Staffing Issues Shouldn’t Derail Patient Rounds

High census, low staffing, and competing leader priorities are causing some facilities to suspend leader rounding on patients, but at what cost? Have expectations about safety and patient experience related to value-based purchasing and reimbursement suddenly changed? Can facilities afford to leave ‘money on the table’ from sub-par patient satisfaction data or severe patient safety events that cost thousands of dollars?

Why Keep Rounding 

There has never been a more important time to sustain or expand patient rounding, and here’s why.

• Patient safety and quality healthcare is critical when staffing is compromised. Rounding on the patient and the environment reduces risks. Even a brief round can identify environmental issues such as loose cords, inactive bed alarms or even slip and trip risks for the patient, family or staff

• Rounding on visitors enlists their help to monitor safety. No one cares more for the safety and well-being of a patient than their family. When a loved one is in the hospital, visitors want to help but often do not know how. Welcoming them and giving them even one small task to help keep their loved one safe makes a difference to them, to the patient, and to the team. A leader round can accomplish that.

• Proactive rounds reduce requests and improve satisfaction. Proactive and purposeful rounds don’t have to be just the hourly rounding with which we are familiar. Finding out the things that comfort a patient, or even delight them, can make it easier for staff to meet their emotional needs early and often, during their stay. Using admission leader rounds to discover their core concerns and normal routines can assist staff to tailor care to those routines whenever possible. For example, expecting a teenager to respect lights out at 9:00 or 10:00 pm just might not be realistic if they normally stay up until midnight. Do their daily labs need to be at 6:00 am or can the routine be adjusted to meet their needs? That is patient-centered care.

• Building patient trust isn’t about time, it’s about substance. When the unit is being slammed with patients and half the staff are agency, a leader round can make all the difference even if it is brief. The key is how the round is completed. Offering a comforting touch to the patient or family member, sitting down and listening to what’s on their mind, or acknowledging their pain or fear lets them know that they are valued. Closing the loop on requests also contributes to trust because they know they are in your thoughts, even when you are not with them.

• Leader rounds save staff time. Done in conjunction with other patient needs, a leader round can save staff time. Connecting with a patient might occur while helping to set up their meal tray or assisting them with their morning hygiene. Asking about home routines and what gives them joy can occur during the patient admission process if the nurse leader is proficient in completing the admission profile and history. Helping with even one or two patient admissions a shift can not only build a rapport with the patients. It can also send a strong message of support to staff and provide an opportunity to interact and observe agency staff competency.

Evaluating Rounding Strengths and Opportunities –

Use data to focus discussions. A leader should never round on a patient without some prior knowledge of their needs, concerns, and the goals for their care. By using data from the admission history, previous rounds, or huddles the leader can create a truly personalized round. Knowing that the patient is awaiting the results of a key diagnostic test or anticipating the arrival of family from out of town gives the leader a meaningful opening for a caring conversation.

Identify patients at risk. Patient risks fall into two key categories that can be impacted by a leader round – patient safety and quality and satisfaction.

• Safety should always be the primary objective when staffing is an issue, especially for patients who have had a previous adverse safety event, such as a fall. Vulnerable and fragile adults and the elderly should always receive extra safety precautions. Patients receiving high-risk, low-frequency therapies or with multiple newly prescribed medications are also at high risk for safety issues.

• Patient dissatisfaction risks can also be assessed. There are patient groups which have a high potential for dissatisfaction during a patient stay. These can include those who gave an unsatisfactory rating on patient surveys after a previous encounter with the facility. It might also be those that have already had a service issue during the current stay, such as a lengthy delay in the ED waiting for an inpatient bed. Parents of small children may also be at risk because of their strong commitment to protect their child. Patients who are alone or have limited family support may need more attention from leaders and staff. Out of town family members can also quickly become disengaged and impact the patient’s perceptions of excellent care if they aren’t provided prompt information and connection to their loved one.

Don’t ignore happy patients. Patients with a history of frequent positive admissions or encounters with the facility should not be taken for granted. Explore the reasons for their strong engagement and assure that those needs are met whenever possible. Often these patients with few requests or special needs are deprioritized for leader rounds. They may not wish to bother busy staff members with their needs. A leader round can thank them for their continued trust in the facility and determine any special needs during this stay.

Key Strategies to Maintain Rounding –

• Compromise with low rounding instead of no rounding. Identifying the specific needs of patients at risk and those who are loyal to the facility can allow leaders to round on high priorities first or to sequence rounds differently. Conducting ‘happy patient rounds’ every second or third day or even a brief but personalized round will help keep these patients engaged and feeling valued.

• Make rounding more efficient. As with most things, preplanning can increase the efficiency of leader rounding. Just 10-15 minutes spent learning more about the patients in the area can help to prioritize those most in need of a round, those who might just need a brief visit, or those for whom a round with family at a later time or through a phone call might be better. Using only questions meaningful for the specific patient situation can streamline the time spent with each patient, while still making a meaningful connection with them.

• Real-time round documentation. Rounding without thorough documentation of the discussion and observations is a missed opportunity. Real-time documentation of the information in a leadership rounding tool is critical. If a busy leader must find time to complete a round and then also make time to document later in a spreadsheet there is a strong chance that one or both activities will not occur.

• Expand the rounding team. When the patient census is high, recruiting non-clinical leaders to assist with leader rounding can make a huge difference. Enlist executive leaders to round on the happy and engaged patients. They can easily thank patients and families for their trust and continued utilization of the facility. Train leaders from other clinical departments to assist with focused leader rounds on patients at high risk. For example, when dietary resources are stretched during high census or low staffing, these leaders can not only collect general patient needs and information, but they can also help to promote satisfaction with meal services at the same time.

• Swarm to the patients at risk. Make sure that everyone on the care team is aware of a patient safety or service risk. Address their needs in huddles, discreetly flag the patient room, or offer extra concierge services before issues arise. Leverage information collected about their individual needs and preferences to deliver the services that matter to them.

• Support nurse leader workflow and capacity. Nurse leaders cannot be expected to round on patients or support their staff at the unit level if they are constantly pulled into other mandatory activities or are assigned to multiple units. Consider rotating leader attendance at mandatory meetings like the safety huddle, throughput meeting, interprofessional care conferences, device rounds (HAI prevention), or discharge huddle. Creating nurse manager or assistant manager pairs can support them to alternate coverage of rounds or meeting attendance to ‘divide and conquer’ more tasks.

The current shortage of nurses and nursing leaders isn’t going away any time soon. Nurse leader stress is contributing to the record turnover of this group. Stress reduction and wellbeing initiatives are helping but listening to their needs and employing creative ways to support them are also needed. Especially when it comes to rounding on patients. You can’t afford to stop patient rounds.

Blog written by:

Teresa L. Anderson: EdD, MSN, NE-BC

Nobl Chief Nursing Officer