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ntensive and Critical Care Nursing (2013) 29, 256—260

Available online at www.sciencedirect.com

j our na l homepage: www.elsev ier .com/ iccn

PN-led nursing rounds: An emphasis onvidence-based nursing care

ea Mahanesa,∗, Beth D. Quatrarab, Katherine Dale Shawb

Nerancy Neuroscience Intensive Care Unit, University of Virginia Health System, Box 801436, Charlottesville,A 22908, United StatesUniversity of Virginia Health System, Charlottesville, VA 22908, United States

KEYWORDSAdvanced practicenursing;Evidence-basednursing;Guideline adherence;Hygiene;Quality indicators,healthcare;

Summary In today’s healthcare environment, nursing staff are challenged to care for patientswith increasingly complex needs in an ever-changing environment. Nurses are expected to stayup to date on a tremendous number of institutional initiatives, best practice guidelines, andpolicies and procedures. These practice imperatives are often disseminated through passivemeans of information-sharing such as staff meetings and electronic mail. In this setting, it isdifficult for nurses to simultaneously focus on incorporating practice updates while continuingto value basic nursing functions such as oral care, skin care, and incontinence management. Theconcept of Interventional Patient Hygiene emphasises that basic nursing functions are not onlytasks, but also important evidence-based interventions that contribute to improved health for

Staff development the patient. Interventional Patient Hygiene facilitates the integration of science and practice.This article describes a quality improvement intervention, Advanced practice nurse-led nursingrounds, which supports Interventional Patient Hygiene and be used to help staff integrate bestpractices while balancing the multiple priorities inherent in nursing care.

© 2013 Elsevier Ltd. All rights reserved.

Implications for Clinical Practice

• APN-led nursing rounds assist nurses in integrating best practices and institutional initiatives into the complex careenvironment.

• APN-led nursing rounds aid staff in connecting basic nursing tasks, such as evidence-based hygiene measures, topatient outcomes.

• Staff feedback and available quality data can be used to adapt nursing rounds to meet the needs of individual units

or care settings.

∗ Corresponding author. Tel.: +1 434 924 2164; fax: +1 434 243 2779.E-mail address: sdm4e@virginia.edu (D. Mahanes).

964-3397/$ — see front matter © 2013 Elsevier Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.iccn.2013.03.004

257

Nursing RoundsPresenting RN Guide

Age, sex, diagnosis Current situation Relevant Past Medical History Relevant details of hospital course

Current priorities of careMedical Management (brief overview)Safety and Quality of Care (choose two)

o Fall risk/prevention o Aspiration risk/preventiono Pressure ulcer risk (Braden)/prevention o Restraints/alternativeso CAUTI risk /preventiono VAP risk /preventiono CLABSI risk/prevention o S urgical site infection risk/prevention o Delirium risk/prevention (CAM-ICU)o Pain assessme nt/treatment/documentation o Patient/family satisfaction

What’s keeping the patient in the ICU?

Worst case scenario?

Other concerns?

Key:CAUTI = catheter-associated urinary tract infection VAP = ventilator-associated pneumonia CLABSI = central line-associated blood stream infection CAM-ICU = Confusion Assessment Method for the ICU

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APN-led nursing rounds

Introduction

Interventional Patient Hygiene (IPH) is a concept introducedby Vollman et al. (2005) to bring attention to the importanceof performing ‘‘basic’’ nursing care activities according toevidence-based standards. Although initially focused on oralcare, bathing and incontinence management, the concept ofIPH has expanded to include other essential nursing func-tions such as mobility, catheter care and hand hygiene.These activities contribute significantly to improved patientoutcomes by decreasing the risk of healthcare-acquiredconditions such as pneumonia, pressure ulcers and skinbreakdown (Carr and Benoit, 2009; McGuckin and Torres-Cook, 2009; Vollman, 2006).

Clinical leaders are challenged to create a culture inwhich basic nursing care is evidence-based and appropri-ately prioritised within the myriad of tasks that nurses face.Evidence-based guidelines, protocols and procedures areoften written to integrate science into practice but arerarely implemented to the fullest extent. One reason forless than full implementation is that a passive approach isused to introduce the best practice. Passive disseminationof information is insufficient to change practice whereasa multi-faceted, interactive approach is more likely to besuccessful (Grol, 2001; Gross et al., 2001).

Nursing rounds have been used in a number of settings toprovide education and enhance patient care. In some sett-ings, rounds focus primarily on staff education and criticalthinking (Brault et al., 2009; Guin et al., 2002; Segal andMason, 1998). In other settings, the primary purpose is todevelop or enhance the nursing plan of care (Catangui andSlark, 2012; Coleman and Henneman, 1991). Nursing roundshave not been explicitly linked to empirical outcomes, inpart because nursing rounds do not focus on one interven-tion, but rather the integration of multiple interventionsinto bedside practice. Outcomes reported include mostlyprocess measures, such as participation and staff willingnessto present information.

Advanced practice nurses (APNs) are viewed as resourcesthat can assist staff in linking direct care to current evidence(Gerrish et al., 2011). APNs are well-poised to bring evidenceto the nurse clinician, and to develop innovative strate-gies to assist nurse clinicians in integrating the evidenceinto practice. One quality improvement initiative that mayimpact nurse-sensitive indicators is APN-led nursing rounds.

Methods

In response to quality data, a group of APNs at a largeacademic medical centre in the Mid-Atlantic United Statesdeveloped the concept of APN-led nursing rounds to focuson the application of evidence-based nursing practice atthe bedside. Three APNs covering four units were involvedin the initial roll-out of the project. By emphasising thebasics of good nursing practice, the group hoped to improvenurse-sensitive patient outcomes. The APNs on the par-ticipating units used quantitative data collected as part

of the hospital’s standard quality framework to deter-mine the initial focus of nursing rounds in their areas.The APNs continue to review these data monthly to deter-mine trends and adapt practices. This is an ongoing quality

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igure 1 Presenting guide for nursing rounds in the NICU.

mprovement intervention and thus the format for nursingounds is not strictly dictated; the APNs are encouraged todapt Rounds to meet individual unit needs. A descriptionf the structure and process of nursing rounds follows.

Neurosciences Intensive Care Unit: Emphasising theasics and Encouraging Critical Thinking

In the 12-bed Neuroscience Intensive Care Unit (NICU),ursing rounds led by the unit-based Clinical Nurse SpecialistCNS) occur on Sunday afternoons. Additional nursing roundsre integrated into the unit’s Neurocritical Care Course, ave-week series attended by all newly hired nurses withoutrevious NICU experience. A template is provided for theresenting nurse (see Fig. 1). After presenting the patient,he nurse is asked to identify two quality indicators for dis-ussion. For example, the nurse might identify the patients at risk for ventilator-associated pneumonia. Discussionould then focus on the Ventilator Bundle, including the

mportance of evidence-based interventions such as headf bed elevation and comprehensive oral care. Electronicesources are utilised; if a question arises about oral care,he staff is coached in locating the on-line nursing proce-ure. Head of bed elevation is assessed and raised if not

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lready elevated at least 30 . Everyone present participatesn the discussion, both to keep everyone engaged and toncrease their comfort level with providing and receivingeer feedback.

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Because the NICU has many inexperienced nurses, iden-ification and management of the ‘‘worst case scenario’’s also emphasised to develop critical thinking skills. Forxample, a nurse caring for a patient with a subarachnoidaemorrhage might identify neurological deterioration dueo cerebral vasospasm as the worst-case scenario. An inter-ctive discussion of the management of vasospasm wouldollow with an emphasis on immediate nursing actions.ther topics addressed include collaborative managementf seizures, herniation syndromes and cardiorespiratorymergencies.

In the NICU, staff nurses have the opportunity to serve as‘champions’’ or ‘‘on-unit experts’’ for a variety of nurse-ensitive quality indicators. When present on rounds, thehampions are identified and asked to provide input. Thiselps the staff identify available resources, and builds thehampion’s confidence in providing guidance and coaching.

eurosciences acute care units: sharing ideas tomprove outcomes

PN-led nursing rounds occur twice weekly on thecute/intermediate neurosurgery unit, and once weekly onhe acute care neurology/neurovascular unit. Rounds areoordinated by an experienced Acute Care Nurse Practi-ioner. The stated purpose of nursing rounds on these units is‘to highlight nursing indicators for each patient and provide

time for sharing of ideas to improve outcomes’’. Onhe neurosurgical unit, nursing rounds occur early on Mon-ay mornings (4:45 a.m.) to facilitate participation by nighthift staff in addition to times later in the day. Commonlyddressed themes include management of constipation,ncontinence care, pain management and mobility. Nursesre asked to identify their most ‘‘vulnerable’’ patient. Dis-ussion focusses on what makes the patient vulnerable;xamples include fall risk, non-English speaking, or alteredental status. The group discusses and determines indi-

idual nursing interventions to eliminate potential harmnd promote patient autonomy, safety, and recovery. Dis-ussion is based on the needs of the patient and nurses,nd may be centerd on ethics, evidence-based practice,athophysiology and/or discharge planning. For example,ne such discussion focused on the research that led tohe development of a new protocol for the managementf indwelling bladder catheters in the surgical patient.he APN takes advantage of the opportunity to show theurses tools to access evidence-based practice via the healthystem’s library, culture and ethics information, and commu-ity resources.

Six months after nursing rounds started, the APN onhe Acute Care Neurosciences Units sought feedback fromhe staff via an informal survey. Information was solicitedegarding the value of nursing rounds as well as specific pre-erences such as date and time. This information was usedo make changes to meet staff needs better.

edical-surgical acute care unit: rounding with a

ew lens

PN-led nursing rounds are not limited to the neurosciencereas. On one acute care medical-surgical unit, the CNS

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D. Mahanes et al.

eads rounds that focus on nursing care to prevent compli-ations. Nursing rounds on this unit occur weekly. Roundsre designed to emphasise participation by newer cliniciansnd new graduate nurses. The presenting nurse determineshich patient will be highlighted. Identified patients areiscussed in terms of their overall medical and nursingare needs but an emphasis is placed upon prevention ofospital-acquired pressure ulcers, catheter-associated uri-ary tract infections (CAUTI), central-line associated bloodtream infections (CLABSI) and falls. Appropriate nursingnterventions and best practices are discussed. For exam-le, pressure ulcer prevention is addressed by reviewinghe Braden scale and the subscale measures that placehe patient at risk for an ulcer. Interventions such asurning, moisture protection, nutrition and mobility areeviewed. If necessary, consults with interdisciplinary teamembers occur. Similarly, if the patient has been identi-ed as at risk for falls (either before or in the processf nursing rounds), the group insures that evidence-basedractice interventions are in place. They check that theatient is wearing a fall bracelet, the bed is in lowosition with the bed exit alarm engaged, and that theatient can reach necessary items such as tissues andhe call bell. Patients and families are incorporated intoursing rounds as appropriate. Patients and families are edu-ated about strategies to prevent healthcare complicationsnd are encouraged to help support best practices. Thisngages patients and families as members of the health-are partnership and provides an opportunity for the CNSo role model effective communication with patients andamilies.

esults

valuation of the effectiveness of APN-led nursing roundss ongoing, and includes qualitative feedback from partic-pants and trending of nurse-sensitive quality indicators.ecause APN-led nursing rounds are by design adaptedo meet the needs of participants and address unit-pecific data, it is not possible to directly correlatehis intervention with specific outcomes. In addition, thempact of nursing rounds cannot be isolated from thempact of other concurrent initiatives. However, posi-ive trends in indicators such as CAUTI, CLABSI, fallsnd pressure ulcers have been noted on the unitsctively participating in APN-led nursing rounds. Nurs-ng rounds are being implemented in additional areasf the hospital because of their perceived value andmpact on the pilot units. Other measures used to eval-ate APN-led nursing rounds include participation bytaff, perceived value, and practice changes made inesponse to information gathered during rounds, as notedelow.

Nursing rounds in the NICU typically include 3—11 careroviders. Most are nurses, but patient care assistants,espiratory therapists and students also participate. In addi-ion to nurse-sensitive quality indicators and critical thinking

kills, practice issues addressed on rounds have includedonsistent neurological assessment, appropriate use of tac-ile stimuli, assessment of spinal cord function and nursingocumentation. Nursing rounds are gradually becoming a

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part of the unit’s culture, with staff sometimes initiatingthem.

When surveyed, over 60% of respondents on theacute care neurosciences units rated nursing rounds as‘‘extremely valuable’’. Comments from staff indicatethat nursing rounds promote learning and interactionand enhance knowledge of pathophysiology. The neurol-ogy/neurovascular unit has asked the NP to increase nursingrounds from once to twice weekly on that unit, which is anindicator of the perceived value.

On the acute care medical-surgical unit, several processissues have been identified and addressed as a result ofAPN-led nursing rounds. For example, the CNS identifiedthat a chlorhexidine-impregnated sponge used for CLABSIprevention was not being properly applied. This was notonly due to deficits in staff knowledge but also becausethe catheters were sutured too tightly to permit appropri-ate placement. Education was provided to the nursing staff,and feedback was provided to practitioners involved in lineplacement. Similarly, staff noted difficulty avoiding depend-ent loops when caring for patients with indwelling bladdercatheters. This information helped the CNS target an educa-tional strategy using pictures to demonstrate proper tubingsecurement.

Discussion

APN-led nursing rounds have been implemented on severalunits at this large academic medical centre. The facilita-tors identify flexibility and persistence as key contributorsto success. Each unit has its own culture and the approachto rounds has been individualised to meet unit needs. Forexample, the nurses in the NICU prefer in-depth discussionof selected indicators on a few patients, while the acutecare neuroscience floors find more benefit in focused reviewof those patients perceived to be at risk. The process ofnursing rounds is also adapted based on staffing mix, withcomplexity increasing when more experienced nurses arepresent.

A primary challenge identified by the facilitators isdecreased participation in times of high acuity or lowstaffing. Strategies to alleviate this challenge includealtering the time of rounds and encouraging staff to partici-pate for whatever time they are available, even if they mustperiodically leave rounds to attend to patient needs. It isalso important to acknowledge that there will be days whenrounds will not occur or when the APN will round individuallywith staff nurses because of unit activity.

Staff discomfort with presenting patients to a groupis also a potential barrier to effective nursing rounds.Strategies to address this barrier include providing a consis-tent format for presentations, allowing staff to choose thepatients presented and encouraging group contributions todiscussion of the plan of care. For example, when discussingskin care strategies, the facilitator may ask the presentingnurse to describe the patient’s current skin condition, andthen ask the group to provide input on pressure ulcer pre-

vention strategies.

Finally, some units do not have an APN available to leadnursing rounds, either because the unit does not employAPNs or because the APNs lack time for or interest in staff

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evelopment. This barrier can be addressed by emphasis-ng the connection between improved nursing practice andatient outcomes (and thus the importance of staff devel-pment), and by utilising APNs from other areas as ‘‘Guestacilitators’’. APNs are ideal facilitators for nursing roundsecause of their educational preparation and competencies.owever, other clinical leaders such as Nurse Educators,harge nurses, and experienced staff nurses can also beffective.

onclusion

t is difficult to isolate the impact of APN-led nursing roundsn the quality of nursing care, but that does not dimin-sh the potential benefits. Nursing rounds contribute torevention of blood stream infections, catheter-associatedrinary tract infections, hospital-acquired pressure ulcers,entilator-associated pneumonia and falls. These nurse-ensitive quality indicators are impacted by attention toasic care needs such as hand hygiene, antisepsis withatheter manipulation, skin care, incontinence care, mobil-ty and oral care. Nursing rounds enhance the effectivenessf education and practice improvement strategies by guid-ng staff in applying knowledge in practical situations.ursing rounds contribute to a culture of inquiry, ongo-

ng peer review and collaboration, and pride in nursingractice. By focusing on Interventional Patient Hygienehile also discussing other aspects of care, Nursing roundsmphasise that IPH is as important as other nursing respon-ibilities. A sense of responsibility and accountability isnstilled by linking IPH to the overall quality and safety ofare.

cknowledgement

he authors acknowledge Suzanne M. Burns, RN, MSN, RRT,CRN, ACNP, FAAN, FCCM, FAANP for her guidance and sup-ort in developing and implementing this project.

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