Whiteboards and Hourly Rounding in Postpartum Pain Management

Introduction and PICOT Framework

Patients in hospitals often complain of pain regardless of their diagnosis. Several aspects of a patient's life contribute to pain, including amount of sleep, daily activities, and quality of life (Alaloul, Williams, Myers, Jones, & Logdson, 2015). While healthcare expenses have increased significantly over the years, there have been meaningful improvements in increasing both family and patient involvement in medical care. Hourly rounding is one strategy that has worked well in various healthcare settings. Although hourly rounding has shown success in several areas, its use in urgent pediatric settings has not been well documented (Emerson, Chumra, & Walker, 2013). Opportunities still exist to examine pediatric family preferences and perspectives regarding the use of whiteboards (Cholli et al., 2016).

Several studies conducted in different settings are referenced in this paper. The research projects include in-patient surveys, quasi-experimental design analyses, installation of whiteboards, incorporation of hourly rounding methods, and one-on-one interviews. The study highlights the role of communication in patient satisfaction and pain management. The discussion covers various areas of concern supported by the following:

• Large quantitative data and sample sizes that yielded concrete findings.
• Highly specific implementation of whiteboard use, which increased knowledge of its effectiveness in postpartum units.
• Tracking of hourly rounding metrics, which showed reductions in fall rates, among other outcomes.

Ensuring open communication between the interdisciplinary team, the patient, and family members is one of the key components of Patient-Centered Care (PCC). For patients to arrive at informed decisions about the care they want administered, they must have an open line of communication with their healthcare providers. Physicians often meet with patients to discuss treatment plans, but it is not always the case that patients understand what is happening or what options are available to them. Nurses attend to many patients, and it is not easy to keep track of every patient's information even with the help of a patient chart. Whiteboards beside patients' beds can be used to bridge the information gap: physicians can update them with necessary information about the treatment plan, and nurses can update the patient chart accordingly. This approach can help improve patient safety, address communication needs, and significantly improve patient outcomes (Karn, 2016).

PICOT Question

Patient/Problem: Women undergoing either caesarean or vaginal delivery.

Intervention/Phenomena of Interest/Issue: Use of whiteboards and hourly rounding.

Comparison/Context: Compared to no use of whiteboards and no use of rounding.

Outcome/Evaluation: Improved pain management and patient satisfaction.

Time: A trial period of three months.

Significance of the Problem to Nursing Practice

Most of the metrics used to measure the success of postpartum hospital experiences depend on patients' interactions with nurses. The broad goal should be managing the expectations of postpartum patients and their families regarding their hospital stay — from the moment of admission to the moment of discharge — by using a whiteboard and a postpartum roadmap. Feedback from patients indicates that new families were often unsure of what to expect from their caregivers and what their own responsibilities were in learning newborn and postpartum skills required for a successful discharge. The whiteboard and postpartum roadmap are valuable tools because they allow patients and nurses to communicate effectively throughout the entire hospital stay and to manage postpartum care expectations (Horgan, Roe, Yocom-Piatt, & Cohn, 2014).

Literature Search Strategy

PICOT Question Search Terms

• Emotional, mental, environmental, physical, and associated factors linked to labor pain.
• Level of relaxation and events that represent a positively perceived delivery experience.
• Dissatisfaction with equipment, hospital staff, facilities, and expenses.
• Awareness of one's newborn and family preparation for taking the baby home, including knowledge of postpartum medical examinations and readiness for discharge.

Inclusion Criteria

Post-delivery women, regardless of income level, geography, or language, are included in the study.

Exclusion Criteria

Post-delivery women who do not accept the invitation to participate in the study are excluded.

Search Locations

Google Scholar, reputable medical journals, and research reports released by relevant organizations were considered.

Reference Review

The time and quality of publication of research articles were carefully scrutinized. References of superior quality, for the purposes of this review, refer to articles that are no more than five years old. An additional criterion was whether the research articles and citations were peer-reviewed.

The journals and databases searched include:

• Journal of Nursing Administration
• Various university thesis projects
• The Journal of Emergency Medicine
• Hospital Pediatrics
• Pain Management Nursing
• LVHN Scholarly Works — Research & Neonatal Nursing
• Journal of Obstetric, Gynecologic & Neonatal Nursing
• Journal of Nursing Care Quality
• AWHONN 2013 Annual Convention

Evidence-Based Study Types

Qualitative: Generalizable conceptual studies; descriptive studies.

Quantitative: Systematic review; meta-analysis; randomized controlled trial; cohort study.

Literature Review

Alaloul, Williams, Myers, Jones, and Lodgson (2015) used a quasi-experimental pretest-posttest prospective design. All patients were admitted to two units alongside medical-surgical patients, with one nurse attending to them between August and December 2013. The average length of stay for both units was four days, with approximately twenty-two patients per unit at any given time. The study took place at an academic health center in the southern United States. The independent variables were script-based communication, hourly rounding, and whiteboard use; the dependent measure was patient satisfaction evaluated through pain management effectiveness. No quantitative analysis was carried out. Findings showed that using whiteboards and other communication methods produced clear and consistent communication with patients, creating a positive effect on pain management and patient satisfaction.

Brosey and March (2015) examined minimum patient satisfaction scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, along with hospital-acquired pressure ulcer (HAPU) and fall rates. These metrics were collected and analyzed prior to implementation. Seven-day consecutive monitoring of rounding compliance was assessed monthly throughout the project for 582 eligible discharged patients. The setting was a 24-bed surgical unit with both private and semi-private rooms. A 20-minute education session preceded the intervention. Hourly rounding led to a compliance increase from 48.6% to 69.4% during the first month of implementation; however, this improvement was not sustained, falling to 44.3% the following month before climbing again to 59.2%.

Cholli et al. (2016) examined pediatric family preferences and perspectives on whiteboard use, as well as recommendations for using whiteboards as tools for patient-centered care and communication. The design consisted of semi-structured interviews with twenty-nine families conducted at a pediatric urban academic hospital inpatient surgical service. Two-thirds of respondents reported using whiteboards, and 52% reported that staff had communicated directly with them. Those who had used whiteboards were shown to be six times more active with them than those who had relied solely on verbal communication. A separate analysis found that in 42% of cases parents were the ones writing on the whiteboard, and in 80% of cases only contact information was recorded.

Emerson, Chumra, and Walker (2013) assessed the impact of hourly rounding on patient satisfaction and communication in a pediatric emergency department setting. The observational prospective study used surveys collected between November 2010 and December 2011 in a tertiary care children's hospital. The sample included 200 discharged families, equally divided between pre- and post-implementation data. Hourly rounding was the independent variable and call-bell activations were the dependent variable. The quantitative analysis was limited. Results showed that hourly rounding had no positive effect — or only a very small positive effect — on call-bell activation, and accidental call-bell activations actually rose after hourly rounding was introduced.

Horgan, Roe, Yocom-Piatt, and Cohn (2014) aimed to manage the expectations of postpartum patients and their families regarding their hospital stay using a whiteboard and postpartum roadmap. The design incorporated two interactive tools — a whiteboard and a written roadmap — that outlined every postpartum phase during the hospital stay. All patients and staff in four mother-baby units participated. Patients responded favorably to the visual appeal of the whiteboard. Overall discharge preparedness and patient satisfaction increased by 15.8% as a result of whiteboard use.

Johnston and Fenicle (2014) focused on improving HCAHPS scores through whiteboard implementation. A total of 1,073 whiteboards were installed, and 12 templates were created to meet the needs of specific patient populations. Boards were designed for critical care, medical care, transitional skilled units, labor and delivery, L&D triage, the emergency department, prenatal, mother/baby, pediatric ED, neonatal intensive care, and medical surgery units. Data were collected across 13 units and assessed by auditors for accuracy and completeness. The best completion rate of 90% was recorded by the TOHU unit at Lehigh Valley Health Network.

Karn (2016) sought to improve interdisciplinary communication in the inpatient medical-surgical wards of Ralph H. Johnson VA Medical Center (RHJ VAMC) through the use of personalized whiteboards (PWs) at patients' bedsides. The study involved a microsystem assessment of two inpatient wards. Results demonstrated improvements two months after implementation, though a slight decline was observed at the four-month mark. Surveys of both patients and nurses revealed that personalized whiteboards increased both groups' satisfaction with interdisciplinary communication.

Krepper et al. (2014) aimed to determine whether implementation of standardized hourly rounding processes (SHaRP) through formal education programs could improve efficiency, patient satisfaction, safety, and quality metrics compared with less standardized processes. A two-group quasi-experimental design gathered data over a six-month study period and six months afterward (October 2010 to March 2011). Two 32-bed cardiovascular surgery nursing units at St. Luke's Episcopal Hospital (SLEH) participated. Significant differences were found in weekly and daily call-light usage between the two units (p = 0.001), but no significant variance was found in overall staff "steps" or in staff perceptions of having "sufficient time" (84.6% vs. 87.5%). Differences in 30-day readmission rates and patient falls between units were not significant. The proportion of patients satisfied with nurses' explanations on the intervention unit increased from 60.4% to 69% over the data-gathering period.

Martin (2015) sought to implement an interprofessional initiative aimed at improving patient perception of care and pain-care quality. A committee formed in April 2014 served as unit surveyors, auditors, and champions for a project at a 110-bed community hospital. Patients in three adult inpatient units — telemetry, women's services, and medical-surgical — participated. The independent variable was a pain-care toolkit; the dependent variables were patient satisfaction and pain management.

Massaro and Murphy (2013) implemented unit-specific whiteboards to improve patient-centered communication, summarizing findings presented at an Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) convention. The study involved patients in a mother/baby unit. The independent variable was unit-specific whiteboards; the dependent variables were HCAHPS and Press Ganey survey scores. Both surveys showed that patients in mother/baby units valued the whiteboards and noted improved communication.

Mitchell, Lavenberg, Trotta, and Umschield (2014) conducted a systematic review synthesizing evidence about the effects of hourly rounding on patient satisfaction, with implications for nurse administrators. Sixteen published studies were included. The independent variable was nursing rounds; dependent variables were patient fall reduction and patient satisfaction. The authors used GRADE analysis to evaluate the consistency, quality, and quantity of evidence and to rate the overall evidence base for each type of intervention. Findings of moderate strength indicate that hourly rounds improve fall prevention and enhance patients' perceptions of nursing responsiveness, though measurement of hourly rounding outcomes was inconsistent across studies.

Olrich, Kalman, and Nigolian (2012) examined the effects of hourly rounding on patient satisfaction, call-light usage, and fall rates, replicating a study by Meade, Bursell, and Ketelsen (2006). The sample comprised 4,418 patients discharged from two medical-surgical units in a teaching hospital in the northeastern United States over one year. One unit served as the experimental unit and the other as a control. Patient satisfaction data and fall data were collected over six months prior to the intervention and six months during the intervention. Call-light data were gathered from the call-light retrieval system over two weeks before the study and four weeks during the intervention. Results showed that hourly rounding alone did not decrease call-light usage or increase patient satisfaction; however, it did help prevent falls, reducing fall rates by 23%.

Rondinelli, Ecker, Crawford, Seelinger, and Omery (2012) identified common outcomes, processes, and structures associated with hourly rounding, drawing on the Donabedian model of structure, processes, and outcomes. Fourteen participants drawn from eight hospitals in the Southern California Kaiser Permanente integrated healthcare organization and three additional regional hospitals were interviewed between December 2007 and August 2008. Hospitals ranged from 200 to 450 licensed beds; implementation periods ranged from one month to one year. Qualitative data analysis identified 15 major themes. Structure themes included specific rounding behaviors; process themes included use of library tools to incorporate staff and patient feedback; the two main outcome themes were patient perception and patient satisfaction.

Tan, Evans, Braddock, and Shieh (2012) examined whether whiteboard use increased patients' satisfaction and understanding of their care, explored barriers physicians faced when using whiteboards, and considered how physician practices might change with access to study findings. The study was grounded in the Institute for Healthcare Improvement's Plan-Do-Study-Act (PDSA) cycle. The three-week pilot involved whiteboard use across multiple disciplines and included 104 patients on the general medicine service. A brief in-person survey was administered to two groups: (1) fifty-six patients on two inpatient units where whiteboards were used and (2) forty-eight patients on two units where whiteboards were not used. Additionally, twenty-five internal medicine residents and forty consulting physicians, family members, case managers, and therapists were surveyed about challenges in whiteboard use. T-tests and one-way ANOVA were used to analyze the data. Whiteboard use was associated with patients knowing their physician's name (p ≤ 0.001), understanding the goals of their admission (p ≤ 0.0016), and reporting better satisfaction with their hospital stay (p ≤ 0.0242).

Conclusion

The hourly rounding method failed to show any significant improvement in provider-patient communication or patient satisfaction as measured by family discharge opinion surveys, patient satisfaction data, or call-bell data. This area may require further study to identify analytical methods that can detect, if they exist, the effects of hourly rounding — particularly in pediatric settings (Emerson, Chumra, & Walker, 2013). Regarding whiteboards, only half of patients were made aware of them and only one-third actively used them. The reasons patients did not use whiteboards were generally modifiable. Patients made aware of whiteboards by their care team had a higher likelihood of actively using them. This underscores the importance of staff education and highlights the potential benefits of closing the education gap (Cholli et al., 2016).

References

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

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

Cholli, P., Meyer, E., David, M., Moonam, M., Mahoney, J., Hession-Laband, E., . . . Bell, S. (2016). Family perspectives on whiteboard use and recommendations for improved practices. Hospital Pediatrics, 426–430.

Emerson, B., Chumra, K., & Walker, D. (2013). Hourly rounding in the pediatric emergency department: Patient and family safety and satisfaction rounds. Journal of Emergency Medicine, 99–104.

Horgan, J., Roe, M., Yocom-Piatt, M., & Cohn, N. (2014). Creation of a postpartum roadmap and whiteboard: A family's step-by-step guide toward their journey home. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 22–23.

Johnston, E., & Fenicle, J. (2014). Communication whiteboards: Enhancing patient, family, and care team communication. LVHN Scholarly Works.

Karn, C. (2016). The use of personalized whiteboards in the inpatient acute care setting and their effect on patient and nurse perception of communication. Theses, Dissertations, Capstones and Projects — USF Masters.

Krepper, R., Vallejo, B., Smith, C., Lindy, C., Fullmer, C., Messimer, S., . . . Myers, K. (2014). Evaluation of a standardized hourly rounding process (SHaRP). Journal of Healthcare Quality, 62–71.

Liberati, M., Altman, T., & The PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine.

Martin, L. (2015). Implementing a pain care toolkit to improve patient perception of pain care. Journal of Continuing Education in Nursing, 295–296.

Massaro, D., & Murphy, S. (2013). White boards: An innovative tool for patient-centered communication. JOGNN, 557–558.

Meade, C., Bursell, A., & Ketelsen, L. (2006). Effects of nursing rounds: On patients' call-light use, satisfaction, and safety. American Journal of Nursing, 58–70.

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

Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly rounding: A replication study. Medsurg Nursing, 23–36.

Rondinelli, J., Ecker, M., Crawford, C., Seelinger, C., & Omery, A. (2012). Hourly rounding implementation: A multisite description of structures, processes, and outcomes. Journal of Nursing Administration, 326–332.

Tan, M., Evans, C. H., Braddock, C., & Shieh, L. (2012). Patient whiteboards to improve patient-centred care in the hospital. BMJ Journals.