Description
Synthesis of Evidence Paper (100 points)
** Remember: Synthesize and cite. Do not just list or regurgitate information from studies. You have already analyzed these works; use this analysis to create your own synthesis of the evidence presented in these publications.
**You are expected to critically appraise and synthesize the research in your own words.
Required elements: (use the bolded elements as subheadings – APA)
Title of Project (Upper/lowercase unbolded)
Introduction (No Heading) (20 points)
What is the clinical practice issue/problem (i.e. clinical practice, policy, intervention/treatment)? Background – Why did you identify this as an issue/problem?
What is the significance of this problem to nursing practice?
Research Question (Level 2 Heading) (5 points)
What is the clinical practice question? (PICOT/PICo)
Identify the outcome/dependent variable (PICOT) OR the phenomenon of interest (PICo) that you are
What do the studies say that is similar?
What is the point of agreement?
What does one study add to the evidence that is unique?
Do any of the studies disagree or have dissimilar outcomes? What is the point of difference?
interested in
Search Process (Level 2 Heading) (5 points)
Discuss the search process that you used to find current evidence (include: databases, keywords, limits, total # of studies found, total # of studies reviewed).
*At least 15 primary sources/studies (within last 5 years unless considered a classic). DO NOT use secondary (embedded) references.
Synthesis of the Evidence (Level 2 Heading) (40 points)
Synthesize the critical appraisal of the evidence to create an evidence base.
Compare (Level 3 Heading)
Contrast (Level 3 Heading)
Conclusion (Level 1 Heading) (20 points)
What are the strengths and limitations of the evidence base?
Did your research question get answered? Explain.
How could this evidence impact a change in practice?
Is further investigation needed? Explain.
o Proposed change
o Recommendations
References (begin on separate page, Upper/lowercase unbolded)
Evidence Table (10 points)
Submit your completed evidence table with at least 15 primary sources/studies (within last 5 years
unless considered a classic). DO NOT use secondary (imbedded) references.
*APA (7th ed.) format/grammar/spelling/references/citations (up to 10% deduction)
*Note: If using bibliography software for references and citations, convert to static text prior to submission.
*Expected to be 8 – 10 pages (excluding Title & Reference pages) double-spaced, 12-point Times New Roman font
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Focused Clinical Practice Issue
Student Name
School Name
N6323: Evidence-Based Practice
Instructor
5 September 2023
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Focused Clinical Practice Issue
Recent studies emphasize the need for proper staffing strategies to improve the quality
of care. Based on the issue, quality is described in terms of timeliness, accessibility of nurses,
patient outcomes, and cost-effectiveness. Poor and inadequate staffing is associated with
missed care, the potential for failure to rescue, job-related stress, and work dissatisfaction
(Simpson et al., 2018). For instance, inadequate staffing leads to increased fatigue among
nurses, increasing the risks of documentation and medication errors, eventually leading to
poor patient outcomes (Simpson et al., 2018). Additionally, poor staffing may lead to
increased cost of care or under-provision of expertise based on patients’ care needs (Simpson
et al., 2018). These consequences of poor and inadequate staffing necessitate adopting proper
staffing approaches.
Despite significant challenges in conducting studies on staffing, there are only two
major categories of staffing, ratio-based and skill-mix. Ratio-based entails dividing the
volume of bedside nurses or nursing services by the quantity of patient care services. These
may be further categorized into patient-to-nurse ratios, hours of nursing care delivered by
various personnel per patient day (HPPD), and full-time equivalent positions concerning
average patient census over a particular period (Lucchini et al., 2018). This category divides
nursing professionals or services according to patients or patient care services. Skill mix
involves examining nursing skills based on nursing bands and allocating them based on
patient needs. Therefore, bedside nurses are allocated based on patient needs (Lucchini et al.,
2018). Additionally, the skill mix aims to achieve the least financial reimbursement possible
that would give positive patient outcomes.
Using the PICOT format, the population is bedside nurses; the intervention is skillmix staffing; the comparison is ratio-based staffing; the outcome is decreased nurse fatigue;
time is at the end of six months. The PICOT question is, “How does the use of skill-mix
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staffing delivery systems influence nurse fatigue for nurses working at the bedside six months
after implementation?”
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References
Lucchini, A., Pirovano, M., De Felippis, C., & Comisso, I. (2018). Nurse staffing levels: Skill
mix and nursing care hours per patient day. In I. Comisso, A. Lucchini, S. Bambi, G.
D. Giusti, & M. Manici (Eds.), Nursing in Critical Care Setting: an Overview from
Basic to Sensitive Outcomes (pp. 465–488). Springer International Publishing.
Simpson, K. R., Lyndon, A., & Ruhl, C. (2018). Consequences of inadequate staffing include
missed care, potential failure to rescue, and job stress and dissatisfaction. Journal of
Obstetric, Gynecologic & Neonatal Nursing, 45(4), 481–490.
https://doi.org/10.1016/j.jogn.2016.02.011
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Intentional Rounding and Patient Falls: Synthesis of Evidence
Student Name
Methodist College
N6333
Instructor
Fall 2023
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Intentional Rounding and Patient Falls: Synthesis of Evidence
The practice of rounding has become commonplace in hospitals and healthcare facilities
across the world. This practice can be referred to by different names such as hourly rounding
(HR), purposeful rounding (PR), and intentional rounding (IR) and procedures may vary across
facilities. Rounding is primarily performed by nursing staff with responsibilities spread between
nurses and assistive personnel (AP). During common practice rounding, the nurse or AP will
enter a patient’s room and work through a mental or physical checklist to ensure the patient has a
clean, comfortable, safe environment to stay in (McLeod & Tetzlaff, 2015). Facility protocol for
rounding may differ, as well as documentation. Some facilities include rounding in the electronic
healthcare record (EHR) and some use a physical paper checklist or schedule. The purpose of
rounding is to ensure that patient’s needs are met. These needs are commonly referred to as the 4
P’s which stand for the patient’s pain level, position, potty (elimination), and capability to reach
possessions (Mazzei, 2020). In practice, rounding is generally completed hourly during the day
and every two hours at night to prevent disruption of patient sleeping patterns.
A frequently named reason for rounding is to reduce patient falls, which is an event
where a patient’s body has suddenly come into contact with another object from a higher level to
a lower level. Previous data from the United States has shown that approximately 1% of inpatient
falls, around 11,000 falls in total, resulted in patient death after severe injury (Currie, 2008). It
has been suggested that preemptively meeting a patient’s needs with rounding will discourage
the patient from trying to ambulate without assistance, in turn, decreasing the number of falls.
Risk factors for falls include musculoskeletal weakness, change in gait or balance, vitamin D
deficiency, certain medications (tranquilizers, sedatives, antidepressants), reduced vision, foot
pain, improper footwear, and environmental hazards (Centers for Disease Control and
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Prevention, 2017). Facilities with high populations of patients with these risk factors, such as
skilled nursing facilities, must put measures in place to reduce the likelihood of patient falls. A
primary intervention to reduce falls is to screen all patients to establish their risk of falls. The
Morse Fall Scale (MFS) is one of the most commonly used screening tools in the United States.
It evaluates a patient’s history of falls, diagnoses, use of ambulatory aids, use of IV therapy, gait,
and mental status where each category is assigned a score and any resulting score of over 45
indicates the patient is at a high-risk for falls (Agency for Healthcare Research and Quality,
2013).
In this review, IR will be defined as purposefully checking on and proactively addressing
a patient’s needs for pain management, position change, possession placement, and personal
needs for elimination. The MFS may be used as a tool to predict variables such as a large
population of high fall risk patients residing in a facility. For research purposes, in this review,
IR is considered to be the independent variable, and the number of patient falls is the associated
dependent variable.
Purpose and Research Question
The purpose of this literature review is to discover if there is a negative correlation
between falls and the use of IR. The research question is as follows: In skilled-nursing facility
residents assessed to be at high risk for falls by the Morse Fall Scale, does the use of intentional
rounding reduce falls over one year?
Search for the Evidence
A systematic literature review was completed. First, a broad literature review was
completed on the topic. This was a general search completed in EBSCO on the topics of
‘rounding’ and ‘Morse Fall Scale’. However, only two results were found based on these terms.
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Instead, a general search was completed in EBSCO on the search terms “rounding” and ‘patient
fall” where 49 results were found and abstracts were reviewed. Many studies were found on the
concept of nursing opinions on the benefits of rounding. However, these were not considered
because they did not offer observable and documented evidence of the impact of rounding on
patient falls. Next, a focused review was completed on EBSCO and PubMed with the search
terms “hourly rounding” or “intentional rounding” or “purposeful rounding” and “falls”. Search
modifiers were set to only review articles published from 2015-2020. Inclusion criteria required
the following: 1) The research was published in English, 2) utilized either HR, PR, or IR as a
nursing intervention, 3) indicated the impact of rounding as an intervention on patient falls 4)
used rounding as the independent variable, 5) used the number of falls as the dependent variable
and 6) was published in 2015 or after. A total of 23 articles were found and after assessment 15
were selected for further evaluation in this literature analysis.
The Evidence
Systematic Review
Two of the articles chosen for this literature review were determined to be systematic
reviews. Hicks (2015) sought to find if HR was effective in preventing patient falls. This is
similar to the research question outlined in this literature review. Their literature review found 14
articles that met the inclusion criteria. Of the 14 articles reviewed, 10 demonstrated a reduction
in fall rates, one study showed an initial decline but the fall rates returned to near baseline after
one year of implementation, two studies showed no change in falls rates, and one study had no
falls during the trial period (Hicks, 2015). These results demonstrate that the majority of articles
examined showed a reduction in patient falls after the implementation of rounding practices.
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Sims et al. (2018) published an integrative literature review which was designed to
cultivate models of IR and establish what factors improve or impair the efficacy of IR practices.
A lengthy literature review process, which consisted of three steps, led to an initial sampling of
89 papers. After the inclusion criteria were considered, 44 articles were identified. This article
was included for this literature review due to the use of similar inclusion criteria for rounding
practice. In their article, Sims et al. (2018) reviewed multiple outcomes of IR but for the purpose
of this literature review the outcome of “patient falls” will be examined. From the 44 articles
identified, 22 discussed patient falls as an outcome of IR. Of these 22 studies, Sims et al. (2018)
identified that 13 showed a decrease in patient falls, 5 reported no change in patient falls, 1
showed an initial reduction in patient falls them return to baseline, 1 showed an increase in
patient falls, and 2 studies established that the decrease in falls could not be attributed to IR
alone. The results of this literature review show that the majority of studies that discussed patient
falls as an outcome of IR revealed a decrease in patient falls. Interestingly, Sims et al. (2018)
noted that out of the 13 studies which showed a decrease in patient falls, 6 demonstrated
evidence that nurses rounded on high-risk patients more frequently than advised by their
rounding protocol. This finding expresses the link between nursing practice and prioritization of
frequent rounding on high fall risk patients over low-fall risk patients.
Randomized Control Trial
From the selected articles in this literature review, one randomized control trial was
identified. Roberts et al. (2020) conducted a pilot intervention study to explore if a 20-minute
rounding protocol reduced patient falls. This study was selected for review because it was
designed to establish if there was an impact on patient falls after a implementing rounding
protocol. Amongst 5-aged care facilities, 41 residents met the inclusion criteria and were able to
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consent at the beginning of the study. A randomized number generator was used to assign these
41 patients to two groups. There were 21 patients placed into the control group, who received
traditional care, and 20 patients were placed into the intervention group, which received 20minute rounding by staff. The results showed no significant difference between the control (p =
0.379) and intervention (p = 0.156) group for falls both in the preceding 193-day period and
during the 193-day intervention period (Roberts et al., 2020). However, a nonsignificant
decrease (p = 0.056) in the average number of falls was documented across facilities from before
the intervention with a mean of 60.4 ± standard deviation of 35.7 and during the intervention
with a mean of 53.4 ± standard deviation of 37.4 (Roberts et al., 2020). To note, one site did
report a slight increase in falls from 107 preintervention to 108 during the intervention.
Ultimately, the results of the study did show a decrease in falls. However, this was considered to
be non-significant and there was no significant difference found in the number of falls between
the control group and experimental group.
Cross-Sectional
There were two cross-sectional studies identified from the selected articles. Sun et al.
(2020) set up a cross-sectional study to explore the relationship between HR, bedside shift report,
and inpatient falls. This study was included in this literature review because the research
question sought to address how rounding affected inpatient falls. Data was collected through
direct observation from 4 hospitals (2 urban and 2 community) located within the same
healthcare system, within 11 units over 281 nursing shifts from 168 nurses. The results indicated
that HR was observed in 57.5% of observations (n = 5595) where HR was possible and bedside
report was observed 18.9% of the time in each shift (n = 53). An association between falls on day
versus night shift was found ([chi]2 = 5.34, p = 0.02) with more falls on night shift and the
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practice of HR was found to be near significance, each time HR was missed, the odds of a fall
increased by factor 1.20 (Sun et al, 2020). Ultimately, the study showed that consistent HR may
reduce patient falls and this should be considered during evening hours, as this study showed
falls to be more common on the night shift.
Zadvinskis et al. (2019) conducted a cross-sectional study over 6 months to establish if
there was a relationship between work engagement, bedside report, adherence to PR, and the
impact on patient falls. This study was included in this literature review because it examined the
relationship between PR and fall rates. RNs across 7 facilities and 41 units, were asked to
complete an online survey featuring the Utrecht work Engagement Scale (UWES-9). The
response rate was 27.8% (n = 808) after the exclusion criteria were applied. Results showed that
work engagement scores were higher in nurses who identified fall risk signs during bedside
report (p
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