gregson, 2011). The nurse assesses the patient’s needs
including the 4 P’s: potty, position, pain, and possessions. Does the patient need to use the
bathroom? Offering toileting can reduce the risk of patient falls, and accidents if they attempt to
go it alone. Is the patient’s position satisfactory? Repositioning helps to prevent skin breakdown
and pressure ulcers. Is the patient’s pain controlled? Lastly, are the patient’s possessions within
reach? Overall, these 4 P’s address several questions included on the HCAHP survey (Hospital
Consumer Assessment of Healthcare Providers and Systems [HCAHPS], 2015). The purpose of
this review was to determine the effect of intentional rounding on call bell usage and patient
satisfaction in hospitalized patients.
Methods
The objective of this integrative literature review is to examine the existing literature to
determine the effects of intentional nurse rounds on call bell usage and patient satisfaction in the
acute care setting. Databases used for this search included CINHAL, Cochrane Database of
Systematic Reviews, PubMed, OneSearch, and Academic Search Premier. All searches were
limited to peer-reviewed, research articles. Initially, the search was dated 2009-2015, but then
had to be broadened to 2006-2015 when an inadequate number of studies were found for the first
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time frame. The language was limited to English. Keywords included: hourly round, rounds,
rounding; patient satisfaction, call bell, call light; nurse, nursing round. Various keyword
combinations were used in the search box and the “apply related words” box was checked to
allow for synonyms to be searched.
The abstracts of all the results were read, and the articles were narrowed down based on
the two outcomes of interest: call bell usage and patient satisfaction. Articles were included if
quantitative research studies with statistical results were discussed, i.e. systematic reviews,
quasi-experimental design, controlled clinical trial, correlational study, and action research
design; inpatient setting; studies published in the year 2006 and beyond, HCAHPS outcome
measure. Articles were excluded if studies used experiments in the intensive care units or
emergency departments, and a qualitative research study or literature review design was utilized.
The quality of evidence from this integrative literature review was determined using the
hierarchy of evidence rating system published by Melnyk and Fineout-Overholt (2014).
Results
Search Results
A total of fifty-five articles were found using a multi-database search on EBSCOhost.
All duplicates were removed. Titles were skimmed, and those that appeared relevant, were
further analyzed using their abstract. Ten primary studies were found to meet inclusion criteria.
After carefully reading these articles, four more were excluded, as they did not present data with
statistical results. Final studies used for this integrative literature review are depicted in Table 1
below. Two main themes, patient satisfaction and call light usage, were examined in regards to
intentional nurse rounds.
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Patient Satisfaction
All studies included in this review examined the effects of routine nurse rounding, either
hourly or two-hourly, on patient satisfaction. Primary studies assessed patient satisfaction using
questionnaires after discharge, comments from leadership rounds, and/or Press Ganey Survey
scores. Two specific questions on the Press Ganey Scores were used during data collection.
These included “promptness to call” and “nurses’ attitude toward request (Berg, Sailors, Reimer,
O’Brien, & Ward-Smith, 2011). Many researchers used Meade, Bursell, and Ketelsen (2006) as
a guideline, as this was one of the first studies completed that evaluated the effects of routine
nurse rounds.
All six studies reported an increase of patient satisfaction with the implementation of
routine nurse rounds. Interestingly enough, hourly rounding during the day, and two-hourly
rounding during the night did not affect patient satisfaction during the second day of
hospitalization, but increased significantly on day five of the inpatient stay (Negarandeh,
Bahabadi, & Mamaghani, 2014). Two studies found results were statistically insignificant,
although their patient satisfaction scores improved on the units (Saleh, Nusair, Zubadi, Shloul, &
Saleh, 2011; Olrich, Kalman, & Nigolian, 2012).
A systematic review completed by Mitchell, Lavenberg, Trotta, & Umscheid (2014)
found all but two studies showing an increase in patient satisfaction with the implementation of
hourly and two-hourly rounding. However, most of these studies did not report any statistical
evidence supporting the data. Overall, routine nurse rounds had a positive impact on patient
satisfaction.
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Call Light Usage
Five studies reported data on call bell usage with the implementation of routine rounding
on nursing units. All studies reported that routine nursing rounds decreased mean call bell usage,
with the exception of the experiment by Olrich,et al. (2012), which found no significant effect.
As discussed with patient satisfaction, Meade et al. (2006) was a model for many subsequent
studies, which showed a reduction in call bell usage among patients for the hourly and twohourly rounding groups. However, only the two-hour nurse rounds showed statistical
significance. All other studies revealed that routine nurse rounds decreased call bell usage (Berg
et al., 2011; Saleh et al., 2011). The biggest reduction was revealed in the study performed by
Mitchell et al. (2014), with call light usage reduced by 54%.
Table 1
Primary
Study,
Country
Mitchell et
al. (2014),
United
States of
America
Design, Level of
Evidence, Sample
‘Systematic
Review’
Level I
16 published
studies reviewed
15 pre-post
studies
1 nonrandom
studies
Total sample size
n=9493
Characteristics of Intervention
Results
No direct intervention. Medline,
EMBASE, and CINHAL databases
were used.
Systematic review of regular
nurse rounds and the impact on
patient satisfaction, call bell
usage, falls, and nurse efficiency.
Two research analysts viewed
100 randomly selected search
results and 16 were determined
to meet inclusion criteria.
GRADE system was used to
determine evidence quality for
each outcome on the scale of
high, moderate, low, and very
low.
Call light usage
10 studies reported
call light usage.
Decreased from 23%70%, median reduction
was 54%.
4 studies with
statistical data
reported routine nurse
rounding significantly
reduced call light
usage.
Overall GRADE
strength was
moderate.
Patient satisfaction
11 total studies
reported patient
satisfaction scores.
9 reported
12 studies utilized hourly rounds
with specified tasks, i.e. 4 P’s, 7
of them performed 2-hourly
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Berg et al.,
(2011),
United
States of
America
‘Longitudinal
Research,
Correlational
study’
Level IV
28 bed
medical/surgical
inpatient unit
Convenience
sample of 35
days of call light
data was used
pre and post
rounding
implementation
n=70
Press Ganey
responses
n=569
Negarandeh ‘Clinical trial with
et al.
non-equivalent
(2014), Iran control groups’
Level III
100 total
participants
50 in
experimental
group
50 in control
group
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rounding at night.
2 studies implemented 2-hourly
rounds.
1 used a Practice Partnership
Model of care, which used 1-2
hourly rounds.
improvements with
hourly rounding, 7
studies reported
statistical data, and 4
of these were
significant.
Overall GRADE
strength was
moderate.
Pre-Post design: Unit secretaries
documented reason for call light
request prior to and after
implementation of hourly rounds
on flow sheets. 70 randomly
selected sheets (35 preimplementation, 35 postimplementation) were used for
analysis.
Press Ganey scores were
assessed pre and post hourly
rounding. Two areas specifically
were analyzed: “promptness in
response to call lights” and
“nurses attitude toward
request”.
Call light usage
-Pre- 11.329 +/- 4.215
-Post- 19 +/- 4.728
Total pre-Total post
p<0.001, 95% CI 1.727,
5.67286.
Call light usage
decreased from 11.32
to 7.62 per day after
hourly rounding
implementation.
Nurses were taught proper
rounding and supervised by the
researcher in 20-minute training
sessions prior to implementation.
In the experimental group,
nurses visited patients every 1-2
hours, from 8 a.m. to 10 p.m.,
assessing their needs, focusing
on pain, comfort, assistance, and
training needs.
Control group received care as
Second day of
hospitalization:
Control- 59.8 +/- 16.3
Experimental- 57.5 +/17.6
P=0.499
Fifth day of
hospitalization:
Control- 55.3 +/- 12.7
Experimental- 68.8 +/8.8
Patient satisfaction
“promptness to call”
pre- 88.9 (n=104)
post-89.3 (n=180)
“nurses’ attitude
toward request
pre- 90.6 (n=106)
post- 92.3 (n=179)
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Saleh, et al.,
(2011),
Saudi
Arabia
Meade, et
al., (2006),
United
States of
America
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usual, using task-oriented
nursing care.
Patient Satisfaction with Nursing
Care Quality Questionnaire was
completed on the second and
fifth days of hospitalization.
P<0.001
‘Quasiexperimental
non-equivalent
design’
Level IV
104 patients from
a 26- bed stroke
unit
8 week study
Nurse rounds system (NRS):
Hourly rounds performed during
7 a.m. to 10 p.m., and 2-hourly
rounds during 10 p.m. and 7 a.m.
Baseline data was collected for 8
weeks prior to study. Call bell use
was divided into 7 categories
based on patient needs or
requests. Unit secretaries
collected data using logs, which
were then compared to Hill-Rom
electric call light recording
system data.
The study did not reveal how
patient satisfaction was
measured.
Call light usage
Pre-98.8 +/- 21.2
Post- 29.3 +/- 7.4
z-value=24.5, p<0.001.
‘Quasiexperimental
design with nonequivalent
groups’
Level IV
Six-week study
Data was
collected from 27
nursing units in
14 hospitals
nationwide
Hospital units were randomly
assigned to a one-hour rounding,
two-hour rounding, or a control
group. Rounds in the one-hour
rounding group were performed
between 6AM and 10PM, and
once every two hours between
10PM and 6AM. Two-hour
rounding was defined as rounds
every two hours throughout the
entire 24-hours. Baseline
measurements were taken for
two weeks prior to
implementation, and the round
experiment lasted four weeks.
The control groups continued
usual nurse rounds.
Call bell requests were logged
Call light usage
Hourly Rounds:
Pre=13,216
Post=8,315
P=0.007
Two-Hour Rounds:
Pre=14,201
Post=11.507
P=0.06
Control:
Pre=13,494
Post=13,106
Patient satisfaction
was increased by 7.5%,
but was not
statistically significant.
No further data given.
Patient satisfaction
Hourly Rounds:
Pre= 79.9
Post= 91.9
(t=736.58, p=0.001)
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Olrich, et
al., (2012),
United
States of
America
with each call, grouped into
seven categories. Both control
and experimental units
documented logs.
Patient satisfaction was
measured using nationally
recognized patient surveys.
Scores were converted to a 100point scale.
‘QuasiHourly rounding: Baseline data
experimental
for patient satisfaction reports
design, with non- were collected 6 months before
equivalent group’ implementation, and 6 months
Level IV
during hourly rounding
2
intervention. Call light data was
Medical/Surgical obtained 2 weeks before and 4
inpatient units
weeks during intervention.
divided into 1
Nurses and nurse assistants were
experimental and provided education on hourly
1 control group,
rounding by their CNS. One-hour
sample included
rounding occurred from 6 a.m. to
all discharged
10 p.m., and 2-hour rounding
patients (n=4418) from 10 p.m. to 6 a.m.
1-year study
10
Two Hour Rounds:
Pre= 70.4
Post= 82.1
(t=657.11, p=0.001)
Control: No data listed
Hourly rounding had
no significant effect on
call bell usage.
No statistics reported.
There was no
statistical significance
between patient
satisfaction and hourly
rounds. p=0.383
Limitations of the Evidence
This review is not without flaws in the evidence, as there were limitations present with
these studies. Much of the research presented did not include randomized selection when
assigning experimental and control groups, and experimental groups had small sample sizes.
Considered selection bias, the validity of these studies can be compromised (Melnyk & FineoutOverholt, 2014). The systematic review had inconsistency in the result data reported, possibly
compromising the quality of the review (Mitchell et al., 2014). The patient populations were
inconsistent across the studies. The call bell data might have been skewed due to confused
patients on the unit, causing an increase in number of accidental calls (Olrich et al., 2012).
Lastly, measuring patient satisfaction is subjective when using questionnaires during data
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collection. Perception of satisfaction varies from person to person, especially in the hospital
setting. This depends on a patient’s experience during their stay, expectations, and attitude.
Also, it may have been more difficult to see an increase in patient satisfaction on units that
already had a high satisfaction rate prior to implementing intentional nurse rounds (Negarandeh
et al., 2014).
Recommendations
The data analyzed from these studies shows that intentional nurse rounding has a positive
effect on patient outcomes. The success for implementation of nurse rounds lies in the support
by hospital administrators and leadership staff. Adopting programs designed specifically to
teach staff the proper rounding techniques and goals can help hospital units provide costeffective, quality patient care (Mitchell et al., 2014). Olrich et al. (2012) suggest the use of staff
unit champions, whose focus is to perfect nurse rounds, and integrate them into everyday nursing
care. It is also important to determine ways to engage staff consistency, and integrate it as a
routine piece of nursing staff daily practice. Healthcare organizations should also adopt
intentional nurse rounds into their policy and procedures to ensure all nursing staff consistently
use this practice.
Future Research
It is recommended, in future studies, researchers evaluate the effectiveness of routine
nurse rounds over a longer period of time, 6 months or greater, and experiment using a larger,
more diverse sample size. Ideas for future research include assessing how intentional rounding
affects patient falls and skin breakdown and pressure ulcer development. Some research articles
reviewed for this study included data in these areas, but this theme was not included in this
review. Furthermore, future research should look at compliance among nurses in completing
THE EFFECTS OF INTENTIONAL NURSE ROUNDING ON
routine rounds over a long period of time. Intentional nurse rounds should be completed
consistently. Some authors of the articles reviewed feared that nurses would stop using the
routine rounding upon completion of the study (Saleh et al., 2011).
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