Hourly Rounding in Nursing Care

The research topic

The researcher studied if hourly rounding had impacts on the incidence of patient falls in a rehabilitation hospital. Margo Halm referred to hourly rounds as “intentional checking on patients at regular intervals” (Halm, 2009, p. 581). Hospital support staff and nurses normally conduct hourly rounds at a given period, but patients expect visits after every one or two hours based on the schedule. Halm observed that nurses and support staff evaluated 4Ps during hourly rounds, which included “pain, positioning, potty (elimination), and proximity of personal items” (Halm, 2009, p. 581).

Studies have shown that the concept of hourly rounding as a method of improving patient safety has been in use for many years. However, hourly rounding has experienced changes as new practices emerge. Nurses and their support staff normally check on patients on hourly schedules and must document outcomes of their interaction with patients.

Patients’ perception of hourly rounds may vary based on their experiences (Ford, 2010). Nurses have critical roles in promoting patient safety outcomes, care standards, and levels of satisfaction. Hence, health care facilities should focus on new strategies of promoting nursing services. Studer Group identified “hourly rounding as an appropriate method to address these issues” (Studer Group, 2007).

Patient safety may affect their levels of satisfaction with qualify of care and nursing services. The Joint Commission has its “accredited health care institutions with a list of National Patient Safety Goals and mandates with the requirements necessary to improve patient safety” (Joint Commission, 2008).

Why the topic was chosen

The concept of hourly rounding is not new in the provision of health care service to inpatients. However, there has been increasing complaints from patients and care providers regarding the lack of attention to patients, patient safety, and poor responses to call lights. These factors have led to increments in negative health care outcomes.

The researcher believed that effective hourly rounding would enhance patient safety, save time, and lessen the use of call lights. In addition, the topic addressed key issues that nurses should concentrate in during their hourly rounding.

Call lights are important in care facilities, but they normally frustrate nurses. Call lights remind nurses on patients’ needs. However, most of these needs are not urgent. Thus, constant responses to call lights can occupy a whole day of a nurse. Past studies have proved that the use of hourly rounding reduced cases of call lights by significant margins. Calls are critical to patients’ well-being. Thus, hourly rounding could save time, eliminate interruptions, enhance quality of care, and allow patients to complete their duties without interruption.

The use of hourly rounding is a part of proactive care, which saves time. A number of nursing units normally respond to issues after they have taken place. This led to hurried activities alongside work-related stress among nurses. In some cases, nurses failed to respond to call lights and patients would get angry.

Hourly rounding can help in identifying nursing units that operate efficiently and the ones that do not. Patients would feel the gap in poor responses to their needs. It may be contrary to nurses’ expectations when asked to dedicate one hour to hourly rounding with the aim of saving their time. The hourly log would help such nurses to manage their patients and save time. It would lead to low usages of call lights and eliminate frequent reactions to patient needs.

The study provided key areas that nurses should address during hourly rounding. These are mainly the 4Ps, which include “pain, positioning, potty (elimination), and proximity of personal items” (Halm, 2009, p. 581). These are core issues, which increase the rate of call lights among in-patients.

Nurses could have contributed to high rates of call light usages. In most cases, nurses inform patients to use call lights if they needed any assistance. Nurses can use hourly rounding to cater for patients’ needs. This implies that call lights would only be for emergencies.

The researcher noted that there are barriers to effective implementation of hourly rounding. Thus, the study provided ways of overcoming such barriers, allow nurses to manage their workloads, and provide a consistent manner of addressing patients’ needs.

Importance of the project to nursing discipline

Hourly rounding is a nursing practice that has positive outcomes in health care provisions. However, it has not been effective as expected. Thus, there is a need for improvement in hourly rounding.

The project provided important insights by which health care facilities, nurses, and support staff can implement changes in hourly rounding, which would have positive outcomes on primary health care facilities and improve risks to patients.

The project helped to identify gaps in the current practices with regard to hourly rounding. This helped in promoting effective understanding of challenges in hourly rounding. The project showed what health care facilities, nurses, and support staff could do in order to improve hourly rounding and reduce negative outcomes associated with a lack of hourly rounding.

The researcher gained valuable knowledge in hourly rounding practices. This was useful to stakeholders in nursing and primary care providers. The aim was to encourage health care providers to engage in the best practices in care provision. The project aimed to encourage the use of evidence-based practices in the provision of primary health care services to in-patients. Hence, the project was a way of participating in a useful research agenda that would transform patient safety.

One must note that primary care is experiencing rapid changes. The scope of nursing has improved while care providers operate in diverse settings. Thus, the project was helpful in identification of the best practices in hourly rounding in a given care setting.

Hourly rounding has been a source of concern for nurses. New knowledge would help in tackling current problems and create positive impacts. This is a systematic research that yield new knowledge, fills the current gaps in hourly rounding, and helps in developing effective approaches for enhancing patient services and outcomes.

The problem

Fall events reflect nursing-sensitive quality indicator. However, patient fall events have continued, and have caused severe outcomes in care facilities (Tucker et al., 2012, p. 18). The US National Institutes of Health notes that incidences of “falls in hospitals are constant issues with 2.3 to 7 falls occurring in the US hospitals every 1000 patient days” (US National Institutes of Health, 2008, p. 1).

A fall is an unpleasant incident that is unanticipated drop from a given position, which could also include sliding from a bed or chair. Falls cause insults with different outcomes, including severer ones. In addition, there are cases of mortality related to falls. Patients of all ages experience falls in health care facilities. Most falls usually occur when patients are alone or are engaged in other activities without assistance.

Analysis of incidences of falls usually entails ambulation as it is a major contributor to fall events. Thus, hourly round is an effective approach of mitigating fall events in health care settings. In addition, support staff and nurses can also conduct assessment of environmental conditions, which facilitate risks of falls. Falls normally increase costs of hospital stay.

Background information of falls in health care facilities

Every year, many patients in care facilities fall. Falls can occur to all patients irrespective of age and gender. However, older patients (over 65 years) experienced high rates of falls than other patients. Falls result in serious insults like broken hips and bodily injuries, which could result in deaths of patients. In addition, falls cause traumatic brain injuries, fear among patients, reduced activities, and they reduce chances of independent living. Luckily, falls are preventable, and one approach of reducing falls is hourly rounding.

According to Centers for Disease Control and Prevention, among three adults aged 65 years, one must fall every year (Centers for Disease Control and Prevention, 2012). However, majorities do not report their cases to health care providers. As a result, fall has been a leading cause of injuries and related deaths. Falls also result in nonfatal injuries and trauma. In some cases, falls result in emergency treatment. The Centers for Disease Control and Prevention estimated that the direct medical “cost of falls was $30.0 billion” (Centers for Disease Control and Prevention, 2012).

In the past decades, deaths related to falls have increased tremendously. Men were prone to deaths from falls than women (Centers for Disease Control and Prevention, 2012).

Possible causes of falls

Several factors in hospital settings exposure inpatients to risks of experiencing fall events.

Many cases of patients’ falls are common in primary care facilities. Scholars have noted that different factor like patient characteristics, situations, and activities are the generally contribute to fall events. Mental conditions, hospital environments, and certain medication may contribute to falls. Moreover, patients may attempts activities like moving around, which may cause falls. In this context, patients may contribute to their own falls, environmental factors may facilitate falls, or certain situations may be responsible for falls. These are individual, extrinsic, and situational factors. However, some health care facilities may use their available resources to mitigate incidences of falls.

Research Questions

1. How does hourly rounding affect the incidence of patient falls?
2. How does patient acuity affect the number of patient falls?
3. What places do patients experience increased risk for falls?
4. What is the most frequent time falls occur?
5. Has hourly rounding increased patient satisfaction scores?

Research Hypothesis

Hourly rounding would decrease the incidence of patient falls in the facility.

Definition of Terms

The following terms were utilized for this research study:

Hourly Rounding- “Intentionally checking on patients at regular intervals” (Halm, 2009)

Patient Falls- “Unplanned descent to the floor with or without injury to the patient” (Anderson, G et al, 2009)

The best practices

These are methods, which provide the best outcomes in hourly rounding studies. As a result, many researchers in this topic have applied them in their studies. The aim was to identify effective methods of conducting the study in order reduce cases of unforeseen challenges.

Researchers have considered and acknowledged their sources in the literature review section. The process was objective and did not reflect personal views of researchers. Studies have shown that results are measurable, valid and can be retested. This eliminates cases of skewed data that could affect source materials and validity of results.

Studies are credible and adhere to ethical requirements in scientific research. In addition, methods of studies are clear to show that results are confirmable. Researchers also show that their results are applicable in the field of study. In this case, data collection approaches should be consistent when applied in the future in a similar study.

Past studies indicate how they recruited research participants. All studies provide detailed accounts of participants’ characteristics relevant to the study. This is critical area in hourly rounding and assessment of falls among patients. During recruitment of research participants, researchers observed ethical practices in order to protect themselves, research participants, and their institutions.

Studies do not demonstrate any form of bias in data collection. Thus, study questions do not provide support researchers’ point of view only. Thus, the process remains objective. Finally, researchers also declare the purpose of data collected, sources of funds, personal interests, weaknesses of studies, and implications for practitioners and fellow researchers.

Literature Review

Nursing hourly rounding

Current studies show that nursing hourly rounding among in-patients may improve the patient safety outcomes, patients’ satisfaction, perception of care, and reduce cases of safety events (Krepper et al., 2012). Hourly rounding or commonly referred to as intentional rounding has been effective in enhancing the quality of care in most health care facilities. For instance, Dean noted that intentional rounding was applied in orthopedic and general medical with the aim of putting “patients at the center of care, which consisted of checking on their condition at hourly or two-hourly intervals, recording their nutritional status and skin integrity, and asking if they need pain relief or help with eating” (Dean, 2012). The approach was effective in improving the quality of care for in-patients in health care facilities.

In some cases nurses have take the initiative of adopting the hourly rounding concept for certain patient populations. They normally aim at improving care services to such patients through process feedback, lesson learned, and different strategies for improving rounding (Kessler et al., 2012). Other scholars have shown that hourly rounding is a multidisciplinary concept that has shown improved “communication, a reduction in medical errors, a shorter hospital stay, and consequently, economic savings” (Cardarelli et al., 2009). Cardarelli and colleagues aimed at assessing the cost of hourly rounding and time nurses consumed during the process. They noted that when nurses approached hourly rounding as a multidisciplinary initiative, costs were low. This resulted into benefits for all stakeholders. Hence, they argued that there was a need for culture change and the use of available resources when implementing hourly rounding, particularly during training. However, they noted that multidisciplinary teams needed to reflect their approaches and realities in time usages (Cardarelli et al., 2009).

Hourly rounding as multidisciplinary practice implies that team members can share responsibilities while making hourly rounds. For instance, Halm proposes that a physical therapist can “assess the 4 P’s and assist the patient to the bathroom while assessing their transfer ability and gait” (Halm, 2009). A physical therapist would then communicate cases that he cannot handle to the relevant nurse or unit for follow-up.

A number of studies have demonstrated the proof that hourly rounding is important for nursing. For instance, it reduces cases of patient falls, reduce the use of call light for emergencies, and eliminates skin breakdown. Amidst all these benefits, it is the overall satisfaction of the patient and care providers that prove the importance of hourly rounding.

These benefits have demonstrated that hourly rounding is important in health care facilities. In order to achieve the benefits of hourly rounding, health care facility manager and nurse leaders must ensure that nurses are accountable for their hourly rounds. This would provide a chance for evaluating the program and its outcomes, including behaviors of patients and nurses during hourly rounds. Hourly rounding is a full service that requires commitment and engagement from all stakeholders.

Hourly rounding and falls

Fall is common in most health care facilities. Most falls have severe consequences to the patient, including deaths and injuries (Centers for Disease Control and Prevention, 2012). However, fall prevention, patient satisfaction, and usages of call lights inpatients are challenges that nurses face during their duties or rounds (Olrich, Kalman and Nigolian, 2012). Thus, falls have persisted as common and dangerous events in health care facilities. Structured nursing rounds interventions (SNRIs) have proved to be effective in reducing cases of fall in health care facilities (Tucker et al., 2012). While SNRIs were successful, there was a need to implement them through adapting and sustaining such practices in clinical environments. Tucker and colleagues identified potential challenges that rounds could face during and after implementation. For instance, they noted that SNRIs were effective in reducing falls at initial stages. However, this changed with time as fidelity to the rounding initiative declined within the first year during implementation subsequently leading to loss of gains achieved in fall reduction. Thus, implementation alone was not enough, but the initiative required constant evaluation.

Falls are mainly common among older patients in health care facilities, but they generally affect all patients. Vu, Weintraub, and Rubenstein noted that there were “approximately 1.5 falls occurring per nursing home bed-years” (Vu, Weintraub and Rubenstein, 2004). Although not all falls resulted in injuries, some cases resulted in severe injuries and fractures that led to hospital admission.

Given such negative outcomes of falls, primary care providers should strive and reduce cases of falls among inpatients in health care facilities. At the same time, they must also reduce fall-related morbidity in care facilities. Some fall prevention approaches have proved to be useful in reducing in-patient falls. However, there are few existing studies to provide supporting data for the effectiveness of these interventions in care facilities.

There are several ways of controlling falls, such as “medication reduction, the optimal nature and intensity of exercise programs, and patient targeting criteria to maximize the effectiveness of nursing home fall prevention programs” (Vu, Weintraub and Rubenstein, 2004). Scholars concur that modern approaches to fall prevention should be multifaceted in order to enhance their effectiveness. These approaches should incorporate risk factor assessment, nurse training, education, modification, and other assistive devices. This study looks at how hourly rounding has been effective in minimizing falls among patients in health care facilities.

Meade and colleagues noted that effective hourly rounding resulted in “reductions in falls by 52%, use of call lights by 37%, and development of pressure ulcers by 14%” (Meade et al., 2006). However, one must recognize that some units with “high rates of patient satisfaction and low cases of patient falls will not record high rates of changes from hourly rounding” (Meade et al., 2006). Thus, it is important for different units of health care facilities to keep records of their practices. This would allow them to determine the extent of changes due to enacting new methods of care provision or changes in cultures and practices. Given mixed outcomes from hourly rounds, further studies, which can assess address impacts of hourly rounds in different settings, are necessary so that nurses and scholars can note past outcomes from such interventions. In addition, such studies can show what changes are necessary for future programs. We must note that making hourly rounds is not an end in itself, but rather a way of improving quality of care for in-patients and health care outcomes. This is a sure way of improving patient satisfaction in health care facilities.

Hourly rounding and patient satisfaction

Health care facilities have noted the importance of customer service and patient satisfaction. While there are several areas in which health care facilities can focus on to enhance customer care with their limited resources, timely responses to needs of patients have remained among the most important interventions in health care facilities (Tea, Ellison and Feghali, 2008). Tea and colleagues noted that health care facilities have adopted various strategies of hourly rounding in order to improve nurse responsiveness to needs of patients. These are approaches of improving patient satisfaction through rounding. Some researchers have noted that a model for enhancing nurse responsiveness should be proactive rather than reactive (Tea, Ellison and Feghali, 2008). Thus, hourly rounding based on proactive approaches would result in positive outcomes for nurses and patients (Weisgram and Raymond, 2008).

Hourly rounding has been a preferred method of improving patient satisfaction and safety in acute hospitals. At the same time, it is the preferred means for enhancing work environments for nurses (Gardner et al., 2009). However, the major challenge is that there is no effective implementation of the practice to provide the required feedback for its mass adoption. Tests should evaluate patient satisfaction with hourly rounds and nurses’ perception of the practice. In addition, the study should also assess the effectiveness of study instruments in evaluating hourly practices. Gardner and colleagues’ study showed that there were no significant changes in patient satisfaction (Gardner et al., 2009). This could have been possible if the standards of patient satisfaction were high in such health care facilities. Thus, study instruments should account for such outcomes in the final implications.

Hourly rounding also reduces the use of call lights in health care facilities (Kalman, 2008). However, few studies exist about the use of call lights and its impacts on patient management, patient satisfaction, and patient safety. On this note, Meade and colleagues studied the use of call light frequencies and associated reasons. They also explored the impacts of one and two hour rounds on the use of call lights. In addition, their study also aimed at establishing patient satisfaction during hourly rounds, cases of falls, and patient safety (Meade et al., 2006). They noted hourly rounds and subsequent actions of the nurses had statistically significant impacts on the use of call lights, reduction of patient falls, and enhanced patient satisfaction (Meade et al., 2006).

Call lights have caused distress to nurses, especially when they go off after short internals from the same patient. An effective approach to reduce the use of call light has been either one-hour or two-hour hourly rounds that focus on specific actions during the rounds (Culley, 2008). Studies have proved that hourly rounds significantly reduced patients’ usages of call lights, enhanced their satisfaction with the quality of care, and eliminated cases of falls (Meade et al., 2006). Such results have proved that health care facilities should change their practices and embrace hourly rounds into their practices. Thus, nurses can realize effective patient management outcomes, patient safety, and patient satisfaction.

Hourly rounds aim at addressing the key issues, which drive patients to use their call lights. Usually, nurses or support staff enquire about the patient’s needs in relation to potty, the patient’s pain condition, change of position, and ensure that all items that the patient may require are within the patient’s arms reach. These may include water, books, and glasses among other items. Walls noted that since their facilities introduced hourly rounds, the number of call lights declined significantly because nurses met patients’ needs during the rounds or patients knew that nurses would address their needs shortly (Krischke, 2009).

This has been purposeful hourly rounding rather than just hourly rounding (Association for Patient Experience, 2011). Purposeful hourly rounding entails interaction with the patient in order to know their needs and meet them immediately or shortly (Dearmon et al., 2013).

Hourly rounding challenges

In most circumstances, when health care facilities introduce hourly rounds, they note that nurses do not embrace such initiatives (Krischke, 2009). They note that hourly rounds would affect their duties and add extra work on them. This is a common problem in many institutions whenever they try to introduce new ways of conducting activities. Workers generally resist changes in practices and cultures. Thus, the first trepidation reactions are normal under such circumstances.

Despite such negative acceptance of hourly rounds among nurses, they eventually embrace the practice and realize its benefits to them and patients. Nurses have noted general improvement in their scores. This has encouraged them to use hourly rounding (Krischke, 2009).

One major challenge is how to introduce the concept of hourly rounds to patients upon admission. In some cases, patients may feel that they will lose their privacy when nurses check on them after every one or two hours. As a result, patients become anxious about hourly rounds. Thus, health care facilities need to develop effective ways of informing patients about hourly rounds in order to reduce anxiety.

Another challenge is that small nursing units may not practice hourly rounds effectively, particularly during emergencies. Emergencies may disrupt hourly round schedules, as nurses would attend to them. This has been a major problem for lack of consistency in hourly rounds in high dependency units (Lowe and Hodgson, 2012).

In most cases, health care facilities introduce hourly rounds before training and educating nurses about the concept. Training and educative programs concerning hourly rounds are necessary for effective implementation and evaluation for improvement. Besides, other support staff should also get training about hourly rounds so that they can assist during emergencies. While support staff may not perform specialized duties like pain management, they can ensure that patients can reach their possessions and communicate patients’ unmet needs to relevant nurses.

Hourly rounds may experience challenges of leadership during implementation. There are challenges of encouraging critical thinking among nurses to evaluate the importance of hourly rounding. This is where leadership is necessary in a health care facility. This leads to the challenge of acuity. In other words, it may be appropriate for nurses to “attend only to high-acuity patients and ignore patients who are in stable conditions during hourly rounds” (Halm, 2009). Hospitals may argue that the approach is effective for subsequent good outcomes (Halm, 2009), but it remains debatable.

In some cases, hourly rounds may not be effective due to poor communications during implementation among nurses and support staff when communicating unmet needs of patients. Ineffective communication can derail the approach (Shepard, 2013). Thus, communication remains a key component of successful hourly rounds (Deitrick et al., 2012). Support staff must also perform their duties and communicate with nurses in order to ensure that they meet all needs of patients (Halm, 2009).

Documentation during hourly rounds has been a source of major concern among nurses. Nurses have to take care of many documents, including regulatory requirements, patients’ assessment records, and other therapeutic results among others. This implies that nurses must also document all outcomes from all hourly rounds. While documentation of hourly round outcomes is useful for accountability, nurses may oppose them as extra burden on their duties. However, nurses must recognize that documentation of completed outcomes is useful in their duties so that all stakeholders may know the condition of patients. This eliminates unrealistic expectations and provides feedback about the effectiveness of the program. Nurses should also record patients’ outcomes like position so that other members of the team can know such outcomes during their visits. Overall, making hourly rounds improve communication among nurses and support staff for effective care provision (Woodard, 2009).

Hourly rounding implementation

Hourly rounding can only be effective when planned and implemented effectively. The process involves significant changes in nursing activities and workflow. In addition, nurses should also undergo training and education in order to ensure that the process is successful during implementation (Krepper et al., 2012). Major health care facilities have taken initiatives to implement hourly rounding. Hutchings referred to this as intentional rounding. He noted that the process required “transformational leadership and meaningful interactions, which were the basis of a new approach to rounding i.e., Caring around the Clock” (Hutchings, 2012). The author noted that effective implementation under transformational leadership led to 32 percent reduction in usages of call lights. Nurse education and training were major factors that contributed to positive outcomes of the program.

Rondinelli and fellow researchers noted that their study proved that frequent “reevaluation of structures and processes promote achievement of desired outcomes in relation to hourly rounding” (Rondinelli et al., 2012). As a result, they noted that health care facilities should dismiss routine procedures and embrace flexible approaches in order to enhance successful implementation and adoption of hourly rounding.

Scholars have noted that introduction of new evidence-based practices like hourly rounding in hospital facilities can be difficult tasks and results may be difficult to get (Baker, 2012). Deitrick and colleagues investigated challenges that affected hourly rounding implementation in health care settings. They noted poor communication, planning, implementation strategies, and evaluation were not effective. Thus, they recommended, “careful planning, communication, implementation, and evaluation were necessary for successful implementation of a nursing practice change” (Deitrick et al., 2012).

Literature Summary

Falls among in-patients in health care facilities have provided opportunities for nurses to improve care provision and change their culture and practices in health care settings. Such events have motivated nurses to embrace new methods of improving patient safety. Most studies support the concept of hourly rounds in combating the frequent use of call lights, reducing patient falls, improving patient satisfaction, and enhancing overall health care outcomes.

Hourly rounds experience challenges during implementation and sustainability. Leadership is crucial during these stages. In addition, staff must maintain constant communication for successful adaptation of the program. Overall, ongoing evaluation and reinforcement of hourly rounding are necessary for its success. Staff’s feedback is useful for improving the concept to both patients and nurses. This could help in reducing barriers to successful implementation.

Future studies should develop new strategies of supporting hourly rounds so that nurses and patients can realize its full benefits. In this context, usages of data on patient safety, patient satisfaction, and fall rates are critical for improving the practices.

Conclusion

Previous studies have shown that health care facilities that have adopted hourly rounds have recorded improved patient safety and low usages of call lights. Nurses identify and address the 4Ps of patients during hourly rounds. Nurses should document the outcomes of all these 4Ps and remind the patient of another visit within the next one hour.

Hourly rounds have helped in reducing cases of “pressure ulcers, use of call lights, patient falls, and in improving patient satisfaction with care qualities” (Agency for Healthcare Research and Quality, 2011). However, one must recognize that in health care setting, there are numerous quality improvement initiatives. Thus, it becomes difficult to identify the extent or contribution of a single program on improving health care quality. Overall, leaders believe that hourly rounds have played significant roles in improving specific areas that they aim to improve in patient quality of care.

Methodology

Introduction

This section provides the method of collecting the necessary data in order to respond to the research objective. “Methodology must be judged by how well it informs research purposes, more than how well it matches a set of conventions” (Howe and Eisenhardt, 1990, p. 2) during data analysis. For hospitals, patient falls are a major safety concern. In this research, an examination of the relationship between performing hourly rounding and its impact on patient falls occurred. Defined as “Intentionally checking on patients at regular intervals”, hourly rounding continues to be at the front of hospital administrators and nursing unit’s topics of conversations (Halm, 2009). The study helped to establish answers to the previous questions defined in Chapter 1. How does hourly rounding affect the incidence of patient falls? How does patient acuity affect the number of patient falls? What places do patients experience increased risk for falls? What is the most frequent time falls occur? Has hourly rounding increased patient satisfaction scores?

Before starting the collection and analysis of data related to this project, two things were accomplished. The first was to obtain authorization from the CEO of Reliant Northwest Hospital (Appendix A), and the second was completing an online program to obtain a certificate of completion for Protecting Human Research Participants (Appendix B).

Evaluation methods and tools

Press Ganey from the American Nurses Association National Database of Nursing Quality Indicators (ANA-NDNQI) was the data collection instrument. It collects information on cases of patient falls. Press Ganey collects all information related to patient fall during patients’ stay at the rehabilitation center. This tool also provided data on general nursing services, patient safety, and patient satisfaction,

The researcher utilized data from eRehab, too. This was information collected from April 1, 2013 to the last day of data collection for the study.

eRehab Data provided data on patient fall events, as well as data related to patient satisfaction with hourly rounding, nurses, hospital environments, and general quality of care.

The researcher gathered data in a modern rehabilitation facility located in an urban setting. The facility consists of 60 beds. Date, time, age, gender, diagnosis, injury level, risk score prior to fall, and time since the last fall risk assessment, was collected as well. These data were then inserted in a spreadsheet and analyzed by utilizing Microsoft Excel, allowing trends to be formulated and captured. The results were interpreted by comparing each group for fall rates per 1000 patient days. Reliant Hospital utilizes a paper charting system. Data was collected from fall reports that were collected by the house supervisor, each time a fall occurred. The supervisors submitted these reports to administration, and administration placed the data onto an Excel spreadsheet. The house supervisors validated and verified the reports with the primary nurse caring for the patient (Flow sheet 1).

Reliability and validity of the evaluation methods and tools

Press Ganey can yield valid and reliable results with limited samples, but this also depends on the size of the sample population. For instance, Press Ganey states that only “30 survey responses are needed to draw meaningful conclusions, although they prefer to have at least 50 responses before analyzing the data” (William & Joe, 2010). The researcher used adequate sample in order to ensure that data was reliable and valid.

In addition, study instruments measured variables related to patient falls, use of hourly rounds, patient safety, and satisfaction. No instruments measured what was beyond the scope of this study.

eRehab can identify mismatching data during data entry. This safeguarded data validity.

Maintaining data integrity

The major threat to integrity of data in this study is self-reporting. Patients provided data on the level of their satisfaction with hourly rounds, quality of care, and overall satisfaction with nurses. Patients rated some outcomes poorly or positively based on their satisfaction with the care provider or immediacy of response to calls. In order to prevent bias from self-reporting, the researcher included questions that confirm some of the earlier asked questions in a different way. Any deviations would indicate data bias. Such data was not used in analysis. Only willing participants took part in the study. eRehab is contracted through Reliant Hospital. eRehab sends patient survey after patient discharge, and results are mailed back to eRehab in self-addressed envelope. The results, are placed to a spreadsheet, and forwarded to Quality Control Officer at Reliant, for evaluation (Appendix D & E).

The researcher remained objective throughout the process of study. Thus, the researcher’s personal opinion or observations did not influence study outcomes.

Research Design

The study design was quantitative and it explored the relationship between hourly rounds and fall prevention. The quantitative approach was beneficial for this study because empirical data was examined and collected. In quantitative research, the actual number of falls was studied to obtain more information. The data collected was the number of falls from May 1, 2012 pre hourly rounding versus the number of falls post implementation of hourly rounding (April 1, 2013). The research attempted to quantify the impact hourly rounding had on patient falls.

Data Analysis Techniques

The researcher relied on the matched pair t- test (paired-samples t-test) as the data analysis technique. Statisticians observe that paired-samples t-test is useful in situations where one wants to “compare the mean scores for the same group of people on two different occasions, or when you have matched pairs” (Pallant, 2005, p. 209). A statistically significant difference between the two main variables of the study would determine the relevance of hourly rounds on fall prevention.

This is a repeated measure strategy of data analysis. It involved gathering data from the same group of respondents (patients in this case) on two different situations and conditions in order analyze impacts of hourly rounds on fall events and levels of patient satisfaction with overall nursing services.

Research Method

This was a quantitative correlational study design. A correlation study would show the association between the use of hourly rounds and fall prevention outcomes. It would also show the relationships among other variables like patient satisfaction, use of call lights, and other safety outcomes.

Correlational study design shall allow the researcher to provide a clear association between the use of hourly rounds and fall prevention outcomes. In addition, the study was appropriate for exploring other challenges in the use of hourly rounds for managing the 4Ps.

Research Participants

Study participants included all adult patients who fell in the rehabilitation facility. They were male and female inpatient participants who had been in the facility since May 1, 2012 to June 30, 2013. The study population may consist of geriatric individuals with mental, emotional disabilities, or traumatized individuals. They also consisted of non-English speakers, individuals at or above the age of 45 years and economically disadvantaged.

This research entailed a controlled, quantitative, retrospective, analysis of the number and severity of falls that occurred before and after, implementing a comprehensive fall prevention program. The charts that were reviewed were those of patients that had been discharged. To ensure that patient identity remained anonymous in this study, the medical record number and not the patients name was used.

During this study, data collection was locked in a secured file cabinet, in a private office, at Reliant Hospital. Documentation was reviewed and placed on a data collection documentation tool (Appendix C).

Data Analysis

Presentation of Results

The researcher conducted a study to determine the relationship between fall events and hourly rounding in rehab. The study participants were in-patients who had experienced fall events previously. Data were collected from May 2012 to June 2013 through eRehab and Press Ganey. eRehab was used to collect data for patient satisfaction while Press Ganey collected data for patient falls, fall rates, incidents, incident rate, legal claims, grievances, grievance audit, and patient deaths.

Both male and female inpatients took part in the study.

Table 1: Risks 2012 – 2013

After the hospital committee intervened, incident rates and fall rates declined gradually.

Most falls occurred on the floor i.e., patients who fall were found on the floor (88.7 percent).

Falls were common in the toilet, bathroom, and the bedroom

The hospital adopted different intervention actions in order to reduce cases of falls. As a result, they noted slow declines in cases of falls between the month of January and June 2013. However, in the month of May, cases of falls increased slightly. The hospital committee noted that it was important for all staff to engage in fall prevention in order to decrease the rate of falls.

Most events and other incidents resulted in no injuries to inpatients. Injuries that affected heads, arms, legs, and other body parts were not many.

T-tests

The researcher adopted paired-samples technique for data analysis. The aim was to conduct a test on the sample on two different occasions. The general assumption for this technique is that the researcher used a random sampling technique to collect data for analysis. However, this assumption may not be the case in a real life situation.

Another assumption was that there was an independence observation of research participants. In addition, there was also independent collections of data i.e., the researcher did not influence or interfere with the process of data collection or responses. In this context, observation implies that the two periods of data collection were independent of each other i.e., no data collection from the previous year did not affect data collection in the subsequent year. Researchers warn that the violation of the independent observation assumption is a serious offence in a paired-samples technique (Pallant, 2005). However, not all studies can guarantee the assumption of independence during data collection. This assumption will be critical when evaluating patient satisfaction outcomes. For instance, the response of one patient could have influenced others, particularly when they were rating services as a group. This could have violated the independent assumption in paired-samples technique. Patients from the same ward or room could have influenced one another about nurses and service provisions. This in turn would influence the independent observation assumption. Nurses’ responses could have influenced the rating of patients. This implies individual behavioral rating could not have been independent. In other words, it could be difficult to obtain a test result from a group or in cases where research participants interact with one another without influences from other members of the group. Thus, such results are suspects. On this note, researchers have stressed the importance of ensuring independent observation at all tests. In a case of a violation of the independent assumption principle, the value for alpha should be stringent.

The technique for this study also makes assumption of the homogeneity of variance. In other words, populations of the study were of equal variances.

Ideally, the researcher wanted a test that would properly determine whether or not there were significant differences in fall rates and incident rates when nurses intervened by improving on hourly rounding. The researcher used the power of test to establish the differences between the groups. In most cases, other factors may affect the power of test under different circumstances. These include:

• The size of the study sample
• The effect size, i.e., the differences of the strength between the groups
• The value of the alpha that the researcher may set (in this study, the alpha value is.05)

Some of the key details that the researcher focused on during the analysis were:

• The aim of the test
• The name of the test
• The t-value of the test
• The test probability value
• The degrees of freedom (df)
• Standard deviation
• The means
• Eta squared (the effect size of the analysis)

Sig. 2-tailed is the probability value =.051

This value is equal to.05. This implies that there is a significant difference between fall rates of 2012 and 2013. In case the value could have been less than.05, the researcher could have concluded that there was no statistically significant difference between the rates of falls 2012 and 2013 because of nurse interventions. The probability value is equal to.05 and not more than.05. In this case, the researcher concluded that there was a significant variation between fall rates of 2012 and 2013. The t-value is 2.56 while the value for the degree of freedom (df) is 5.

Once the researcher established

the significant difference between the rates of falls, he determined the highest score between 2012 and 2013 scores. The result for this involved establishing the differences between the mean scores between 2012 and 2013 rates. In this case, the mean for 2012 was 7.79 while the mean for 2013 was 6.04 (these mean scores are available in the Paired Samples Statistics output). In this context, the researcher noted that there was a significant decline in the rate of falls between 2012 and 2013 after intervention.

From the above results of rates of falls between 2012 and 2013, the result would be as follows:

The researcher conducted a paired-samples test in order to assess the effect of the nurse interventions on the rates of falls and incidents at the rehabilitation center among inpatients. The analyst revealed a statistically significant decline in the rates of falls from 2012 (M=7.79, SD=2.85) to 2013 [M=6.04, SD=1.93, t (5) = 2.56, p=.051]. The effect size difference (eta squared) was 0.567. This value shows a large difference in the effect size of the analysis.

In the analysis of the incident rates between 2012 and 2013 by using the paired samples technique, the study revealed a significant difference between the rates as follows. It showed that from 2012 (M=30.73, SD=13.20) to 2013 [M=19.68, SD=4.75, t (5) = 2.74, p=.041]. The effect size difference (eta squared) was 0.6. This value showed a large difference in the effect size of the analysis.

Given the statistically significant association between variables, the researchers confirmed the research hypothesis that hourly rounding would decrease the incidence of patient falls in the facility.

Although both results showed significant differences in fall rates and incident rates between 2012 and 2013 due to interventions from nurses, one may investigate other factors, which could have contributed to the drop in rates of falls and incidences.

Rehabilitation centers are complex environments in which different factors interact to bring about different changes. Hence, one cannot assume such factors. For instance, changes in patients’ conditions with time could have contributed to the decline in fall rates and incident rates. Perhaps patients’ improved on the health status or the rehabilitation center upgraded its facilities to prevent falls and incidents. The point is that there could be other confounding factors, which this study did not take into account.

Patient Satisfaction Results

The total respondents were 127 in which 50 (39.4 percent) patients were male while 77 (60.6 percent) were female. Transfer patients were 21, which represented 16.5 percent of the total participants. While the researcher collected data from all the necessary fields in eRehabData, for analysis purposes, the researcher used data that were relevant to research question and hypothesis.

From the results on patient satisfaction, generally, patients rated most factors highly within the facility. However, in relative to the national regional ratings, the rehabilitation rates were low.

The rehabilitation recorded a score of 78.70 percent in pain control to acceptable levels. This score was below both the national and regional scores, which were 87.39 percent and 86.03 percent respectively. This shows that the rehabilitation center should improve in pain management, which is a major role of nurses during their hourly rounding.

Nursing night shifts, which indicated hourly rounding by nurses and other supportive staff, were rated as follows:

• 47.5 percent as excellent
• 25.4 percent as very good
• 10.7 percent as good
• 6.6 percent as fair
• Zero percent for poor

Nursing shifts during the day (84.71 percent), evening (85.00 percent), and night (74.48) showed rates of falls and incidents in hospitals. For instance, cases of falls and incidents were common at night when shifts were poor.

Overall, patients made recommendation for the rehabilitation center as follow:

• Definitely yes, 72.7 percent
• Probably yes, 20.7 percent
• Not sure, 4.1 percent
• Probably no, 2.5 percent
• Definitely no, zero percent

Patients’ needs for nursing care differed based on their needs (fig. 5), but majorities (47 percent) got excellent care from the facility.

Discussion

Generally, falls are rampant in the rehabilitation center as the study findings have shown (table 1 and fig. 1). Most falls occurred when patients were engaged in different activities without assistance from nurses or other support staff (table 3). This finding supports those other researchers in the past studies. For instance, some studies indicated that falls caused severe impacts to patients (Tucker, Bieber, Attlesey-Pries, Olson, and Dierkhising, 2012). Scholars have noted that different factors like patient characteristics, situations, and activities are the generally contribute to fall events. Mental conditions, hospital environments, and certain medication may contribute to falls. Moreover, patients may attempt activities like moving around, which may cause fall. In this context, patients may contribute to their own falls, environmental factors may facilitate falls, or certain situations may be responsible for falls. These are individual, extrinsic, and situational factors.

What places do patients experience increased risk for falls?

The study revealed that falls and incidents were most common in the toilet (37.7 percent), bathroom (34 percent), and bed/bedroom (18.9 percent) (see table 3). There were also falls that occurred while patients were picking objects from the floor, but they only contributed to 1.9 percent of the falls. Generally, toilet and bathroom activities contributed to the largest cases of falls and incidents among inpatients in the rehabilitation center (table 3). While the above factors contribute to patients’ falls and incidents, this study did not focus on factors that caused falls and incidents among patients. Instead, the study focused on hourly rounding as a form of nurse intervention to mitigate falls and incidents among inpatients in the rehabilitation center.

How does hourly rounding affect the incidence of patient falls?

The results indicated that hourly rounding or nursing interventions significantly reduced cases of falls and incidents in the rehabilitation center. Cases, which were not reported, were the most common in the rehabilitation center. They accounted for 64.2 percent (table 3). Thus, it was difficult to establish the extent of insults on patients. However, cases, which patients reported resulted in x-ray (20.8 percent), CT (9.4 percent), and ACT (1.9 percent). In a weird case, some patients refused to undertake any form of examination. However, this was a small number that accounted for only 1.9 percent of the total patients. The researcher did not note any case of death due to fall. In addition, most patients did not report their cases of falls or incidents while staying at the rehabilitation.

These findings support previous studies by other researchers. Vu, Weintraub, and Rubenstein noted that there were “approximately 1.5 falls occurring per nursing home bed-years” (Vu, Weintraub and Rubenstein, 2004). Although not all falls resulted in injuries, some cases resulted in severe injuries and fractures that led to hospital admission.

What is the most frequent time falls occur?

The study aimed at establishing the most frequent time falls took place. The study revealed that falls and incidents were most common during Thursday (24.5 percent), Friday (20.8 percent), and Saturday (17 percent). Sunday recorded the least frequencies of falls (7.5 percent). In addition, many patients experienced falls in the early morning (am – 60.4 percent) as compared to times of the day (pm – 39.6 percent). In other words, falls and incidents were rampant at night and early periods in the morning.

Has hourly rounding increased patient satisfaction scores?

The researcher wanted to establish if nursing interventions and hourly rounds had positive effects on patient satisfaction scores. The results showed that nursing interventions and hourly rounds increased patient satisfaction. Table (8) shows some of the key indicators of patients’ satisfaction scores.

Table 8: Patient satisfaction scores in different indicators

While these scores appear above average, the facility has failed to match both national and regional scores. In this regard, it must improve on patient safety, quality care, and outcomes in order to improve patient satisfaction scores. Current studies show that nursing hourly rounding among in-patients may improve the patient safety outcomes, patients’ satisfaction, perception of care, and reduce cases of safety events (Krepper et al., 2012). A number of studies have demonstrated the proof that hourly rounding is important for nursing. However, patient satisfaction had critical roles in justification of these benefits.

How does patient acuity affect the number of patient falls?

The study explored how patient acuity affected nurse interventions. The results (fig. 5) indicated that 47 percent of the patients received excellent care and 31 percent received ‘very good’ care while 14 percent received ‘good’ care. Overall, none of the patients received ‘poor’ care at the facility irrespective of their acuity. Thus, inpatient needs for nursing care was effective to many patients. For instance, patients who were in stable situations did not get frequent visits. In other words, nurses and support staff concentrated on patients who were vulnerable and needed high standards of care. This is what Halm established in his previous study about patient acuity. He noted that it was appropriate for nurses to “attend only to high-acuity patients and ignore patients who are in stable conditions during hourly rounds” (Halm, 2009).

Summary

The rehabilitation center recorded positive outcomes in nursing interventions because of regular communication. Moreover, they engaged in constant training of nurses in order to ensure that the interventions achieved the desired outcomes. In most cases, health care facilities introduce hourly rounds before training and educating nurses about the concept. Training and educative programs concerning hourly rounds are necessary for effective implementation and evaluation for improvement. Besides, other support staff should also get training about hourly rounds so that they can assist during emergencies. While support staff may not perform specialized duties like pain management, they can ensure that patients can reach their possessions and communicate patients’ unmet needs to relevant nurses. In some cases, hourly rounds may not be effective due to poor communications during implementation among nurses and support staff when communicating unmet needs of patients. Ineffective communication can derail the approach (Shepard, 2013). Hence, communication plays a critical role in ensuring that hourly rounds are successful (Deitrick, Baker, Paxton, Flores, and Swavely, 2012). Other members of the staff must also perform their duties and communicate with nurses in order to ensure that they meet all needs of patients.

Results and Conclusions

The general purpose of the research

The researcher wanted to investigate if hourly rounding affects the incidence of patient falls in a rehabilitation hospital. Margo Halm noted that hourly rounds were “intentional checking on patients at regular intervals” (Halm, 2009, p. 581). Nurses and support staff normally make rounds at specific hours while on duty. Halm noted that nurses checked for 4Ps while making hourly rounds, which included “pain, positioning, potty (elimination), and proximity of personal items” (Halm, 2009, p. 581). Nurses and their support staff normally check on patients on hourly schedules and must document outcomes of their interaction with patients.

Summary of the research findings

This study supports previous findings, which have shown that nursing interventions to reduce cases of falls and incidents in health care facilities were effective. There are constant discussions about the effectiveness of nurse interventions as methods of reducing falls and incidents among patients.

What places do patients experience increased risk for falls?

Common areas of falls and incidents were toilets, floors, bathrooms, beds, parallel bars, and rotating stools. Patients also experienced falls while they were picking fallen objects from the floor, but these cases accounted for few rates of falls. Overall, most falls occurred in the toilet, bathroom, and bed/bedroom because they accounted for over 90.6 percent of all fall cases in the rehabilitation centers. Hence, nurse hourly rounds should focus on reducing falls in these areas and falls related to activities in toilets, bathrooms, and bedrooms.

How does hourly rounding affect the incidence of patient falls?

Falls and incidents were common when patients engaged in different activities without assistance from nurses or support staff. However, the study indicated that hourly rounding reduced falls and incidents in the rehabilitation center. Contrary to expectations, many patients (64.2%) did not report their falls and incidents. The reported cases led to X-rays (20.8%), CT (9.4%), and ACT (1.9%) examinations. Still, about 1.9% of the patients who fell refused any kind of examination. Overall, there were no deaths from falls.

What is the most frequent time falls occur?

The study found out that most falls and incidents took place at night and in the morning.

It showed that falls and incidents were most common during Thursday (24.5 percent), Friday (20.8 percent), and Saturday (17 percent). Sunday had the least cases of falls (7.5 percent). Falls also took place in the early morning (am – 60.4 percent) relative to times of the day (pm – 39.6 percent).

Has hourly rounding increased patient satisfaction scores?

Hourly rounding increased patient satisfaction scores in the rehabilitation center. Patients rated nurses on courtesy (82.71%), ‘Your Doctor’ (75.62%), staff promptness in responses (75.21%), case management (76.68%), attention to individual needs and preferences (79.24%), and pain control to acceptable levels (78.70%). However, these scores were generally below both national and regional satisfaction scores. Thus, the rehabilitation center must strive to enhance quality of care to patients.

How does patient acuity affect the number of patient falls?

The study showed that 47% of the patient received excellent care, 31% received ‘very good’ care and 14% got ‘good’ care. No patient received ‘poor’ care. Overall, patients agreed on effective quality of care. Patient acuity affected their quality of care. For instance, nurses frequented patients who required high standards of care due to their vulnerable statuses.

The rehabilitation center engaged in regular communication and constant feedback in order to enhance the effectiveness of nurse interventions.

Interventions led to positive outcomes among patients. Patients showed that interventions improved their satisfaction with the facility. However, in comparison to national and regional ratings, the facility had overall poor scores in most areas. This suggested the need to enhance quality of care and improve patient satisfaction.

How the results were obtained

Once the researcher had collected data from the research participants, he conducted data cleaning in order to remove outliers from the data. Data analysis was conducted in order to establish the relationship between nurse interventions and incidents and falls among inpatients in the rehabilitation center.

The researcher used SPSS to analyze the relationship between data collected between 2012 and 2013 against cases of falls and incidents. The methods for analysis were descriptive techniques. These techniques provided data on the rates of falls and incidents. Moreover, the researcher used descriptive data in tables, charts, and graphical representation.

The researcher used paired samples technique to determine the association between nursing interventions on the rates of falls and incidents. In this technique of data analysis, the researcher made general assumptions like homogeneity of the variance, independence of the observation and data collection, and that all data came from random sampling. However, in a real life situation, it may be difficult to meet some of the assumptions of the study. The researcher used the results to make a general conclusion about the study that nurse interventions or hourly rounds led to declines in rates of falls and incidents in the rehabilitation center among inpatients.

Research problems and recommended solutions

The small sample size (53 respondents in nursing interventions) could have negative impacts on the results. On this note, the researcher recommends that future studies should include large samples, which may be appropriate for generalization in other areas.

Data analysis is a technical process. Therefore, researchers should be familiar with their preferred method of data analysis. This is imperative when considering variables, a sample size, and the expected results. Analysis techniques can influence study outcomes when not managed carefully.

Researchers should be transparent when presenting their outcomes even if such study results do not favor their goals. Objectivity of the study is imperative for a good scientific research.

Implications and Limitations of the study

Strengths of the projects

This study has a clear methodology, which other researchers can easily follow and apply in their own studies in a different situation or environment.

The project used current literature based on the best practices within the nursing field. The aim was to identify effective methods of conducting the study in order to reduce cases of unforeseen challenges.

The process was objective and did not reflect personal views of researchers. Studies have shown that results are measurable, valid and can be retested. This eliminated cases of skewed data that could have influenced source materials and validity of results.

The researcher showed how he recruited research subjects. He provided specific accounts of subjects’ characteristics necessary for the study. This is an important scope in hourly rounding and assessment of falls among patients. The researcher ensured that he adhered to ethical principles in recruitment of research participants. The researcher used a clear methodology that can be replicated in other areas for a similar study. From the results, one can simply understand the data analysis process and the inferences. This shows the research process met the basic scientific research conditions.

Weaknesses of the project

The study used a small sample size from Press Ganey to determine the association between the variables. This could have affected the results. However, William and Joe noted that “30 survey responses are needed to draw meaningful conclusions, although they prefer to have at least 50 responses before analyzing the data” (William & Joe, 2010). This implied that the research samples of 53 respondents were within the acceptable range. Hence, the sample did not influence the outcome negatively.

The researcher believed that the association among the inpatients at the rehabilitation center could have influenced participants’ responses with regard to patient satisfaction survey.

Problems during the project

Most challenges in this project were technical and time related. For instance, the most complex and challenging sections of the project were choosing suitable research design and data analysis techniques. One must formulate a research design, which must answer the research hypothesis and questions. In addition, it must align with data analysis techniques. The researcher must get this section right for the whole methodology to be right. This would subsequently affect the study outcomes.

Time is a critical factor in a research process. Failure to adhere to the set timetable can result in delayed project milestone deliveries. As a result, the researcher had to work and complete some tasks outside the timetable in order to meet the required deadlines.

Data collection is another challenge that could have affected the project. For instance, the number of respondents who took part in patient satisfaction survey fluctuated on different responses. Hence, researchers should recognize that not all participants would complete the survey process. Response can affect the result if the researcher fails to mitigate this challenge.

Factors that could have skewed the results

Ideally, the researcher wanted to conduct a study that would be free of skewed results. As a result, he strived to manage any factor that could have influenced outcomes of the study. However, in a real world situation, studies are normally skewed.

The issue of independent observation during data collection is critical for any study. The researcher suspected that a close association among patients could have influenced responses, which were gathered in patient satisfaction survey. Some studies have shown that the violation of independent observation assumption is a serious mistake in a paired-samples technique (Pallant, 2005). The results cannot guarantee independent observation assumption because of the interactions among patients, who rated the facility and nurses. On this note, the interaction among patients could have resulted in skewed data. Such data normally violate the independent assumption in a paired-samples data analysis technique. Patients in the same ward could have influenced one another about nurses and service provisions in the facility. Nurses’ responses when patients alerted them about a situation could have affected patients’ rating. Hence, patient satisfaction survey could have presented skewed data for analysis.

The researcher recognized that was almost impossible to gather data, which were free from influences when a group of respondents interacted with one another or in cases where other factors could have significant impacts on the responses. Based on this observation, authors have suggested the importance of ensuring independent observation at all tests. In a case of a violation of the independent assumption principle, the researcher should set a rigid value for alpha.

The small sample size used in drawing general conclusions about the associations between variables could have affected the study outcomes.

How to improve the study

The study could be improved by conducting the research with a large sample in order to draw a reliable conclusion. This can help in generalization of the findings. In addition, it can eliminate possibilities of skewed outcomes.

The researcher can improve on the process of data collection by ensuring that research instruments set conditions for independent observation or data collection from participants.

The study showed that communication was effective means of ensuring that nurse interventions achieved their desired outcomes. Therefore, practitioners should encourage constant communication when implementing new nursing intervention. This could ensure the success of the project.

Areas for further investigation

• Future studies should explore whether there are other factors beyond nursing interventions that could have influenced declines in the rates of falls and other incidents at the rehabilitation center.
• Other studies should probe patients on factors that influence their rating habits of hospital facilities, doctors, nurses, and other outcomes.

Future study

Any study of a similar nature would require a different approach in the future. For instance, the researcher would ensure utmost independent collection of data to avoid influences from other research subjects. This should happen because any data exposed to influences become bias and suspect in scientific research.

The experiences gathered in this project are critical for subsequent studies. For instance, in the next the researcher would design a rough outline of all areas before embarking on writing. The outline would assist in tackling difficult sections in writing a proposal, data collection, data analysis, and reporting on research outcomes.

Justification of the differences

Future studies would be different because the researcher would have improved on identified areas of weaknesses. Such weaknesses have the ability to derail a project if not well handled. The researcher would strive to adopt the best practices in nursing research and studies. This would guarantee that future studies would be reliable and could be generalized in other areas.

Critique of the Master degree experiences

A reflection of the experience

This has been one of the most organized courses I have undertaken. A master’s degree in nursing is an important part of nurse training that would allow me to become a practitioner or certified nurse in different areas of nursing. This has helped me to develop the required expertise in the nursing profession. This experience will extend beyond the current degree. It would allow me to research different alternatives and their effectiveness in nursing. These contribute to a large volume of evidence-based approaches to nursing, which help in solving both social and economic challenges in the health sector.

I feel that the course has allowed me to assess my personal career goals and relate them to the needs of patients, community, and the health care industry. I have noted that I can apply my Master’s degree in nursing in several areas.

The course incorporated practical and theoretical concepts of nursing and their use in effective provisions and management of health care services. The study that I undertook during my Master’s degree program helped me to realize that research was imperative in providing the foundation for improving the quality of care and approaches to patient management. I had the opportunity of developing the required skills, knowledge, interpersonal relations skills, and leadership abilities expected in a nursing profession. These skills are fundamental in improving the provision of health care services.

Clinical experiences and classroom activities formed the significant part of this study because they influenced the program to the end. We spent quality time interacting and making important notes during discussions. This would later require extensive clinical activities in order to link theories and practice.

In this program, I was able to learn other related course like research management when undertaking a project, statistics, health care ethics, health policy, and their impacts on the researcher, the subject, and the institution. When I commenced this program, I included several areas that would support my area of expertise. As a result, the research process has allowed me to develop key skills required for undertaking studies, which are necessary for evidence-based nursing interventions.

This cause allowed me to succeed because I could understand my individual strengths and weaknesses and adjust them in order to meet the desired career goals. The course programs helped me to development my strengths, as well as improve on my weaknesses.

I was able to have a positive experience of the course because it allowed me to understand my individual strengths and my career desires. Moreover, I believe that I found the best college and faculties that offered what I need to succeed in this course. I also made efforts to educate myself about all the necessary components of the course. As a result, I believe that I got a strong faculty that matched my Master’s degree in nursing.

How the experience and skills I have gained can apply in my work environment

The Master’s degree in nursing was an important program that would nurture me to become a nurse practitioner, educator, or a clinical nurse leader. The course offers a transformational process for nursing students and the entire health care sector. One can observe the ongoing changes in the sector today.

The course would allow me to perform physical examinations, diagnose, and conduct treatment on patient’s injuries, control chronic conditions, administer immunizations, perform x-rays, and other related laboratory operations.

The program incorporated theories and practices required in real life situations in nursing profession. This would allow me to have knowledge for health care management systems. Knowledge from the field research would be useful in undertaking studies for improving health care techniques and patient management and care provisions. I also had a chance of developing skills needed in nursing leadership, interpersonal relations, and health care research. These are core skills of improving health care conditions. The program ensured that nurses develop effective interpersonal and communication skills. In addition, the course exposed learners to different aspects of human behaviors, which could influence provisions of health care services. These skills would be useful for me to help my patients to understand aspects of current health care services. Such approaches would obviously improve patient satisfaction with health care services.

I noted the Master’s program had many areas of clinical practices that I would require later in the industry. This meant that I would be ready for certification. Moreover, I undertook a study that provided new knowledge in nursing. These are core aspects of enhancing health care provisions in health care facilities. Past literature guided me to develop new knowledge, which is necessary for practical practices.

Today, the health care industry emphasizes the concept of cost reduction and effective use of resources. The focus has been on controlled health care services. This suggests that health care professional will have to justify their treatment, effectiveness, and expenses. The course prepared me to deliver quality services to patients and the industry. In addition, there is a deliberate attempt to lower the cost of health care services and processes without lowering the quality of services.

It is the duty of all health care stakeholders to ensure patient satisfaction. However, it is the responsibility of nurses to ensure maximum delivery of quality services to nurses.

Lastly, the course introduced me to the concept of flexibility in a nursing environment. In the recent past, several health care facilities have gradually reduced their capacities and have transferred other patients to specialized care facilities. Based on this observation, the course prepared me to be a flexible nurse, who could fit in any nursing environment like homes, community-based facilities, and clinics. I have noted that the need for high quality health care services has increased steadily. Moreover, improvements in health care technologies and innovations have changed the industry. Still, nurses will have to deliver effective health care services. This suggests that nurse graduates must acquire skills required for the future health care industry.

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Appendix A

Appendix B

Appendix C

Flow Sheet 1