Approximately 48 million adults older than 65 currently reside in the United States; this number is predicted to increase to more than 98 million by 2060 (United States Census Bureau, 2017). As of 2014, approximately 18% used some form of long-term care services, with the highest daily rate usage in skilled nursing facilities (SNFs) (Harris-Kojetin et al., 2016). To improve health care for this population, the Centers for Medicare & Medicaid Services (CMS; 2017a) requires “a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes” (para. 1). One way to comply with this mandated quality assurance process improvement (QAPI; Centers for Disease Control and Prevention [CDC], n.d.) process is purposeful engagement of the “backbone” of SNFs: certified nursing assistants (CNAs) (Abrahamson, Davila, & Hountz, 2018).
CNAs perform approximately 70% to 80% of direct patient care in residential long-term care centers, including feeding, toileting, personal hygiene, and other tasks based on residents' needs (Squires et al., 2015). CNA work is often viewed as low-status, due to variable working conditions, few opportunities to engage in decision making, and significant physical and emotional demands. Job stress is frequently associated with high turnover rates and absenteeism (Jetha, Kernan, & Kurowski, 2017). To mitigate these disruptive outcomes, Sikka, Morata, and Leape (2015) suggest adding a fourth aim to the well-known Triple Aim. The main goal of this fourth aim is to improve workforce engagement and safety to help staff find meaning, joy, and positive experiences from their work. For this purpose, the current team, like Abrahamson et al. (2018), purposively chose CNAs in SNFs as project champions for this intentional rounding (IR) pilot project.
IR, also known as purposeful or hourly rounding, is defined as a pro-active strategy used predominately by acute care nursing staff to improve patient safety and satisfaction by focusing on the “4Ps” (potty, position, possessions, and pain) (Blakley, Kroth, & Gregson, 2011; Fabry, 2015). However, IR is not without controversy. Snelling (2013) suggested that evidence for IR has primarily arisen from underpowered quality improvement (QI) projects and is either politically or commercially motivated. Nevertheless, multiple studies (Blakley et al., 2011; Daniels, 2016; Mitchell, Lavenberg, Trotta, & Umscheid, 2014; Olrich, Kalman, & Nigolian, 2012) support the use of IR to improve patient care.
Positive outcomes in acute care have been reported for patient satisfaction scores (Blakley et al., 2011; Brosey & March, 2015; Daniels, 2016; Shin & Park, 2018). In addition, a systematic review of pre/post QI studies (N = 16) reported moderate strength evidence that IR improves patient satisfaction with nursing care (Mitchell et al., 2014).
Although satisfaction is a key element in patient-centered care, safety is equally important. In health care facilities, fall-related injuries lead to serious financial and nonfinancial consequences: physical injuries, psychological trauma, and increased costs and length of stay (Jackson, 2016; Vlaeyen et al., 2017). Falls are the number one cause for injuries and death among older adults; therefore, fall prevention should be a priority in health care (CDC, 2017). IR has been shown to reduce patient falls. In one study comparing two medical–surgical units (one experimental, one control), a 23% reduction in patient falls was reported in the unit using IR (Olrich et al., 2012). In a second study comparing falls on a 24-bed medical–surgical unit before and after implementing IR, a 57.7% decrease in falls was found (Brosey & March, 2015). In a third study, Goldsack, Bergey, Mascioli, and Cunningham (2015) conducted a 30-day pilot of IR on two medical units; one unit engaged nurses and patient care technicians in IR, whereas the second unit only included nurses. The combined nurse/patient care technician arm of the study had a statistically significant reduction in falls: from a baseline rate of 3.9 falls/1,000 patient days to 1.3 falls/1,000 patient days. The combined nurse/patient care technician IR group resulted in better patient outcomes than the nurse-only IR group; these findings suggest the value of the patient care technician.
Only two studies were found that targeted SNF CNAs to reduce fall rates. When IR was used to enhance an existing fall prevention program in a 431-bed SNF, Dyck, Thiele, Kebicz, Klassen, and Erenberg (2013) reported positive results; they involved all levels of nursing staff and used early adopters as champions. Staff training was efficient (10 minutes) to assure little disruption of the daily staffing census. Unfortunately, no actual patient outcomes were reported. In a second study, IR was piloted in a 150-bed nursing home (Jackson, 2016). The 10-member project team included nursing assistants (one restorative aide, one medication aide, and two nurse care assistants). A 54% reduction in patient falls (p < 0.05) from pre-implementation (number of falls = 24.5, SD = 0.5) to post-implementation (number of falls = 9.5, SD = 0.5) was reported. Apart from these two studies, no other IR projects were found. The existing literature supports the expanded use of IR in SNFs, but the radically different workflow and staffing mix require setting-specific examination.
Overall, the evidence for IR to improve quality, safety, and satisfaction is of fair to moderate quality, generated mostly in acute care settings (Daniels, 2016). Published articles generally have limitations: small sample sizes, lack of randomization in sample selection, limited intervention timeframes, various approaches to rounding/use of 4Ps, and the evaluation of varied outcomes (Brosey & March, 2014; Hicks, 2015). Nevertheless, two factors support the current pilot: (a) end-users and leaders endorse the value of IR (Brosey & March, 2015; Daniels, 2016; Dyck et al., 2013); and (b) the 4Ps of IR are appropriate to CNAs' level of education and highly applicable to their daily workflow (Dewing & O'Meara, 2013).
The design for the current pilot project was informed by the Plan-Do-Study-Act (PDSA) framework (National Health Service Foundation Trust, East London, 2018) and had five aims (three CNA-focused and two patient-focused):
- Aim 1: Implement IR training and measure uptake.
- Aim 2: Improve knowledge of the IR process (the 4Ps).
- Aim 3: Explore perception of IR as a daily clinical practice.
- Aim 4: Decrease patient falls.
- Aim 5: Reduce number of lost/damaged patient possessions (e.g., eyeglasses, clothing, hearing aids, dentures).
PDSA Cycle: Plan
The project began with an extensive search of six databases, using the terms intentional rounding OR purposeful rounding. Inclusion criteria were full-text, English language, peer-reviewed articles published between 2010 and 2018. The project lead (Y.P.) built relationships with the host company by presenting the project plan at the corporate level and meeting with leadership at the center level. These essential actions of obtaining authority to implement changes and tailoring material to a specific audience are features of knowledge transfer and exchange (KTE), defined as “an interactive process involving the interchange of knowledge between users and research producers” (Mitton, Adair, McKenzie, Patten, & Perry, 2007, para. 1).
The pilot was implemented on a 60-bed unit of a 120-bed SNF. Institutional review board approval was provided by a local university in the southeastern United States. The Plan phase included meetings with Directors of Nursing Services, Staff Development, and Graphic Design; these key stakeholders at the corporate office provided input and design assistance with the training plan and materials. The target population of the project were all full-time CNAs (N = 26); flex, pool, or part-time CNAs were excluded due to the intermittent nature of their work schedule. Participation in IR training was required by management, but the pre/post survey was optional. In consultation with the center, five CNAs were identified and asked to be project champions. This role involved serving as in-house “cheerleaders,” encouraging and providing guidance for coworkers during implementation (Fabry, 2015; Olrich et al., 2012).
Originally, fall reduction was the project's single patient-oriented outcome variable, but stakeholders requested to add lost possessions as a second outcome. In this company, patients are considered “customers,” underscoring the importance of satisfaction on financial and nonfinancial metrics. An ongoing source of dissatisfaction is lost customer possessions. Because the company replaces all missing items, senior leaders were interested in reducing customer/family complaints and replacement costs.
PDSA Cycle: Do
The project team collected data from two sources: de-identified data from CNAs on the pilot unit and aggregated patient data from corporate stakeholders from the parent company.
Because this was a pilot study with a focus on feasibility and improvement of methods through use of the PDSA cycle, quantitative results are presented as descriptive statistics only, without statistical tests. Uptake of IR (fidelity) was calculated as a percentage of each recalled aspect of the 4Ps and graphed for 10 weeks. Tables and matrices were used to analyze the open-ended question in the survey.
Aim 1. Implementation began by obtaining baseline information (demographic data and IR knowledge), which was immediately followed by a one-time 15-minute training. Training was completed over 7 days, to accommodate all work schedules. Participants were taught the “what, why, and how” of IR: what described the essence of IR (the 4Ps); why blended a simple overview of the published literature with the host company's mission statement; and how taught CNAs to address the 4Ps during each patient encounter.
To assure intervention fidelity, the project lead conducted all training sessions using a single two-sided hand-out (reinforcing the verbal training) and a laminated “badge buddy” with the 4Ps (IR tool). The badge buddy was two-sided: side one named the 4Ps, with plain directions for CNAs; and side two was the company's entire mission statement, with five words in red that supported the project. Training materials featured a professional layout and company logo. The project lead administered all pre/post participant surveys, stressing that completion was optional.
Aim 2. A one-page pre-training survey obtained baseline CNA information (i.e., demographic data and IR knowledge). Pre/post CNA knowledge was measured by a simple fill-in-the-blank question: What are the 4Ps of IR? The aggregate number of actual correct answers, versus potential correct answers, was reported with descriptive statistics.
Aim 3. After 10 weeks, participants were invited to complete the same one-page demographic and knowledge survey. However, an open-ended question was added to query CNAs about the IR experience.
Aims 4 and 5. The project team chose two patient-oriented outcome variables: patient falls (Aim 4) and lost personal possessions (Aim 5). Personal possessions were operationalized as the number and cost of lost/damaged eyeglasses, clothing, hearing aids, cell phones, cash, and dentures; these items were chosen by the host company.
Confidentiality was protected on several levels. CNA surveys did not collect any personal identifying information. For all patient outcome measures, corporate stakeholders supplied only aggregate, de-identified data (falls and personal possessions). Finally, the project lead did not have access to patients' records; enter any patient rooms; and did not use, collect, or store any protected health information.
The Plan and Do phases purposefully engaged CNAs because they have intimate knowledge of each resident and have valuable contributions to improve quality and safety. Yet, at most long-term care centers, CNAs are not afforded the opportunity to champion a QAPI project (Abrahamson et al., 2018). Successful implementation of this project was predicated on KTE principles (Mitton et al., 2007); exemplars of facilitators and barriers are shown in Table 1.
Exemplars of Knowledge, Transfer, and Exchange (KTE) Facilitators and Barriers
PDSA Cycle: Study
Aim 1. After initial IR training, the project lead conducted fidelity checks two to three times per week for 10 weeks. A rotating schedule was used to cover all shifts on weekdays and weekends. The project lead did not enter any patient rooms; therefore, CNAs were asked to describe how each IR element (potty, position, possessions, and pain) was used with their patients for that shift. Uptake of each recalled element was recorded separately. The project lead intentionally used the concurrent trainer–CNA interactions to coach and mentor on the IR tool, reinforcing the importance of the 4Ps and answering any questions.
Each week, the aggregate percentage of actual correct answers for each IR element, versus potential correct answers, was graphed over time. It took 4 weeks of coaching to exceed 90% fidelity for each element of the 4Ps. Even after 10 weeks, 100% fidelity for each element for all shifts of the week was only reached during Week 6, which supports the need for ongoing reinforcement to sustain practice changes.
Aim 2. Pre-implementation, all full-time CNAs participated in the training. Participants were primarily female (n = 23; 88.5%) with >5 years of CNA experience (n = 17; 65.4%), yet most had never heard of IR and the 4Ps. The post-implementation sample was relatively consistent, with 21 female participants (95.5%) with >5 years of CNA experience (n = 15; 68.2%). Vacation and turnover accounted for the attrition of four participants (two men, two women). There was a dramatic increase in knowledge from pretest (mean = 9.4, SD = 23) to posttest (mean = 91.7, SD = 22.9).
Aim 3. Two questions were used to assess CNAs' perceptions: “How did IR make a difference (or not) in your work as a CNA?” and “Should IR be officially adopted as a process of care?” The resulting responses (N = 22) were analyzed using a modified content validity index technique (Lynn, 1986). This technique involved placing the verbatim responses in a table. Five independent content experts familiar with IR (two RNs and three nursing assistants) were asked to evaluate each response as positive, negative, or neutral. The content experts determined that 75% of the comments were positive. For example, one comment stated: “It make the job more better [sic] to know what to say to better serve the customers.” In the second category, 13% of the comments were coded as negative by evaluators. An example from this category stated: “This is what a CNA should do.” In the third category, some CNAs stated that the basic tenet of IR was already a part of daily workflow, and these verbatim responses (12%) were viewed as neutral. In addition, the project team grouped the comments into four naturally occurring categories: IR fostered better workflow and time management, IR improved customer service and quality outcomes, IR increased safety awareness, and IR improved communication (Table 2). Overall, CNAs expressed positive responses and unanimously endorsed adopting IR as a process of care.
Certified Nursing Assistants' (CNA) Open-Ended Responses to Intentional Rounding (IR) (N = 22)
Aim 4. The pre/post implementation falls rates were analyzed based on the number of falls per 1,000 occupied bed days. There was a 44% reduction between the 3-month pre-implementation falls rate (442 falls per 1,000 occupied bed days) and the 3-month post-implementation falls rate (247 falls per 1,000 occupied bed days).
Aim 5. There was an 81% reduction in replacement costs of lost personal possessions. The 3-month pre-implementation cost was $4,211 (from dentures, hearing aids, clothing, eyeglasses, and cash), and the 3-month post-implementation cost was $822 (from hearing aids, clothing, and one cell phone).
PDSA Cycle: Act
The authors analyzed the results of the pilot project and presented findings to all stakeholders. Several actions were developed to support sustainability. The education department plans to tape a 15-minute voiceover PowerPoint® on IR, which will be incorporated into the center's new employee orientation. The host company plans to include the IR training for other frontline staff who routinely interact with patients, such as restorative, dietary, housekeeping, and laundry aides. Finally, the company is considering expanding IR to its other nine long-term care centers.
The current pilot project implemented IR, informed by the PDSA framework, and showed positive outcomes for each aim. CNA training was easily implemented with meaningful uptake after coaching. CNAs' knowledge of IR improved, and they perceived it helpful and sustainable. Finally, patient falls and lost possessions decreased.
Based on these findings, replication of this project in other SNFs is recommended, given the current small and underpowered study. Larger, fully powered studies in diverse (i.e., geographical and organizational culture) settings are needed before IR can be considered evidence-based. Similarly, outcomes were only measured from September to December. Collecting outcome data over 12 months would allow the examination of pattern changes over time. Finally, several of the 16 quality measures for long-term care facilities relate to pain and pressure ulcers (CMS, 2017b). As these quality measures are publicly reported, future investigators might consider these outcomes in a replication project.
CNAs spend most of their time performing direct care activities, thereby developing intimate knowledge of each SNF resident. This work needs to be valued, recognized, and harnessed. The current findings suggest that IR's 4Ps were readily accepted by CNAs and fostered improvements in quality, safety, and satisfaction. Use of IR in long-term care has the potential to improve financial and human aspects of care for older adults.
- Abrahamson, K., Davila, H. & Hountz, D. (2018). Involving nursing assistants in nursing home QI. American Journal of Nursing, 118(2), 11. doi:10.1097/01.NAJ.0000530228.48458.09 [CrossRef]
- Blakley, D., Kroth, M. & Gregson, J. (2011). The impact of nurse rounding on patient satisfaction in a medical-surgical hospital unit. MedSurg Nursing, 20, 327–332.
- 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, 153–159. doi:10.1097/NCQ.0000000000000086 [CrossRef]
- Centers for Disease Control and Prevention. (2017). Take a stand on falls. Retrieved from https://www.cdc.gov/features/older-adult-falls/index.html
- Centers for Disease Control and Prevention. (n.d.). QAPI: Quality assurance & performance improvement. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/nhqapi.html
- Centers for Medicare & Medicaid Services. (2017a). Nursing home quality initiatives: Questions and answers. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/Nursing-Home-Quality-Initiatives-FAQ.pdf
- Centers for Medicare & Medicaid Services. (2017b). Quality measures. Retrieved from https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/nhqiqualitymeasures.html
- Daniels, J.F. (2016). Purposeful and timely nursing rounds: A best practice implementation project. JBI Database of Systematic Reviews and Implementation Reports, 14, 248–267. doi:10.11124/jbisrir-2016-2537 [CrossRef]
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- Hicks, D. (2015). Can rounding reduce patient falls in acute care? An integrative literature review. MedSurg Nursing, 24, 51–55.
- Jackson, K.M. (2016). Improving nursing home falls management program by enhancing standard of care with collaborative care multi-interventional protocol focused on fall prevention. Journal of Nursing Education and Practice, 6(6). doi:10.5430/jnep.v6n6p84 [CrossRef]
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- Mitchell, M.D., Lavenberg, J.G., Trotta, R. & Umscheid, C.A. (2014). Hourly rounding to improve nursing responsiveness: A systematic review. Journal of Nursing Administration, 44, 462–472. doi:10.1097/NNA.0000000000000101 [CrossRef]
- Mitton, C., Adair, C.E., McKenzie, E., Patten, S.B. & Perry, B.W. (2007). Knowledge transfer and exchange: Review and synthesis of the literature. The Milbank Quarterly, 85, 729–768. doi:10.1111/j.1468-0009.2007.00506.x [CrossRef]
- National Health Service Foundation Trust, East London. (2018). PDSA. Retrieved from https://qi.elft.nhs.uk/resource/the-pdsa-cycle
- Olrich, T., Kalman, M. & Nigolian, C. (2012). Hourly rounding: A replication study. Medsurg Nursing, 21, 23–26, 36.
- Shin, N. & Park, J. (2018). The effect of intentional nursing rounds based on the care model on patients' perceived nursing quality and their satisfaction with nursing services. Asian Nursing Research, 12, 203–208. doi:10.1016/j.anr.2018.08.003 [CrossRef]
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Exemplars of Knowledge, Transfer, and Exchangea (KTE) Facilitators and Barriers
|KTE Facilitators||KTE Barriers||Implementation Exemplars|
|Building of trust||The project lead learned the names of all CNAs and their work history|
|Ongoing collaboration||The project lead kept in constant contact with the leadership at the center and corporate levels of the host company|
|Lack of experience and capacity for assessing evidence||Long-term care company partnered with research-based university|
|Provision of support and training (capacity building)||The company's graphic designer provided the layout and editing for all printed training materials|
|Sufficient resources||A site coordinator served as a liaison between the company and university|
|Relevance of research||The project lead conducted an extensive literature review on intentional rounding (IR)|
|Frequent staff turnover||The host company's Learning Specialists taped a 15-minute overview on IR, to be used in the orientation of all new hires|
|Information overload and traditional academic language||Health literacy principles to keep all training materials at an 8th grade reading level|
|No actionable message||The 4Ps provided an actionable message for CNAs|
Certified Nursing Assistants' (CNA) Open-Ended Responses to Intentional Rounding (IR) (N = 22)
|Categories||Definition||n (%)||Sample Verbatim Responses|
|Fostered better workflow and time management||CNAs expressed that IR helped them be more efficient||12 (55)||“It reduces the amount of call light going off.”
“Using the 4Ps help with time management. Saves time and keeps customer happy and prevents falls.”
“It help me a lot because I can ask the [patient] only one time what she needs because if I get busy I know I took care of her with everything.”|
|Improved customer service and quality outcomes||CNAs belie ved this tool had the potential to improve outcomes||8 (36)||“It keeps falls down and helps meet the customer needs.”
“In my own opinion, I think it was a very good exercise. Though some may not like it due to series of questions it would actual [sic] improve and prevent fall, loss of items, and many more.”|
|Increased safety awareness||CNAs reported a heightened awareness to customer (patient) needs||8 (36)||“This made difference by helping me be more aware and accommodating to the customers, it helped to anticipate their needs and to carry out my job more effectively.”
“Most of the strategy is like second nature but it does make me more aware in case I miss a step.”|
|Improved communication||The tool provided a framework for listening to customers (patients)||6 (27)||“I think the project helps improve communication with the customers and helped the caregiver with better care.”
“I began to slow down and ask the questions to ensure that all [their] needs was met before exiting the room if they wasn't [met], I would try to see what else I could do as a CNA. Sometimes they just want some one to talk to or for someone there to listen.”|