4

HOURS

Continuing Education

ORIGINAL RESEARCH

B Y C HRISTINE M. M EADE , P H D, A MY L. B URSELL , P H D, LYN K ETELSEN, MBA, RN

Effects of Nursing Rounds

on Patients Call Light Use, Satisfaction, and Safety
S CHEDULING

REGULAR NURSING ROUNDS TO DEAL WITH PATIENTS MORE

MUNDANE AND COMMON PROBLEMS CAN RETURN THE CALL LIGHT TO ITS
RIGHTFUL STATUS AS A LIFELINE .

ABSTRACT
OBJECTIVE: There is limited research on patient call light use as it pertains to effective patient-care management, patient safety, and patient satisfaction. Therefore, this study sought to determine the frequency
of and reasons for patients call light use, the effects of one-hour and two-hour nursing rounds on
patients use of the call light, and the effects of such rounding on patient satisfaction, as well as patient
safety as measured by the rate of patient falls.
METHODS: A six-week nationwide study was performed using a quasi-experimental nonequivalent
groups design; baseline data was taken during the first two weeks. Analyses were performed on data
from 27 nursing units in 14 hospitals in which members of the nursing staff performed rounds either at
one-hour or two-hour intervals using a specified protocol.
RESULTS: Specific nursing actions performed at set intervals were associated with statistically significant reduced patient use of the call light overall, as well as a reduction of patient falls and increased
patient satisfaction.
CONCLUSIONS: A protocol that incorporates specific actions into nursing rounds conducted either
hourly or once every two hours can reduce the frequency of patients call light use, increase their satisfaction with nursing care, and reduce falls. Based on these results, we suggest operational changes in hospitals, emphasizing nurse rounding on patients to achieve more effective patient-care management and
improved patient satisfaction and safety.
KEY WORDS: Call light, rounds, patient safety, patient satisfaction, learning, patient-care management

Christine M. Meade is executive director of the Alliance for Health Care Research, a subsidiary of the
Studer Group, a health care leadership and service excellence consulting firm in Gulf Breeze, FL. Amy L.
Bursell is president of Bursell Research, a research firm in Alexandria, VA. Lyn Ketelsen is a senior leader
and coach for the Studer Group. Contact author: Christine M. Meade, chris.meade@studergroup.com.
The Studer Group funded the time and travel of the Alliance for Health Care Research staff involved in
this study. Each participating hospital funded any costs related directly to the study. Participating hospitals
are acknowledged at the end of the article. The authors of this article have no other significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.
Editors note: the authors published a brief summary of this study in the February 2006 issue of Nurses
World Magazine.

58

AJN t September 2006

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http://www.nursingcenter.com

he call light can be a lifeline for hospitalized

patients, but it can also impose considerable
demands on nurses time. Several studies
have documented the unfavorable effects of
patients frequent use of the call light on the effectiveness of patient-care management on inpatient
units,1-3 which may already be compromised by
staffing shortages4-6 and burnout and job dissatisfaction among nurses.7-9 The empirical literature on
call light use and on systematic approaches to conducting bedside rounds (referred to here as rounding) as a strategy for patient-care management is
sparse. The impetus for this study was therefore
twofold: to verify the authors observations as
researchers and practitioners regarding the amount
of time nurses spend responding to call lights and
how this affects patient-care management, and
to address the dearth of empirical evidence surrounding this topic, in order to better assist hospitals and nurses to improve daily operations and
patient safety.
Research has shown that patients use call lights
largely for problems that do not require responses
from an RN or LPN and that can be appropriately
handled by certified nursing assistants (CNAs).2, 10
Van Handel and Krug categorized and quantified
patients reasons for using the call light and found
that most use occurred at meal and medication
times, when staff was busiest.3 This led to two interventions to reduce patient call light use: the addition of a nonnurse staff position (a unit assistant),
and the implementation of reactiveproactive
procedures (such as, when responding to a call
light, asking the patient and his roommates
whether they need any additional assistance).
Moreover, Gersh reported that the use of an unlicensed patient service partner (whose job
description included housekeeping, food service,
and nursing technician tasks) decreased call light
response time, improved the attitudes of those
responding, and increased the time that RNs and
LPNs had available for patient education and documentation.1 And Castledine suggested the initiation of patient comfort rounds every two hours
to assess the adequacy of pain control, to observe
patients general condition (including cleanliness
and need to use the toilet), and to meet any other
nonmedical needs but did not conduct research to
directly measure the effectiveness of such an intervention.11 In summary, rigorous assessment of
patient-care management systems is needed to
determine the best ways to reduce call light use and
burnout and fatigue among hospital personnel, as
well as increase patient satisfaction and safety.
The use of interdisciplinary rounding teams with
certain types of patients and hospital units has
ajn@wolterskluwer.com

resulted in reduced incidence of pressure ulcers

among patients in the surgical ICU and among
patients who stay in the ICU for more than 72
hours.12 Researchers have reported mixed results on
the question of whether daily interdisciplinary
rounding increases operational efficiency across
patient and unit types as measured by length of
stay,13-15 but there is evidence of increased staff satisfaction.15 Finally, Sterman and colleagues found
more effective pain management and improved
patient satisfaction among patients with cancer
when nurses engaged in specific actions, such as
making semiweekly pain management rounds, educating patients on pain management, and recommending changes in pain management approaches
to physicians.16 Interdisciplinary rounding can,
therefore, positively affect patient care and operational efficiency. However, an important, still unanswered question is this: Can a systematic,
nursing-only (rather than interdisciplinary) rounding protocol that anticipates patients needs result
in better patient-care management?

A patients perception of the quality of

nursing care largely depends on the nurses
ability to meet the patients needs.

Hospitalized patients often require assistance

with basic self-care tasks, such as using the toilet,
ambulating, and eating, and usually communicate
their needs by using the call light. Therefore, a
patients level of satisfaction with nursing care
depends principally upon the patients perception
of how well the nursing staff has been able to meet
his needs. Research attempting to measure patient
satisfaction by measuring perceptions of the quality
of nursing care has assessed both humanistic and
more concrete behaviors.17-19 Several studies have
evaluated patient perception of nursing care and
consistently identified specific elements of nursing
care that are very important to patients: smiles,
humor, reassurance, kindness, compassion, gentle
touch, and a nurses ability to anticipate the
patients needs. These elements of care largely
determine whether a patient will be satisfied with
the care given.18, 20, 21 Not surprisingly, these studies
also emphasize the importance of a nurses physical
presence to a patients perception of nursing care.
Moreover, research and training programs discuss
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59

TABLE 1. Actions to Be Taken by Nursing Staff

Members During Rounding
(Each nursing staff member in the experimental groups received the following instructions regarding actions to be performed for each patient
during one-hour and two-hour rounding.)

The following items will be checked and performed for each patient.
Upon entering the room, tell the patient you are there to do your rounds.

Assess patient pain levels using a pain-assessment scale (if

staff other than RNs are doing the rounding and the patient
is in pain, contact an RN immediately, so the patient does
not have to use the call light for pain medication).

Put medication as needed on RNs scheduled list of things

to do for patients and offer the dose when due.

Offer toileting assistance.

Assess the patients position and position comfort: ask if

patient needs to be repositioned and is comfortable.

Make sure the call light is within the patients reach.

Put the telephone within the patients reach.

Put the TV remote control and bed light switch within the
patients reach.

Put the bedside table next to the bed.

Put the Kleenex box and water within the patients reach.

10

Put the garbage can next to the bed.

11

Prior to leaving the room, ask, Is there anything I can do for

you before I leave? I have time while I am here in the room.

12

Tell the patient that a member of the nursing staff (use

names on white board) will be back in the room in an hour
(or two hours if two-hour protocol is in use) to round again.

how patients perceptions of the quality of nursing

care are influenced not only by nurses physical
presence but by the quality of attentiveness or emotional awareness that they bring to the encounter
an essential feature of care.22, 23 The nurse has to
demonstrate her availability in a manner that the
patient finds meaningful or comforting.24-28 Other
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AJN t September 2006

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important aspects of patients perceptions of nursing care quality relate to more concrete nursing
actions, such as correct and prompt attention to
physical needs, timely administration of medication, and pain assessment.29
In summary, a patients perception of the quality
of nursing care largely depends on the nurses ability to meet the patients needs as well as foster a
relationship with the patient. The premise of the
current study is that patients would perceive that
proactive nurses who provide consistent care will
meet their physical and emotional needs.
Specifically, we hypothesized that nursing rounds
on medical, surgical, and medicalsurgical units,
conducted on a regular schedule by nursing staff
who perform a specific set of actions, would
reduce call light use.
increase patient satisfaction.
improve patient safety, as measured by the
frequency of patient falls.
METHODS
Design. To test the hypotheses, we used a quasiexperimental design with nonequivalent groups.30
There was nonrandom assignment of hospital units
to experimental and control groups; in this case,
chief nursing officers and nurse managers at the
participating hospitals assisted in the assignment of
each unit to one of the three study groups: control,
one-hour rounding, and two-hour rounding.
(One-hour rounding was defined as rounds being
performed once an hour between 6 am and 10 pm
and once every two hours between 10 pm and 6
am. Two-hour rounding was defined as rounds
being performed once every two hours during the
entire 24-hour period.)
The decision to perform one-hour or two-hour
rounding was made by each hospital, after discussions with the principal investigator (CM), who
ensured that the sample was stratified according to
type of unit (medical, surgical, or combined medicalsurgical), unit size, and frequency of rounding.
In several cases, units were asked to change to a different rounding protocol to ensure that the sample
was balanced.
There were two conditions in each experimental
group: baseline measurement that lasted for two
weeks and either one-hour rounding or two-hour
rounding, which lasted for four weeks. The measurement of call light use was divided into two-week
time periods so that the interventions (one-hour
and two-hour rounding) could be compared with
the baseline. Therefore, at each hospital, the study
lasted six consecutive weeks, and hospitals could
choose to begin at any time from January 15 to
April 1, 2005, to minimize interference with hospital operations. Final data from all participating
hospitals were collected by June 1, 2005.
http://www.nursingcenter.com

Participating in the Call Light Study

ONE

N U R S E M A N A G E R E N C O U R A G E S H E R S TA F F TO M A K E H O U R LY R O U N D S .

n the beginning, I didnt believe it, admits nurse

manager Bette Dructor, RN, of the medicalsurgical
unit at Northeastern HospitalTemple University Health
System in Philadelphia. Researcher Christine Meade
(one author of this study) was seeking to convince her
and another units nursing manager that her staff
should take on additional rounds for a study she was
conducting on call light use. The demands on staff
were high, but the benefits, Meade promised, would
prove to be far reaching.
There are some patients youre just never going to
please, no matter how many times you go into their
rooms, Dructor says of her initial reluctance to participate. I just thought this was one more thing for our limited staff of nurses to do.
But when she heard Meades presentation, she
warmed up to the idea. The researcher impressed
Dructor with her argument that additional rounds could
create a better work environment for staff. Meade
assured her that regular, hourly rounds would result in
fewer calls from patients. This would in turn lead to fewer
distractions, a quieter work environment, and better
organization.
Once shed been convinced, Dructor had to convince
her staff of 28. I told them they wouldnt be interrupted
by call lights anymore while giving medications or
patient education, she says. But the realities of nursing
demands made her staff skeptical. You can get so frustrated in nursing, says Dructor, kicked down by the
patients and the politics.
Her staff balked. The nursing assistants were especially disgruntled; they believed they would bear the
brunt of what they perceived to be extra work, Dructor
says. But once the hourly rounds were initiated, aides
were surprised to find RNs pitching in on rounds aides
were unable to do. And everyone appreciated the unfamiliar quiet on the floor: call light use was cut by 65%.
You never hear RNs say they have more time,
Dructor notes. I didnt believe that if they did, they
would ever admit it. But thats exactly what they said
Meades interventions gave them during the month-long
study intervention; they also reported a decrease in the

Observations made in the first two weeks served

as a baseline measurement of call light frequency
and the reasons for call light use. A list of 26 reasons for call light use was devised based on our
review of the literature (for example, Van Handel
and Krugs 1994 study3) as well as our clinical experience. The rounding conditions were implemented
over the next four weeks. All members of the nursajn@wolterskluwer.com

Nursing assistants Elizabeth Bonk and Kim Lyons discuss with

medicalsurgical unit manager Bette Dructor, RN, the implementation of hourly rounds.

Courtesy of Northeastern HospitalTemple University Health System

patient fall rate, fewer pressure ulcers, and less skin

breakdown. Dructor hopes that the number of lawsuits
against the hospital will drop, too.
The patients love it, she says. I hear them tell their
family members during visiting hours when rounds are
being done, Oh, shes just checking on me to make
sure Im all right. Shes amended the protocol since
the end of the study by cutting rounds back to once
every two hours from 10 PM to 6 AM she has found
that patients have fewer needs during these hours and it
avoids waking them unnecessarily.
Soon other units in the hospital were hearing about the
positive results of participating in the study, and all units
have since mandated hourly rounds. She told managers
of other units, You learn so much from the rounding logs.
Youll see the trends in pain control: if we see that a
patient asked for pain medication six times in 24 hours,
we know were not controlling that patients pain.
But the best part of participating in the study, Dructor
says, has been seeing the success of her staff. We are a
small hospital without a lot of resources. I am so proud of
them for pulling it off.Alison Bulman, editorial coordinator

ing staff, including RNs, CNAs, LPNs, patient care

assistants, and patient care technicians (PCTs),
were required to perform specific actions during
every patient interaction in both the one-hour and
two-hour rounding conditions (see Table 1, page
60). As is consistent with standard hospital practices, patients were not awakened if they were
sleeping, during either day or evening hours, unless
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61

TABLE 2. Average Daily Census and Hours per Patient Day in Study Units During
the One-Hour and Two-Hour Rounding Periods
National
mean*
Average daily
census

Hours per patient

day

8.12

One-hour control One-hour round- Two-hour control Two-hour roundunits (mean)

ing units (mean)
units (mean)
ing units (mean)
24.6
8.73

22.7

29.8

8.33

31.9

8.65

8.81

Note: hours per patient day are hours of work spent in direct patient care.
* Taken from Cavouras CA, Suby C. 2004 survey of hours report: direct and total hours per patient day (HPPD) by patient care units. 15th ed.
Phoenix: Labor Management Institute; 2004.

TABLE 3. Comparison of Call Light Use, According to Major Reason Category

Control group;
% (number of calls)

One-hour rounding group;

% (number of calls)

Two-hour rounding group;

% (number of calls)

Serious Medical Concerns

36.7 (4,953)

34.3 (4,527)

39.6 (5,628)

Secondary Medical
Concerns

19.9 (2,684)

21.9 (2,894)

18

Nonserious Personal or
Health Issues

14.3 (1,932)

13

12.3 (1,740)

Major reason category

1.8 (241)

1.4 (191)

1.6 (231)

27.3 (3,684)

29.4 (3,886)

28.5 (4,049)

Room Amenities
No Reason/Miscellaneous

100

Total

(13,494)

it was necessary for treatment. The control group

units simply collected data on the frequency of and
reason for call light use as it occurred for the entire
six-week period.
Each unit implemented the rounding schedule
that would best fit its staffing patterns and patient
needs. However, on 95% of hospital units, CNAs,
PCTs, or nursing aides rounded on the odd hours
and RNs rounded on the even hours. Nursing staff
members who performed the rounding were
required to complete all patient-care tasks, unless
they werent authorized to dispense medication or
work with IVs. Additionally, all hospital units in
the experimental and control groups provided the
principal investigator with internal patient satisfaction and safety data (the number of falls) for the
month prior to the four weeks of rounding.
For further details on the studys design, see
More on Methods and Statistics, page 68.
RESULTS
Of the 22 hospitals (46 units) that participated in
the study, data from eight hospitals (19 units) were
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AJN t September 2006

(1,718)

(2,553)

Vol. 106, No. 9

100

(13,216)

100

(14,201)

excluded from analyses because of poor reliability

and validity of data collection. Hospitals and units
were excluded if rounding logs revealed that more
than 5% of data elements were missing, suggesting
that nursing staff members hadnt consistently performed the rounding and, therefore, had produced
unreliable data. Its important to note that approximately 72% of the hospitals had existing internal
checks and balances to verify the accuracy of the
call light records, including Hill-Rom electronic call
light recording systems (four hospitals, 29%) or 24hour communication centers or nursing desk staff
whose primary job was to receive all the call light
requests from patients and page nurses to the
rooms (six hospitals, 43%).
The average daily census and direct (worked)
hours per patient day in the experimental and control groups are provided in Table 2 (above), as are
nationwide normative data.
Frequency of call light use. Data on 108,882
instances of call light use were collected from 14 hospitals (27 units) over a six-week period: the mean
number of call lights answered was 4,381.7 on the
http://www.nursingcenter.com

20

F IGURE 1. M OST C OMMON R EASONS

15

FOR

15.4
14.5

14.8

Experimental groups (aggregated)

14.4

Control group

14
12.8

PERCENTAGE

C ALL L IGHT U SE

12.6

12.7

10

9.5

8.9

7.6

5
4.1

bathroom,
bedpan
assistance

IV problems,
pump alarm

accidental
call

miscellaneous

REASON

pain
medication

nurse or certified
nursing assistant
needed

repositioning,
mobility
assistance

Note: none of the differences between the experimental and control groups was statistically significant. Percentages do not add up to 100 because these are only the
seven most common of the 26 reasons for call light use. The total number of calls was 108,882.

15 experimental units (total number of call lights

answered was 65,726) and the mean number of call
lights answered was 3,596.3 in the 12 control units
(total number of call lights answered was 43,156).
The top seven of the 26 individual reasons for call
light use are shown in Figure 1 (above). There were
no significant differences between the control and
experimental groups. The 26 individual reasons for
use of the call light were further classified into five
major reason categories: No Reason/
Miscellaneous (for example, accidentally pushed
call light and cant understand patient on intercom
at nursing station), Room Amenities (for example,
move telephone closer and room temperature
adjustment), Nonserious Personal or Health Issues
(for example, personal needs assistance and beverage request), Secondary Medical Concerns (for
example, bathroom/bedpan assistance and repositioning and mobility assistance), and Serious
Medical Concerns (for example, iv problems/pump
alarm and pain medication).
Between the control and experimental groups,
there were no statistically significant differences in
the proportions of call light calls made in each
major reason category, indicating that the groups
were comparable at baseline (see Table 3, page 62).
Serious Medical Concerns and No Reason/
ajn@wolterskluwer.com

Patient satisfaction increased during

the rounding protocol in both the
one-hour and two-hour rounding groups.

Miscellaneous were the major reason categories

with the most and second most calls across all
three groups and all three time periods (at baseline,
week 3 through week 4, and week 5 through week
6). Figure 2 (page 64) shows the dramatic decline
in call light use in both the one-hour and two-hour
rounding conditions, compared with the control
group.
Binomial tests revealed significant reductions
(P = 0.007) in call light use for the one-hour rounding condition across all three time periods and for
all major reason categories, except in the weeks
3 and 4 and weeks 5 and 6 periods for the major
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63

F IGURE 2. F REQUENCY
THE T HREE G ROUPS

OF

C ALL L IGHT U SE

IN

Control group
One-hour rounding group

15,000
14,201
13,494

Two-hour rounding group

14,394

13,216

13,106
12,450

12,000

11,507

NUMBER OF CALLS

9,316

9,000

8,315

6,000

3,000

week 1week 2

week 3week 4

week 5week 6

(baseline, no rounding)

(rounding)

(rounding)

TIME PERIOD

reason categories Room Amenities and No Reason/

Miscellaneous (see Figure 3, page 65). Figure 4 (page
65) illustrates the decline in call light use for the twohour rounding condition from baseline to weeks 56.
As with the one-hour rounding condition, binomial
tests revealed significant reductions across all three
time periods and for all major reason categories,
except in the weeks 3 and 4 and weeks 5 and 6 periods for the major reason categories Room Amenities,
No Reason/Miscellaneous, and Nonserious Personal
and Health Issues (P = 0.06).
Patient satisfaction. We performed t test comparisons of patient satisfaction scores on data from
the one-hour and two-hour rounding units. The
data compared were the patient satisfaction scores
from a four-week period prior to the start of the
rounding protocol and scores collected during the
four-week rounding protocol. (Interestingly, mean
patient satisfaction scores in the control groups at
baseline were slightly higher than in the treatment
groups and declined over the course of the study.)
The mean score for the 28-day period prior to
rounding for the units using one-hour rounding
64

AJN t September 2006

Vol. 106, No. 9

was 79.9 on a 100-point scale, and the mean score

during the rounding protocol on those units was
91.9 (t = 736.58, P = 0.001). Prior to the rounding
protocol, the mean score for the two-hour rounding units was 70.4, and during the protocol, the
mean score was 82.1 (t = 657.11, P = 0.001). Thus,
both groups showed significant increases in patient
satisfaction scores, although its unclear why hospitals and units that performed the two-hour rounding had lower satisfaction scores than those that
performed one-hour rounding at both the beginning and end of the study. (The statistical computations were performed with STATS software, using
the difference between two independent means
procedure.) We did not have access to the raw data.
The vendors at each hospital who were tracking
patient satisfaction supplied mean satisfaction
scores for each unit, the sample sizes, and standard
deviations, which was enough information to do
t test calculations.
Patient safety. We wanted to determine whether
the rate of falls decreased on experimental and control units, comparing the four weeks prior to the
rounding and the four weeks of rounding. Paired
t tests were used to compare the number of falls
during the baseline period to the experimental
period on both the control and experimental units.
The analysis revealed that significant reduction in
falls occurred only with one-hour rounding.
DISCUSSION
This multisite study was designed to test the
hypotheses that a rounding intervention could
reduce hospital patients use of the call light (particularly for minor patient needs), increase patient satisfaction, and reduce the rate of patient falls. Given
the variety of hospital types (small, large, rural,
urban) that participated in the study, we believe
these findings are generalizable to the majority of
U.S. hospitals.
The first hypothesis was supported: regular
rounding during which nursing staff performed
specific actions significantly reduced patient call
light use. Patient satisfaction increased during the
rounding protocol in both the one-hour and twohour rounding groups. Specifically, nurses who
conducted rounds hourly saw patients more often
in a 24-hour period and patient satisfaction levels
were higher for the one-hour condition, when compared with the two-hour rounding condition.
However, this analysis is tenuous for two reasons.
First, as mentioned above, we did not have access
to the raw data; rather, vendors tracking patient
satisfaction supplied the data and we have to
assume it was accurate. Second, its unclear why the
hospital units on which two-hour rounding was
conducted had lower satisfaction levels prior to the
implementation of the rounding protocol, as comhttp://www.nursingcenter.com

NUMBER OF CALLS

NUMBER OF CALLS

NUMBER OF CALLS

NUMBER OF CALLS

pared with those units on which one-hour rounding

F IGURE 3. VARIATION IN F REQUENCY OF C ALL L IGHT
was conducted. Its possible that, because hospitals
U SE BY M AJOR R EASON C ATEGORY OVER T IME IN THE
could choose which
5,000 protocol worked best for them,
O NE -H OUR R OUNDING G ROUP
those that chose the two-hour
4,527protocol may have
Serious Medical Concerns
had less-well-developed patient-care management
No Reason/Miscellaneous
Secondary Medical Concerns
systems to begin with, and therefore
opted to par5,000
3,886
4,000rigorous protocol.
Nonserious Personal or
ticipate in the less
4,527
Health Issues
Patient falls were significantly reduced only dur3,398
Room Amenities
ing the one-hour experimental rounding. While the
3,886
4,000
2,986
number of falls3,000
did decline in2,894
the two-hour round3,398
ing group, the finding was not statistically signifi2,446
2,436
cant. Replication of this study with a larger sample
2,986
2,894
2,114
3,000
may be helpful2,000
in determining whether two-hour
1,792
1,718 staff satisfaction
rounding reduces falls. Nursing
2,446
2,436
was not tested in this study. Initially, when the hos2,114
1,214
pital training was conducted, nursing staff in the
2,000
985 1,718
1,792
experimental 1,000
units expressed concerns about
whether they would have the time to perform the
1,214
191
rounding as well as their normally
scheduled tasks.
985
115
115
1,000
Some also wondered
0 who would do the rounding
2 be week
3week 4
week 5week 6
and said they thought week
that 1week
it should
a team
(baseline no rounding)
(rounding)
(rounding)191
115
115
effort, with RNs and other
nursing professionals
0
sharing the rounds. However, at the end
TWOof-Wthe
EEK P ERIODS
week 3week 4
week 5week 6
week 1week 2
study, anecdotal data verbally reported by nursing
(baseline no rounding)
(rounding)
(rounding)
staff who worked on the experimental units indiTWO-WEEK PERIODS
cated that they were more satisfied with the additional time they had to care for their patients as
well as to perform other tasks (such as charting
and patient education), because the rounding
F IGURE 4. VARIATION IN F REQUENCY OF C ALL L IGHT
reduced the number of call lights they had to U SE BY M AJOR R EASON C ATEGORY O VER T IME IN THE
5,000
answer, thus freeing up time for other tasks.
4,527
Serious Medical Concerns
Nursing staff members who performed one-hour T WO -H OUR R OUNDING G ROUP
No Reason/Miscellaneous
rounding reported that units were quieter; also,
Secondary Medical Concerns
3,886
6,000
4,000
they reported that
they were able
to be more attenNonserious Personal or
5,628
Health Issues
tive and respond more quickly when call lights3,398
Room Amenities
rang, because the ring was not part of the nor4,876
2,986
mal noise on the
unit anymore.
5,000
2,894
3,000
4,619
Taken together, these analyses suggest that one2,446
2,436
hour rounding positively affects patient and nurs4,049
ing staff welfare. Considering the nursing shortage,2,114 4,000
3,718
1,792
issues of fatigue2,000
and burnout,
1,718and the growing
3,515
health care demands of the baby boom generation,
nursing units could greatly benefit by using a one-1,214
985
3,000
protocol to achieve greater effihour rounding 1,000
2,553
ciency. This could translate into greater work
2,340
in fatigue and115
satisfaction and, possibly, reductions
191
115
1,925
burnout, as well as patients
who are more satisfied.
2,000
1,740
0
Limitations. Our study used
quasi-experimental
week a1week
2
week 3week 4
week 5week 6
1,378
1,318
(baselineequivalence
no rounding)
(rounding)
(rounding)
design, which doesnt ensure
between
groups. We dont know all the specific factors each
TWO-WEEK PERIODS
1,000
hospital considered when making decisions about
assignments to control or one-hour and two-hour
231
130
136
rounding groups. However, although the compara0
bility of call light use, in terms of the proportions of
week 1week 2
week 3week 4
week 5week 6
calls made in each major reason category, suggests
(baseline no rounding)
(rounding)
(rounding)
some equivalence between the control and experiTWO-WEEK PERIODS
mental groups, the difference in patient satisfaction
between the one-hour and two-hour rounding
ajn@wolterskluwer.com

AJN t September 2006

Vol. 106, No. 9

65

TABLE 4. C OMPARISON OF F REQUENCIES OF PATIENT FALLS IN THE F OUR W EEKS P RIOR TO

R OUNDING

AND

D URING F OUR W EEKS

OF

R OUNDING

ON

E XPERIMENTAL

AND

C ONTROL U NITS

Number of falls
in the four weeks
prior to rounding*

Number of falls
during the four weeks
of rounding

Statistic and
significance

Control group

18

17

not significant

One-hour rounding group

25

12

t = 3.074
P = 0.01

Two-hour rounding group

19

13

not significant

Group

* All hospital units in the experimental and control groups provided the principal investigator with internal patient data on falls for the month prior
to the four weeks of rounding.

groups at baseline suggests that units in these groups

may not have been equivalent, or perhaps that the
hospitals were attempting to raise low patient satisfaction levels on specific units by assigning them to
a rounding protocol. Repeating the study using
either random assignment or investigator-controlled
matching of units for important characteristics
would be useful.
In research that involves whole organizations,
and in which there is a great deal of human interaction coupled with 24-hour operations, its impossible to ensure that every nurse will perform the
protocol and record data correctly during every
patient interaction. Our thoughts are similar to
those expressed by the Agency for Healthcare
Research and Quality when it completed its nationwide study on patient safety. The authors wrote,
Although all those involved tried hard to include
all relevant practices and to review all pertinent evidence, inevitably some of both were missed. It is
hoped that this report provides a template and
plants a seed for future clinicians, researchers, and
policy makers as they extend and inevitably
improve upon this work.32
It would have been redundant and a possible
irritation to patients to fill out another survey to get
more patient satisfaction data; therefore, we had to
use data supplied by vendors. Our calculations are
dependent upon the data supplied by vendors being
accurate and representative of the discharge dates
requested.
Also, its possible that staff members floating
between the experimental and control units may have
at times performed some of the rounding protocol
actions on the control units. Furthermore, nursing
staff members who are merely exposed to the idea of
participating in a study of this nature may modify
their behavior, particularly in baseline and control
groupsan example of the Hawthorne effect.33
Nursing managers abilities to facilitate the study
varied, and some units experienced management
66

AJN t September 2006

Vol. 106, No. 9

changes during the research. The degree to which

these issues affected the units performance and the
variation among them in call light reduction is
unclear.
Future directions. First and foremost, we hope
other researchers will attempt to replicate these
results, preferably in a nationwide representative
study of at least six months duration, so that more
rigorous assessment of the long-term effects of
these protocols can be made. This would permit
more robust analyses of any enduring effects of
rounding on call light use, patient satisfaction, and
patient safety. Data collection should extend to hospital-acquired decubitus ulcers, particularly among
the elderly and those with conditions that require
longer hospitalizations. Second, more systematic
assessments of both patients and staff members
satisfaction should be made, to determine the best
ways to improve the intervention for both groups.
Third, it would also be beneficial for hospital
administrators, chief nursing officers, and nursing
staff members to track more closely how well the
reduced call light use enables nursing staff members
to redirect their time and energy to other patient
care tasks. Whether and how any time gained by a
reduction in call light use can be used to improve
staffing patterns and whether and under what circumstances nursing staff members other than RNs
can conduct nursing rounds are questions deserving
of further study.
Fourth, hospitals that were excluded from the
analyses because of poor reliability and validity of
data (more than a third of the total number
enrolled) are also those hospitals that didnt have
extensive internal systems of checks and balances in
place to monitor the frequency of and reasons for
call light use. Researchers may want to use this as
an additional criterion for participation in future
studies. Finally, as with any training program, a key
factor to successful implementation of an intervention on a nursing unit is hospital leadership, espehttp://www.nursingcenter.com

One Year Later

F OLLOW - UP

WITH HOSPITAL UNITS PARTICIPATING IN THE HOURLY ROUNDING AND CALL LIGHT STUDY.

any of us know from experience that its easier to

do something for a short time than to make it a
part of our everyday behavior. Health care organizations throughout the country are similarly challenged to
make those interventions and procedures known to work
well a habitual part of daily operationsa process
described by Quint Studer of the Studer Group as
hardwiring.1
Given this understanding, we wanted to follow up
with the hospital units that participated in our call light
study a year ago. Our purposes in doing this follow-up
were to understand
whether the units continued the hourly rounding
after the study period.
whether other units in the hospital had adopted
hourly rounding.
what, if any, enhancements or adaptations were
made to the actions adopted for the study.
how patient satisfaction scores and fall rates had
changed from the beginning of the study.
This summary presents data only from the 14 hospitals
whose data were analyzed in the study.
Of the units that participated in the rounding, 12
(85.7%) continued the practice. Of the two that did
not, one had experienced a management change
and the new manager was unable to sustain the
rounding protocol. The other unit was closed
temporarily because it was being renovated.
Of the hospitals that participated in the study, 13
(92.8%) decided to expand the rounding to other
units or all units in the hospital.
Patient satisfaction scores (that is, scores that
reflected patients perceptions of the overall quality
of care on the unit) continued to increase over the
year. The increase in the mean score for all of
these units was 8.9 points on a 100-point scale,
from 79.9 to 88.8. Note that the units in the
experimental group increased the average rating
by 12 points during the study, so this is a consistent level of improvement, suggesting that hardwiring is taking place on these units. (Two hospitals have monitored the percentage of excellent
ratings rather than the mean score. The two units
in the rounding groups at these hospitals have
increased the percentage of excellent ratings
from 38.3% at the start of the study to 80.1%.)

cially that of nurse managers, who have to ensure

that all members of the nursing staff are diligent in
carrying out the protocol. The hospitals and units
that had to be eliminated from this study are evidence that full compliance with a new protocol
ajn@wolterskluwer.com

Patient Satisfaction and Safety at One Year

Before
Rounding

Current

Patient satisfaction rating reflecting

the overall quality of care on the
unit (mean)

79.9

88.8

Percentage of excellent ratings

38.2%

80.1%

Quantitative Measures

Reduction in falls*

60%

* In the four weeks prior to the start of the study there were 25 falls; in four
weeks one year after the end of the study there were 10.

Comparing the four weeks prior to rounding with

four weeks one year after the study, falls have been
reduced by an overall 60%. Note that the units in
the study reduced falls by approximately 50% in the
one-hour rounding group.
Hospitals have made enhancements to help nursing
staff continually practice the rounding protocol. These
include the following:
Laminated pocket cards have been made for the
nursing staff, so theyre continually reminded of the
actions to perform on the rounds.
Rounding boards were mounted to the outside of
the patients doors to ensure that rounding occurred
and could be easily monitored by anyone walking
through the unit.
Actions to be performed on rounds were printed,
laminated, and posted on the patients doors as a
constant reminder to staff and to let visitors know
how the unit cares for its patients.
Eight hospitals printed cards that nursing staff members can leave on bedside tables so that patients
who were asleep during rounding will know that
rounds were conducted. The cards have space for
the staff member to write in her name and the time
that rounds were performed.
A detailed summary for each participating hospital is
available from the authors at chris.meade@studergroup.
com.Christine M. Meade, PhD
REFERENCE
1. Studer Q. Hardwiring excellence: purpose, worthwhile work
and making a difference. Gulf Breeze, FL: Fire Starter
Publishing; 2003.

doesnt come easily and that staff are sometimes

reluctant to participate.
Our findings provide evidence that improved
patient-care management and patient satisfaction and
safety are achievable with interventions that nurses
AJN t September 2006

Vol. 106, No. 9

67

More on Methods and Statistics

he rationale for the four-week duration of rounding is
based on the cognitivebehavioral and learning literature, which suggests that the more complex the cognitive
behavioral learning program (such as the protocol of
questions that nurses ask patients during rounds), the
longer it may take learners to fully integrate new behaviors into their repertoire. This process is known as behavioral shaping31 and has been widely and successfully
applied in various situations, including humanistic
approaches to psychotherapy.22, 23 The four weeks of
rounding were divided into two two-week periods for the
purposes of analysis, so that the strength of the learning
curvehow quickly the intervention affected patient call
light usecould better be determined.
Hospital sample selection. Hospitals were allowed to
participate if they met the following criteria: per diem
employees from outside agencies accounted for 5% or less
of staff; they had medicalsurgical units, surgical units
(including orthopedic patients), or medical units (including
oncology, telemetry, or neurology patients); and the units
they assigned to the study had to have strong nurse managers who had the ability to oversee the study, supervise
staff, and manage data-collection compliance (the chief
nursing officer in each hospital recommended the units that
had the strongest nurse managers). Twenty-two hospitals
(46 units) participated in the study. All participating hospitals were required to have at least one hospital unit in the
experimental group and one unit with similar types of
patients in the control group. In every hospital that elected
to participate, approval was obtained from the facilitys
institutional review board or through appropriate internal
review processes. The participating hospitals were from
14 states, representing urban and rural populations, and
the number of beds ranged from 25 to more than 600.
Hospital orientation and training. On the units using
the experimental protocol, the principal investigator conducted training sessions to explain the purpose of the
experiment and demonstrate the actions to be performed
while rounding. The sessions were videotaped for staff
members who were unable to attend. On the control
group units, the chief nursing officer and the hospital unit
nurse managers and secretaries met with the principal
investigator to be trained in the methods to be used to
record the frequency of and reasons for call light use.
Nurses from the control group units werent exposed to
any training sessions, to prevent their inadvertent implementation of the specific actions to be performed in the
experimental groups.
Data collection instruments and procedures. Call light
logs were used to record the time, room number, and reasons the patients used the call lights. Call light logs were
kept at the nursing desk and data were recorded on all

68

AJN t September 2006

Vol. 106, No. 9

shifts either by unit secretaries or staff working in the

24-hour communication centers (whose primary job was
to receive all the call light requests from patients and
page nurses to the rooms). In hospitals without such staff
members on duty around the clock to receive and record
call light requests, a call light log was posted in each
patients room as close as possible to the patients bed so
that nursing staff answering call lights could record the
call. The nursing staff member who responded to the call
light determined which of the 26 reasons for call light use
was applicable to a specific occurrence and either used
the code or wrote the reason for the patients use of the
call light, which was then coded by the Alliance for
Health Care Researchs data entry staff.
In addition, nursing staff members who performed onehour or two-hour rounding recorded their rounding times and
provided general comments about the patient in a rounding
log. If a patient was discharged or a room didnt have a
patient, staff members were instructed to indicate in the log
the reason the room was empty, to ensure that every bed
was accounted for in the data collection process. Logs were
collected daily by unit secretaries or nurse managers at
7 AM, the end of each 24-hour period. Nurse managers
reviewed the rounding logs and call light logs on a daily
basis to ensure compliance with the research protocol; if necessary, they took action to ensure compliance. Nurse managers also verified that rounding was being performed by
asking patients. Nurse managers from the experimental and
control groups forwarded data weekly to the principal investigator. The principal investigator visited each hospital during
various stages of the study to ensure compliance with the
research design and methods.
The patient satisfaction data came from surveys developed by commercial vendors used by the hospitals, who in
turn gave the principal investigator the hospital units mean
scores, which were based on the discharge date of the
patient. Although hospitals used different questionnaires and
vendors (vendors used by the units in the study were PressGaney [10 hospitals], NRC+Picker [two], and Professional
Research Consultants [two]), all surveys included a question
about overall nursing care, which was consistent in terms of
content and scale conversion. Specifically, all measures computed a mean patient overall nursing care score (that is,
a patient satisfaction score) that ranged from zero to 100.
Mean patient satisfaction scores were based on a fivepoint Likert-type scale (1 = poor or strongly disagree,
5 = excellent, very good, or strongly agree) and converted to a 100-point scale. (Applying different instruments
to measure the same construct is common. For example,
various IQ and achievement tests are used nationally and
employ different metrics that have been determined to be
sufficiently equivalent.)

http://www.nursingcenter.com

COMMENTARY

Describing Research Methodology

W H AT

D O E S Q UA S I - E X P E R I M E N TA L M E A N ?

hen describing their research, authors try to use

terminology that accurately expresses their
research procedure. This may present a few challenges,
however, when the methodology employed is unique or
involves a procedure that is not usually associated with
that terminology.
Consider, for example, the terms experimental and quasiexperimental. In an experimental design, the researcher randomly assigns study participants to treatment and control
groups. In a quasi-experimental design, however, the group
assignment process is based on a preexisting condition or
naturally occurring event that preceded the study. For example, when examining the effect of eye color on a persons
perceptions of his attractiveness to others, eye color would
be a preexisting condition. The researcher cannot change
this feature; therefore, assignment of participants to groups
would be predeterminedon the basis of the participants
existing eye color. Similarly, if one is examining physical
endurance levels in people who have no history of heart disease, those who have experienced a recent onset of heart
disease (within one year), and those who have a history of
heart disease (longer than a year), the assignment of participants to a treatment condition would be predeterminedon
the basis of their history of heart disease.
In each of these examples, assignment to a treatment condition is based on a preexisting condition or naturally occurring event that is outside of the experimenters control. The
distinction here is that the criteria for including a subject in a
particular experimental condition are controlled by the
researcher. If, as part of a study, participants are assigned to
a treatment condition not as a result of randomization or a
preexisting condition or naturally occurring event but

can initiate and carry out. We hope that hospitals will

embrace the approach outlined here to determine
whether similar operational changes to rounding protocol would be as beneficial to them as it was to the
hospitals that participated in this study. t
REFERENCES
1. Gersch P. Initiating a patient service partner program. Nurs
Manage 1996;27(10):46, 48-50.
2. Miller ET, et al. Nurse call systems: impact on nursing performance. J Nurs Care Qual 1997;11(3):36-43.
3. Van Handel K, Krug B. Prevalence and nature of call light
requests on an orthopaedic unit. Orthop Nurs 1994;13(1):
13-8, 20.
4. Rosseter R. Nursing shortage fact sheet. American
Association of Colleges of Nursing. 2005. http://www.aacn.
nche.edu/Media/pdf/NursingShortageFactSheet.pdf.
5. Horrigan MW. Employment projections to 2012: concepts
and context. Mon Labor Rev 2004;127(2):3-22.
6. National Center for Workforce Analysis. Projected supply,
demand, and shortages of registured nurses: 20002020.
[Rockville, MD]: U.S. Department of Health and Human
Services; 2002 Jul. www.bhpr.hrsa.gov/healthworkforce/
reports/rnproject/default.htm.
ajn@wolterskluwer.com

because of the actions of another person in the study, it

would be difficult to consider the studys design quasi-experimental. If another person who is not the researcher determines the assignment of participants to a treatment
condition during the course of the study, its reasonable to
ask whether this process biases the study methodology in
some way and, possibly, the outcomes.
Clearly, to avoid concerns of bias, its best to ensure
that, when possible, the researcher controls the assignment process or verifies that the assignment of participants to treatment conditions is due to a preexisting or
naturally occurring event. In the rare instance that the
assignment of study participants to a treatment condition
is due to factors other than researcher control or a preexisting event, its best not to characterize such a study
design as quasi-experimental because the method by
which participants were assigned to a treatment condition
may be inconsistent with the procedures assumed in a
study of that kind. Instead, when the assignment of subjects is outside of the experimenters control and not due
to preexisting conditions, the researcher should consider
other terms for describing the study methodology.
In addition, a study design incorporating multiple observations that include baseline measurements taken during
one time period and measurements taken during other periods in time (days or weeks later) can more accurately be
described as a time series or time sampling design, a
type of quasi-experimental research that implies that multiple
measures are obtained at specific time intervals.Deborah
Fish Ragin, PhD, associate professor, Montclair State
University and research assistant professor, Department of
Emergency Medicine, Mount Sinai School of Medicine

7. Aiken LH, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;
288(16):1987-93.
8. Aiken LH, et al. Cause for concern: nurses reports of hospital care in five countries. LDI Issue Brief 2001;6(8):1-4.
9. Buerhaus PI, et al. Is the shortage of hospital registered
nurses getting better or worse? Findings from two recent
national surveys of RNs. Nurs Econ 2005;23(2):6171, 96.
10. Sheedy S. Responding to patients: the unit hostess. J Nurs
Adm 1989;19(4):31-3.
11. Castledine G. Patient comfort rounds: a new initiative in
nursing. Br J Nurs 2002;11(6):407.
12. Halm MA, et al. Interdisciplinary rounds: impact on
patients, families, and staff. Clin Nurse Spec 2003;
17(3):133-42.
13. Curley C, et al. A firm trial of interdisciplinary rounds on the
inpatient medical wards: an intervention designed using continuous quality improvement. Med Care 1998;36(8 Suppl):
AS4-12.
14. Dutton RP, et al. Daily multidisciplinary rounds shorten length
of stay for trauma patients. J Trauma 2003;55(5):913-9.
15. Wild D, et al. Effects of interdisciplinary rounds on length
of stay in a telemetry unit. J Public Health Manag Pract
2004;10(1):63-9.

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16. Sterman E, et al. Continuing education: a comprehensive

approach to improving cancer pain management and patient
satisfaction. Oncol Nurs Forum 2003;30(5):857-64.
17. Dozier AM, et al. Development of an instrument to measure
patient perception of the quality of nursing care. Res Nurs
Health 2001;24(6):506-17.
18. Fagerstrom L, et al. The patients perceived caring needs: measuring the unmeasurable. Int J Nurs Pract 1999;5(4):199-208.
19. Nguyen Thi PL, et al. Factors determining inpatient satisfaction with care. Soc Sci Med 2002;54(4):493-504.
20. Davis LA. A phenomenological study of patient expectations
concerning nursing care. Holist Nurs Pract 2005;19(3):126-33.
21. Kralik D, et al. Engagement and detachment: understanding
patients experiences with nursing. J Adv Nurs 1997;26(2):
399-407.
22. Corey G. Theory and practice of counseling and psychotherapy. 5th ed. Pacific Grove, CA: Brooks Cole; 1996.
23. Corsini R. Current psychotherapies. 3rd ed. Itasca, IL:
Peacock; 1984.
24. Cumbie SA. The integration of mind-body-soul and the
practice of humanistic nursing. Holist Nurs Pract 2001;
15(3):56-62.
25. Godkin J. Healing presence. J Holist Nurs 2001;19(1):5-21.
26. Gonzalez-Valentin A, et al. Patient satisfaction with nursing
care in a regional university hospital in southern Spain.
J Nurs Care Qual 2005;20(1):63-72.
27. Nelms TP. Living a caring presence in nursing: a Heideggerian
hermeneutical analysis. J Adv Nurs 1996;24(2):368-74.
28. Sourial S. An analysis of caring. J Adv Nurs 1997;26(6):
1189-92.
29. Sellers SC. The spiritual care meanings of adults residing in
the Midwest. Nurs Sci Q 2001;14(3):239-48.
30. Tull DS, Hawkins DI. Marketing research: measurement and
method: a text with cases 6th ed. New York: Macmillan; 1993.
31. Kazin A. Behavior modification in applied settings. 4th ed.
Pacific Grove, CA: Brooks Cole; 1989.
32. Shojania KG, et al. Making health care safer: a critical
analysis of patient safety practices. Evid Rep Technol Assess
(Summ) 2001(43):i-x, 1-668.
33. Franke RH, Kaul JD. The Hawthorne experiments: first statistical interpretation. American Sociological Review 1978;
43(5):623-43.

The authors acknowledge the following hospitals, their nursing departments, managers, and staff for participating in this
study: Ball Memorial Hospital (Muncie, IN), Baylor Institute
for Rehabilitation (Dallas), Baylor University Medical Center
(Dallas), Bethesda North Hospital (Cincinnati, OH), Brandon
Regional Hospital (Brandon, FL), Carolinas Medical Center
(Charlotte, NC), Carolinas Medical CenterUniversity
(Charlotte, NC), Cooper University Hospital (Camden, NJ),
DelnorCommunity Hospital (Geneva, IL), Euclid Hospital
(Cleveland, OH), Falls Memorial Hospital (International
Falls, MN), Jewish Hospital (Louisville, KY), Largo Medical
Center (Largo, FL), New Hanover Regional Medical Center
(Wilmington, NC), Northeastern HospitalTemple University
Health System (Philadelphia), Palmetto Health Baptist Easley
Hospital (Easley, SC), Sacred Heart Hospital (Eau Claire,
WI), Sharp Memorial Hospital (San Diego), South Pointe
Hospital (Cleveland, OH), CaritasSt. Elizabeths Medical
Center (Boston), the Valley Hospital and Health System
(Ridgewood, NJ), Temple University Hospital (Philadelphia).
They also acknowledge Lori Rankins, Andrea Harbin, and
Alyce Lunceford for data entry and Jackie Gerard for assistance with literature reviews.

AJN t September 2006

HOURS

Continuing Education

EARN CE CREDIT ONLINE

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GENERAL PURPOSE: To present registered professional

nurses with the details of a study done to determine
the frequency of and reasons for patients call light
use, and the effects of regularly scheduled rounding
interventions on patient satisfaction and safety.
LEARNING OBJECTIVES: After reading this article and taking the test on the next page, you will be able to
describe the background information and research relevant to the authors study of call light use.
discuss the authors methodology and statistical
results for their study of call light use.
outline the authors conclusions, recommendations,
and study limitations.
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