Journal of Gerontological Nursing

Research Brief 

Intentional Rounding With Certified Nursing Assistants in Long-Term Care: A Pilot Project

Mimi Jenko, DNP, RN, CHPN, PMHCNS-BC; Yasmin Panjwani, DNP, ARNP, NP-C; Harleah G. Buck, PhD, RN, FPCN, FAHA, FAAN

Abstract

Intentional rounding (IR) is a strategy used by predominately acute care nursing staff to proactively address patients' needs at regular and consistent intervals. The current project piloted the use of IR with certified nursing assistants (CNAs) on a 60-bed unit of a 120-bed skilled nursing facility (SNF). Using a pre/post intervention design and the Plan-Do-Study-Act (PDSA) framework, the authors measured knowledge of IR's “4Ps” (potty, position, possessions, and pain) and the incidence of falls and lost possessions. Uptake of IR over 10 weeks of implementation and CNAs' perceptions of intervention were also assessed. The pilot showed positive outcomes for each of the five aims. Data suggest that IR was well received by CNAs and changed practice patterns regarding quality, safety, and satisfaction. Based on these findings, replication of this project in other SNFs is recommended, given the current small and underpowered study. [Journal of Gerontological Nursing, 45(6), 15–21.]

Abstract

Intentional rounding (IR) is a strategy used by predominately acute care nursing staff to proactively address patients' needs at regular and consistent intervals. The current project piloted the use of IR with certified nursing assistants (CNAs) on a 60-bed unit of a 120-bed skilled nursing facility (SNF). Using a pre/post intervention design and the Plan-Do-Study-Act (PDSA) framework, the authors measured knowledge of IR's “4Ps” (potty, position, possessions, and pain) and the incidence of falls and lost possessions. Uptake of IR over 10 weeks of implementation and CNAs' perceptions of intervention were also assessed. The pilot showed positive outcomes for each of the five aims. Data suggest that IR was well received by CNAs and changed practice patterns regarding quality, safety, and satisfaction. Based on these findings, replication of this project in other SNFs is recommended, given the current small and underpowered study. [Journal of Gerontological Nursing, 45(6), 15–21.]

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).

Method

Aims

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 Exchangea (KTE) Facilitators and Barriers

Table 1:

Exemplars of Knowledge, Transfer, and Exchange (KTE) Facilitators and Barriers

Results

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)

Table 2:

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.

Discussion

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.

Conclusion

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.

References

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Exemplars of Knowledge, Transfer, and Exchangea (KTE) Facilitators and Barriers

KTE FacilitatorsKTE BarriersImplementation Exemplars
Individual Level
Building of trustThe project lead learned the names of all CNAs and their work history
Ongoing collaborationThe 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 evidenceLong-term care company partnered with research-based university
Organizational Level
Provision of support and training (capacity building)The company's graphic designer provided the layout and editing for all printed training materials
Sufficient resourcesA site coordinator served as a liaison between the company and university
Relevance of researchThe project lead conducted an extensive literature review on intentional rounding (IR)
Frequent staff turnoverThe 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 languageHealth literacy principles to keep all training materials at an 8th grade reading level
No actionable messageThe 4Ps provided an actionable message for CNAs

Certified Nursing Assistants' (CNA) Open-Ended Responses to Intentional Rounding (IR) (N = 22)

CategoriesDefinitionn (%)Sample Verbatim Responses
Fostered better workflow and time managementCNAs expressed that IR helped them be more efficient12 (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 outcomesCNAs belie ved this tool had the potential to improve outcomes8 (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 awarenessCNAs reported a heightened awareness to customer (patient) needs8 (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 communicationThe 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.”
Authors

Dr. Jenko is Consultant, Opis Senior Services Group, Tampa, Dr. Panjwani is ARNP, West Coast Medical Associates, New Port Richey, and Dr. Buck is Associate Professor, College of Nursing, and Coordinator of Chronic Illness Initiatives, University of South Florida, Tampa, Florida. Dr. Jenko is also Instructor, School of Nursing, Greenville Technical College, Greenville, South Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The project team gratefully acknowledges Opis Senior Services Group, whose strong mission statement guides the company, incorporating the concepts of respect, caring, warmth, dignity, safety, and continuous improvement into daily operations. Many were instrumental in the success of the pilot project: senior leaders at the Tampa office (Marilyn Wood, Paula O'Connor, Mary Huss, Pam Carrube, Jennie Rini, Anna Wood, Tara Zimmerman, Jenn Ziolkowski, and Vi Mateo), the leadership and staff at Fairway Oaks Center (Brian Sweetland, Carol Sullivan, Emma Agbaneje Sterlin, and the CNAs on the North Unit), and administrative assistants Gloria Caceres and Kate Alexander.

Address correspondence to Mimi Jenko, DNP, RN, CHPN, PMHCNS-BC, Consultant, Opis Senior Services Group, 10150 Highland Manor Drive, Suite 300, Tampa, FL 33610; e-mail: Mary.jenko@opismr.com.

Received: December 29, 2018
Accepted: February 14, 2019
Posted Online: April 15, 2019

10.3928/00989134-20190328-01

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