Rounding by Nurses in the progressive care unit

Introduction The progressive care unit (PCU) is a practice setting in which the researcher’s health care team is often failing to meet quality care objectives according to patient reporting on the hospital consumer assessment of healthcare providers and systems (HCAHPS). Opportunities for growth in quality care based on the HCAHPS of the PCU include topic areas related to patient inclusion as well as communication skills of the members of the healthcare team.

Patient perception of quality is that the healthcare team in the PCU is unable to explain the care process in a way that the patient and family members feel comfortable with or that allows them to understand the care that is being provided to them.

The researcher has first-hand experience with this challenge in the PCU and has heard first-hand from patients there that the care seems disjointed, that continuity is lacking, and how problematic it is for patients to hear different answers or explanations from different members of the team. Care providers do not seem to be on the same page according to patient responses, and patients and family members, as a result, report feeling helpless and feeling that they are not included in their own care processes.

In order to empower patients, make them feel more engaged with the care process, and increase quality of care in the PCU with regard to the specific areas of involving the patient and patient’s family in the care process, this study identifies specific procedures and processes in the PCU that can be altered in order to positively impact care providers’ approach to promoting the inclusion of the patient.

Specifically, it looks to address the issue with EBP, which is vital for helping nurses and care providers to implement quality care practices based on research and evidence (Melnyk, Fineout?Overholt, Giggleman & Choy, 2017).

EBP applies to the problem of a lack of patient inclusion in the following ways, which indicate the nature of the problem: 1) the PCU nursing team conducts bed shift reports among nursing staff; 2) case management, respiratory therapy, physical therapy, occupational therapy, and the hospitalist group also conduct separate rounds on patients and family members; 3) the teams all have a designated meeting time for interdisciplinary meetings in which patient care issues are discussed; 4) however, the teams do not conduct rounding together in a way that incorporates the patient and or family; 5) this lack of interdisciplinary team work may contribute to patients’ experiences of disjointedness in terms of care that they receive while in the PCU.

EBP is needed to clarify whether involving the interdisciplinary teams in an approach to make the patient feel more included in the care process can increase the sense of quality of care experienced by the patient while in the PCU. This issue is important because currently the PCU team is not scoring well with patients in terms of providing consistent, quality care. In this proposal, the main problem and PICOT question to be examined will be identified.

A literature review will follow that provides a summary of the relevant literature on the subject of interdisciplinary team work in promoting patient satisfaction. The sample, practice setting and clinical context of the study will be provided; a plan for implementation will follow, and the main points of the paper will be summarized in the conclusion.

Identification of Problem The PICOT for this proposal is: For progressive unit patients (P), how does interdisciplinary rounding with patient/family inclusion (I) compared to individual rounding by team members (C) affect patient satisfaction and family anxiety (O) during their hospital stay (T)? PICOT questions are useful for addressing clinical practice issues as they represent an effective way to conduct an evidence-based clinical inquiry. The PICOT acronym helps the researcher to organize the focus of the clinical inquiry (Melynk & Fineout-Overholt, 2015).

The P stands for population of interest, the I for intervention or issue of interest, the C is for the comparison of interest, the O is the outcome expected and T is for the time for the intervention to achieve the outcome. For the PICOT format not, all components are necessarily based on the presented clinical scenario.

Researchers recommend that one should include the population interest, the intervention of interest every time.  Hypothesis It is expected to be found that rounding exercises in which the patient and the patient’s family are included with the interdisciplinary team will increase patient satisfaction scores on the HCAHPS, reduce patient anxiety and possibly facilitate the decrease in the length of stay for patients, if the interdisciplinary team, working together, can collectively identify barriers to discharge.  Literature Review To obtain evidence for this study, online peer-reviewed journal databases were searched using the appropriate key words.

Databases include CINHAL, MEDLINE, and Dynamed, and key words utilized to examine what researchers have documented in the literature about this topic included “interdisciplinary teamwork healthcare,” “patient inclusion interdisciplinary,” “evidence based practice” and “patient inclusion rounding.” A variety of research was found to be available on aspects of this topic.

Selection criteria for the PICOT question included: the study had to be published within the past five years in a peer-reviewed journal or on a professional health care organization website, such as the Institute of Medicine (IOM) or the Centers for Disease Control and Prevention (CDC); the studies had to be of Level III or higher in terms of evidence-based research: this included non-experimental studies such as systematic reviews, qualitative analysis, quasi-experimental studies, and experimental studies (randomized control trials).

McCaffrey and McConnell (2015) provide a systematic review of literature in their Level III study regarding how interdisciplinary team work can help nurses and care providers to better communicate and provide compassionate care (aka a high level of quality care) to patients. The interdisciplinary approach fosters a sense of shared governance among care providers, as Kutney-Lee, Germack, Hatfield et al.

(2016) indicate in their Level III cross-sectional observational study that in hospitals where there is a substantial sense of shared governance among nurses, the outcomes for patients is much higher than in facilities where is less sense of shared governance. Unfortunately, there is a lack of strong evidence on the subject of interdisciplinary rounding and patients’ sense of inclusion in their own care process.

The Level III study by Bhamidipati, Elliott, Justice, Belleh, Sonnad and Robinson (2016) is a systematic review of 22 qualitative studies, which found that there were few high quality research articles on the topic of interdisciplinary rounds and their impact on patients’ quality of care. Al Danaf et al. (2017) showed by way of the case study approach how proactive rounding can facilitate patient oriented care and increase the positive feeling that the patient experiences regarding their care process.

Other studies that have reached the same conclusion support the overall research hypothesis, which is that if teams work together across disciplines to take a more united, proactive and consistent approach to rounding, answering questions, and being mindful of the appropriate ways to educated patients on their care, patients will feel better about their care process overall (Pannick et al., 2015; Braus et al., 2016; Urisman, Garcia & Harris, 2018; Bright, Austin, Garn, Glass & Sample, 2017).

The more that nurses, care providers and staff demonstrate a combined effort to put the patient first and foremost by displaying a consistent and unified approach to care, the better that patient’s experience has been shown to be. However, just because the research has shown that when teams work together and communicate more effectively to promote a higher quality of care for patients, implementing EBP is not always easy, as Sadeghi?Bazargani, Tabrizi and Azami?Aghdash (2014) show in their Level III systematic review of barriers to EBP implementation.

They find that one of the most common obstacles to EBP is a lack of cooperation among care providers in a facility. Their study illustrates the difficulty that care providers face when attempting to provide quality care for patients: there is little cooperation, communication, sense of shared governance, or continuity of care.

Baird, Rehm, Hinds, Baggot and Davies (2016) find in their Level III qualitative research in which they conducted interviews with seven patients and twelve nurses that continuity of care as something that is very important to patients and something that nurses struggle to achieve because of the fact that so many different nurses will take part in rounding processes, be called upon to deliver advice or explanations, and have different approaches to communicating effectively with patients and peers.

EBP has to be implemented in order to improve quality of care, as all professional care is ultimately based on evidence accrued over time to inform care providers on the best practices for all different types of situations. As the health care industry continues to grow and develop, new situations arise that require new studies to help formulate EBP for care providers.

The development of interdisciplinary teams in health care units like the PCU and their cooperative approach to providing care to patients who want to feel more included in the care process is an instance of a health care development that requires study. Counter-Evidence Reeves, Pelone, Harrison, Goldman & Zwarenstein (2017) have shown that interprofessional collaboration fails when team members do not provide adequate communication lines to one another and do not adhere to a formulated and established technique for promoting continuity of care. Reeves et al.

(2017) suggest that interdisciplinary approaches to care have to be grounded in a spirit of mission that is driven by a vision that is ultimately transformative in nature. Their interpretation of findings regarding the impact of interdisciplinary approaches to patient-centered care indicate that this approach is not necessarily a meaningful factor in how well patients feel about their care.

The counter-argument or alternative interpretation of findings that could be used to address this contention is that this is exactly why transformational leadership is a quality of leadership often utilized among nurses (Lin, MacLennan, Hunt & Cox, 2015). Care professionals have to be united under a vision that is given them by leaders and the interdisciplinary approach to rounding will admittedly only be as strong as the vision that drives the process. The relationship between leadership and interdisciplinary success, however, is another subject that would require its own study.

For the purposes of this study, it is enough to expect that the appropriate leadership and leadership vision is in place to help drive the interdisciplinary process. Sample/Practice Setting/Clinical Context Sample Convenience sampling will be used for this study, with the population being patients of the PCU who experience both interdisciplinary rounding and individual team member rounding visits during their stay.

A period of two-weeks in which individual team member rounding is practiced followed by a period of two-weeks in which interdisciplinary rounding is conducted will be the time frame for this qualitative study in which interviews will be conducted with patients in the PCU during this time.

Convenience sampling has its limitations because of the subjective nature of the approach to sampling the population, which may impact the study’s external validity, but it is a useful approach to obtaining participants for a study when resources are limited (Etikan, Musa & Alkassim, 2016). Practice Setting The practice setting is the PCU, wherein a problem of a lack of patient inclusion has been identified in the HCAHPS as an issue that the PCU care providers need to address.

Interviews will be conducted with patients upon discharge during the week in which the two methods of rounding are conducted. There has been little research conducted in this practice setting with regard to the PICOT question, so this study will fill a sizeable gap in the research currently available on the question of whether interdisciplinary team work when rounding can help patients to feel more included in their care process.

Clinical Context The clinical context for this study is that it is rooted in the historical need of care providers to deliver quality of care that enhances the patient’s quality of life. It is not enough for care providers to simply “do the work” of care—i.e., the technical side of providing health and healing—without considering the emotional needs of the patient.

In order to embrace a holistic and total approach to quality care, nurses and care professionals have to engage with patients at a fundamental level that puts the patients’ needs first. To ensure that patients’ needs are always observed in a complex system that is a modern day PCU, care providers have to take extra care to work together and achieve a common goal. This requires communication and a concerted effort on the part of all providers to ensure that patients receive consistent explanations about their care.

Plan for Implementation The key activities of this project will be to conduct the semi-structured interviews with all patients upon discharge from the PCU during the two-week time frame in which individual team members conduct the rounding and during the two-week time frame in which interdisciplinary rounding is conducted. The interviews will be recorded and patient informed consent forms will have to be obtained before the interviews can take place.

The planning steps for this process will include meeting with the head of the PCU and establishing a routine for the interdisciplinary rounding process so that this part of the study can be conducted in a mannerly fashion. The heads of the various disciplines will have to be consulted and a plan for rounding established prior to the beginning of this project. The first part of the project involving individual team members conducting the rounding will not require any extra consideration as this is the process already in place.

Establishing the semi-structure interview process will have to be undertaken so that the discharge nurses understand what questions to ask, and the process for recording the interviews will have to be explained so that all the necessary data is obtained for later review and analysis. Data will have to kept in safe place where it cannot be destroyed or altered and this safe place will have to be accessible by key, which can only be given to the discharge nurses, the heads of the departments and the researcher.

The evaluation plan will consist of conducting content analysis. The interview responses will be transcribed and common themes identified using the process of eidetic reduction and imaginative variation. These processes will help to give shape to the experiences of the patients so that their thoughts and feelings can be better understood with regard to how the two types of rounding impacted the patients’ sense of being part of the care process.

Evaluating outcomes will be based on indicators such as individual behaviors and attitudes that emerge from analysis of the content obtained from the semi-structured interviews. Barriers that might get in the way of the project’s success include a failure of the interdisciplinary approach to take full effect by the time the study is conducted. This step will require collaboration on the part of the professionals operating in the PCU, and since the PCU is unused to collaborating in this manner, the approach might not be effectively conducted.

Overcoming this barrier will require some time so it is advisable that the PCU allow for a practice week in which the interdisciplinary approach is conducted before conducting the interviews with patients upon discharge during a two-week time frame. Resources needed for this study will be: 1) a recording device for interviews, 2) informed consent forms for patients, 3) the assistance of department heads so that the interdisciplinary approach can be conducted, 4) the cooperation of discharge nurses, and 5) a safe place for the data collected along with keys for access.

The method for sustaining this project will depend upon the head of the PCU to ensure that the study is fully supported by staff. This study will, therefore,.