Journal Article Critique Nursing 665 Elizabeth Smith Hollis Misiewicz

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

Overview The article Effects of Nursing Rounds on Patients Call Light Use, Satisfaction, and Safety describes a quasi-experimental nonequivalent group design research study that attempted to determine if nursing rounds conducted on a regular schedule would reduce patient call light use, increase patient satisfaction and improve patient safety as determined by a decrease in falls. The sample was drawn from a nonrandomized sample of hospitals from fourteen states, urban and rural and ranging in size from 25 to 600 beds. Staff was trained in rounding protocols and data was obtained over a six week period, two weeks prior to rounding and four weeks after the rounding protocol was established. This research study exhibited both strengths and weaknesses which will be described in this paper. Strengths The literature search conducted by the researchers was organized and succinct. It identified a gap in the research for the need to quantify whether the initiation of patient comfort rounds would result in increased patient satisfaction, decreased call light use and improve patient safety. The hypothesis was complex and unidirectional clearly stating that nursing rounds on a regular basis would; (1) reduce call light use; (2) increase patient satisfaction and (3) improve patient safety as measured by falls. The sample was stratified to similar types of units between the two experimental groups and the control group to increase internal validity. All participating hospitals were required to have at least one unit in the experimental group and one unit as a comparison group also increasing internal validity. This sample was drawn from a variety of hospital types in various settings that could conceivably increase

the generalizability of the findings to a larger population. The design of the study was clearly explained so replication would be possible. The rounding protocol was clearly stated in specific steps so the independent variable of nursing rounding would be the same within the experimental groups. All members of the experimental groups went to training sessions conducted by the principal investigator. Nurses from the comparison group were not exposed to any training session so they would not inadvertently perform the same actions as the experimental group. This would all relate to increasing internal validity. Compliance with the protocol was verified by nurse managers on a daily basis and the principal investigator on a weekly basis. The four week duration of rounding was determined based on cognitive-behavioral and learning literature which suggests that the more complex the task, the longer it takes to fully integrate it into behavior. The researchers divided the rounding period into two week segments to better analyze the strength of the learning curve. The operational definition of patient safety as a measurement of the frequency of patient falls was clearly stated and easily quantifiable. The researchers did obtain IRB approval at all of the hospitals who participated in the study. Weaknesses The non-random sampling and assignment to groups has an inherently high risk for bias, and the proof of this seems to be clear in the results. Chief nursing officers and nurse managers chose which units would participate in the study and whether they would be in the one-hour rounding group or the two-hour rounding group. The patient satisfaction scores were lower for units that were assigned the two-hour rounding before and after the intervention was applied. Also, units were chosen specifically for the strength of the nurse manager. This selection bias is a threat to internal validity. The results are affected by the very reasons for being chosen for the sample and for being assigned to a certain group. External validity is in question as well, related to how the results from these hand picked units might be generalizable to the larger target population.

Implementation of the treatment (rounding) was unreliable due to possible variations across the personnel implementing the rounds. While all members of the nursing staff were utilized and trained, there can be no doubt that there would be a difference in how rounding was accomplished between RNs, CNAs, LPNs, patient care assistants, and PCTs. Units came up with their own plan for how to rotate the rounding responsibilities. An example of variation is that some personnel would be able to give medications and some would not, causing inconsistency in the resolution of a medication need. Unreliable implementation of the treatment, or lack of treatment fidelity, varying between the personnel and the units, is a threat to statistical conclusion validity. Study results are also affected by data collection techniques. The researchers themselves recognized and discarded data from 41% of the units studied due to poor reliability and validity of data collection. Units did not share a consistent means of collecting call light data which created a lack of reliability. Unnecessary data regarding the reason for call light use was collected that did not have a bearing on the hypothesis. The instruments used for collecting data regarding patient satisfaction were various surveys created by different commercial vendors contracted by the hospitals. Raw scores were not provided to the researchers. The researchers attempted to stitch together mean data from different instruments, reflecting a low level of reliability and questionable content and construct validity in measuring patient satisfaction. This lack of precision in data collection is another threat to statistical conclusion validity. Suggestions for improving scientific vigor and generalizability This study could be improved by the use of a theoretical or conceptual framework to organize and direct the research. A conceptual framework would help the researcher develop a clearer conceptual and operational definition of the variables i.e. improved patient care management and its relationship to call bell use, patient satisfaction and falls. A conceptual model that could apply is Roys Adaptation Model. The nursing goal of promoting client adaptation by regulating internal and external

stimuli fits well with the concept of patient care management. Construct validity is improved when nursing theory provides a framework to link the hypothesis to the intervention and the instrument. In sampling design, a power analysis would help estimate sample size needs. To improve sample representativeness, bias needs to be minimized. A way to minimize bias would be to add randomization to the sampling process. A cluster form of sampling would provide a more cross sectional sample of medical-surgical units. Enhancement to external validity is created by a random sampling design, improving generalizability. Even if units were handpicked or a convenience sample, a random placement to group would have improved the internal validity, giving credence to whether the intervention truly causes the change in the dependent variables. To improve statistical conclusion validity, implementation of treatment must be reliable. An implementation plan should be standardized to the level of personnel that would do the rounding, or what rotation of personnel would be used, consistently across units. For example, have rounding by RN or LPN only, or have the patient care assistants take every other round, with consistency. Data collection procedures should be standardized, as well, to improve reliability and validity of measurement. An instrument that is used across units to measure patient satisfaction would generate raw scores pertinent to the study and would improve reliability. Validity would be enhanced if the instrument was pilot tested to a small group, and subjected to validity testing (content, criterion-related and construct). Call light logging could also be more consistent. One of the criteria for being in the study should be that a call light internal system is already in place. Translation into Practice Even though the sample in this study was nonrandomized and bias does exist, the evidence does support the hypothesis that regularly scheduled rounding does decrease call light use, increase patient satisfaction and increase patient safety. The rounding protocol described in the study would be

amenable to implementation in many hospital settings. Convincing staff that this protocol would result in decreased call light use thus giving nurses more time to devote to other patient care activities could be difficult. Initially it would be viewed as just more work. With strong leadership to guide nurses and ancillary staff, regular rounding could reasonably become a part of the daily routine in a hospital inpatient unit.