Hourly Rounding and Whiteboards for Postpartum Pain Management

Introduction and PICOT Question

Across diagnoses, pain is a common complaint among inpatients. In the U.S. alone, approximately 100 million patients experience chronic pain (Alaloul et al., 2015). Pain negatively affects numerous aspects of an individual's life, including sleep, quality of life, and physical functioning. Pain is also associated with negative psychological outcomes such as depression, extended hospitalization, and a substantial economic burden. In the U.S., for instance, pain imposes an estimated cost of $635 billion on patients and the healthcare system as a whole (Alaloul et al., 2015). Ineffective management of pain can have a negative impact on patient satisfaction, underscoring the need for more effective interventions.

Effective pain management is particularly important in postpartum care, where the experience of pain is common (Eshkevari, Trout & Damore, 2013). However, the management of pain in postpartum care remains quite ineffective, with up to 20% of postpartum patients reporting dissatisfaction with pain management (Niemi-Murola et al., 2007; Espenshade & Hreniuk, 2017). This dissatisfaction stems from factors including poor midwifery care, limited or non-individualized care, poor communication between providers and patients, and lack of patient involvement in decision-making (Mohammed, 2016). For mothers, such experiences may lead to negative childbirth experiences overall. Accordingly, it is crucial for nurses in postpartum care to employ more effective pain management interventions in order to increase maternal satisfaction.

Generally, structured nurse rounding is one of the ways in which patient satisfaction in nursing practice can be improved (Mitchell et al., 2014; Brosey & March, 2015; Alaloul et al., 2015). This intervention essentially involves monitoring the patient on a regular basis — for example, assessing the patient every hour during the day and every two hours during the night. The assessment focuses on a number of patient concerns such as pain, temperature, safety hazards, positioning, and need for toileting (Brosey & March, 2015). Patient satisfaction can also be increased by improving provider-patient communication (Singh et al., 2011; Tan et al., 2013; Alaloul et al., 2015).

Based on this premise, the following PICOT question is formulated: In postpartum women undergoing either vaginal or caesarean delivery (P), does hourly rounding and use of a whiteboard (I), compared to no rounding and no use of a whiteboard (C), increase patient satisfaction with pain management (O) over a 3-month trial period (T)? The following sections provide a critique of five quantitative research articles related to this PICOT question.

Critique of Brosey and March (2015)

Brosey, L., & March, K. (2015). Effectiveness of structured hourly nurse rounding on patient satisfaction and clinical outcomes. Journal of Nursing Care Quality, 30(2), 153–159.

Research Purpose

The purpose of this study was to monitor the impact of structured hourly nurse rounding on patient falls, hospital-acquired pressure ulcers (HAPU), and patient satisfaction. The nursing intervention was implemented in a 24-bed medical-surgical unit within a large community hospital.

Research Design

The study took the form of a descriptive study. The descriptive design is one of the major forms of quantitative research. A descriptive study aims to describe the characteristics of a given phenomenon, meaning that the researcher does not formulate a hypothesis at the outset (Creswell, 2014). A descriptive study also typically does not involve randomization, blinding, or a control group. The chosen design was appropriate for a study examining the effectiveness of structured hourly nurse rounding on patient satisfaction, as the data analysis focused on describing patient satisfaction, patient fall, and HAPU rates at the beginning and end of the study period.

With respect to timing, the study was prospective in nature. A prospective study involves measuring outcomes during the study period with the aim of establishing the impact of a given intervention (Maltby et al., 2015). In this case, satisfaction scores as well as fall and HAPU rates were measured before, during, and after the implementation of the rounding intervention.

Though descriptive research provides information about the attributes of a given phenomenon, it provides little or no knowledge about cause-and-effect relationships (Bryman, 2008). It may not be said with certainty that hourly nurse rounding actually increased patient satisfaction, as satisfaction may be influenced by other factors within the care environment. Furthermore, the lack of randomization and a control group presents challenges to generalization.

Sampling

The study was carried out in a 24-bed medical-surgical unit in a large hospital. In total, 582 eligible patients were discharged during the study period; however, only 81 patient surveys were returned. Given the nature of the study, the recruitment of the sample involved non-random techniques — outcomes were observed in all patients admitted to the unit during the study period. Lack of random sampling presents a threat to internal and external validity due to the possibility of researcher bias (Maltby et al., 2015). Furthermore, the final sample (n = 81) is fairly small relative to the larger population under investigation, making it insufficiently representative.

Measurement Methods

Data collection procedures must be undertaken with a great deal of caution (Maltby et al., 2015). In Brosey and March's (2015) study, the data collection process was preceded by a 20-minute education session that familiarized the unit's staff — including the nurse manager, registered nurses, patient care assistants, and secretaries — with related evidence, the intervention, historical performance indicators, and goals. Training was crucial since the unit's staff would serve as data collectors.

Patient satisfaction was measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The HCAHPS is a nationally applicable tool for measuring patient satisfaction with healthcare, making it an appropriate instrument for this study and enhancing validity and reliability.

Descriptive and Inferential Statistics

The analysis of the data mainly involved descriptive statistics, which was primarily informed by the descriptive nature of the study. Descriptive statistics involve describing the attributes of data using techniques such as frequencies, tables, and graphs (Martin & Bridgmon, 2012). Inferential statistics were not employed; effect sizes and confidence intervals were not reported, and as the study did not involve hypotheses, type I and type II errors are not relevant. Nonetheless, a Cox-Stuart trend analysis was performed on data collected 12 months before the implementation of the intervention to determine the statistical significance of the reduction in patient falls during that period.

Data Management

Data management is an important aspect of the data analysis process (de Broeck et al., 2005). It involves processes such as data cleaning and coding, checking for outliers and data distribution, handling missing data, and establishing inter-rater reliability. In Brosey and March's (2015) article, it is not mentioned whether any procedures were undertaken to clean the collected data prior to analysis, to deal with incomplete responses in the HCAHPS questionnaires, or to determine data distribution. Inter-rater judgment was also not reported. The only aspect addressed is attrition: out of 582 eligible patients, only 81 returned their HCAHPS surveys. The absence of most data management procedures is one of the major weaknesses of the data analysis in this study.

Critique of Mitchell et al. (2014)

Mitchell, M., Lavenberg, J., Trotta, R., & Umscheid, C. (2014). Hourly rounding to improve nursing responsiveness: a systematic review. The Journal of Nursing Administration, 44(9), 462–472.

Research Purpose

This is a systematic review aimed at synthesizing empirical evidence on the impact of hourly nurse rounding on patient satisfaction. As this was not a primary study, no hypothesis was formulated.

Research Design

A systematic review is a type of research method aimed at summarizing and critically analyzing the available evidence on a given research topic (Garg, Hackam & Tonelli, 2008). Conclusions are drawn from numerous studies rather than a single study. For healthcare research, systematic reviews are valuable because readers can readily assess the effectiveness of a given intervention. Indeed, systematic reviews are often described as the most robust form of medical evidence (Maltby et al., 2015). They also involve fewer costs, less time, and offer better generalizability. Nonetheless, the quality of a systematic review is significantly dependent on the nature of the studies included, particularly in terms of date of publication, type of research design, measurement tools used, and outcomes measured (Maltby et al., 2015).

In this case, the studies included were controlled clinical studies. No randomized controlled trial was included, which could be viewed as one of the major limitations of the review. The included studies reported patient satisfaction outcomes resulting from the implementation of hourly nursing rounds for periods ranging from two weeks to five years. Importantly, all included studies had been published within six years of the review's completion, adding to its strength given the significance of up-to-date evidence in healthcare research (Maltby et al., 2015).

Sampling

CINAHL, EMBASE, and Medline databases were used as sources for the articles. In the first stage, an expert evaluated the titles and abstracts of all located articles and identified those to be considered in the second stage. Out of the articles located in the first stage, 100 were selected randomly. A second analyst then evaluated these 100 articles according to the inclusion criteria and checked for possible bias. These procedures are important for improving the reliability of review findings. Eventually, 16 articles met the inclusion criteria — a sufficiently large number for a systematic review, reinforcing the generalizability of the findings.

Measurement Methods

For a systematic review, the data collection process involves locating and evaluating the studies to be included. In this regard, the researchers relied on two tools: the Jadad scale and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) scale. With rigorous application, these scales provide useful guidelines for evaluating the quality of evidence with regard to research design, consistency, and magnitude of effect — with important implications for validity and reliability. Since this was not a primary study, data collector training was not relevant; nonetheless, most of the studies included in the review incorporated personnel training in their data collection processes.

Descriptive and Inferential Statistics

The review reports descriptive statistics to characterize the studies included, particularly in terms of number of subjects, study duration, frequency of nursing rounds, rate of patient falls, use of call lights, nurse responsiveness, and patient satisfaction levels. There is limited use of inferential statistics; the only inferential type reported is correlation (the association between hourly nursing rounds and patient satisfaction). Effect sizes and statistical significance were reported, which was important for demonstrating the strength of the evidence. Confidence intervals were not reported. Since this was a systematic review, type I and type II errors are not relevant.

Data Management

In this systematic review, data management essentially encompassed evaluating the strength of evidence. This was achieved through the use of two independent experts who thoroughly evaluated the titles, abstracts, and contents of all articles, assessing research methodology and potential bias. Each expert conducted an independent evaluation, and results were then compared to identify agreements and disagreements. Little disagreement between the experts was found, and the use of two independent evaluators is one of the major strengths of the data management process in this study.

References

Alaloul, F., Williams, K., Myers, J., Jones, K., & Logsdon, M. (2015). Impact of a script-based communication intervention on patient satisfaction with pain management. Pain Management Nursing, 16(3), 321–327.

Broeck, J., Cunningham, S., Eeckels, R., & Herbest, K. (2005). Data cleaning: detecting, diagnosing, and editing data abnormalities. PLoS, 2(10), e267.

Brosey, L., & March, K. (2015). Effectiveness of structured hourly nurse rounding on patient satisfaction and clinical outcomes. Journal of Nursing Care Quality, 30(2), 153–159.

Bryman, A. (2008). Social research methods (3rd ed.). Buckingham: Open University Press.

Creswell, J. (2014). Research design: qualitative, quantitative, and mixed methods approaches (4th ed.). London: SAGE.

Eshkevari, L., Trout, K., & Damore, J. (2013). Management of postpartum pain. Journal of Midwifery and Women's Health, 58(6), 622–631.

Espenshade, K., & Hreniuk, L. (2017). Partnering with women for postpartum pain management. Nursing for Women's Health, 20(6), 595–600.

Garg, A., Hackam, D., & Tonelli, M. (2008). Systematic review and meta-analysis: when one study is just not enough. Clinical Journal of the American Society of Nephrology, 3(1), 253–260.

Maltby, J., Williams, G., McGarry, J., & Day, L. (2015). Research methods for nursing and healthcare. New York: Taylor and Francis.

Martin, W., & Bridgmon, K. (2012). Quantitative and statistical research methods: from hypothesis to results. Hoboken: John Wiley & Sons.

Mitchell, M., Lavenberg, J., Trotta, R., & Umscheid, C. (2014). Hourly rounding to improve nursing responsiveness: a systematic review. The Journal of Nursing Administration, 44(9), 462–472.

Mohammed, A. (2016). Maternal satisfaction regarding quality of nursing care during labor and delivery in Sulaimani teaching hospital. International Journal of Nursing and Midwifery, 8(3), 18–27.

Niemi-Murola, L., Poyhia, R., Onkinen, K., Rhen, B., Makela, A., & Niemi, T. (2007). Patient satisfaction with postoperative pain management: effect of preoperative factors. Pain Management Nursing, 8(3), 122–129.

Singh, S., Fletcher, K., Pandl, G., Schapira, M., Nattinger, A., Biblo, L., & Whittle, J. (2011). It's the writing on the wall: whiteboards improve inpatient satisfaction with provider communication. American Journal of Medical Quality, 26(2), 127–131.

Tan, M., Evans, K., Braddock, C., & Shieh, L. (2013). Patient whiteboards to improve patient-centred care in the hospital. Postgraduate Medical Journal, 89, 604–609.