Nurse-led rounds give the profession a greater voice in patient decisions
All nurses are key players on the patient care team. However, at Ann & Robert H. Lurie Children’s Hospital of Chicago, this concept is more evident than at most other facilities. At Lurie Children’s, nurses are taking an active and vocal role in rounds. The 40-bed pediatric intensive care unit introduced Nurse Integrated Rounds to encourage its staff to take on additional leadership in patient care decisions.In the former style of rounds, the nurse would be an observer, listening to the physician and pharmacist and receiving the orders. At times, the nurse would not even be present. That way of thinking has evolved into a more inclusive model, with the nurse actually at the center. As Lora K. Byrne, MBA, BSN CNML, director of the pediatric intensive care unit, put it, “We have to discover new ways to take care of these kids.”
Nurses as Teachers
The unit wanted everyone to round the same way for each patient. “What’s unique about our culture is the nurse starts out by giving a snapshot of the last 24 hours,” Byrne explained. Nurses introduce the patient, explain the patient’s medical history, and give current vitals. Then the physicians follow up with discussion of the disease processes and provide teaching opportunities for the residents and the nurses. Nurses complete the rounds by bundling the patient, summarizing what was said, and reviewing orders and medications so that all clinical staff members are on the same page.
“It was a big shift in culture,” Byrne acknowledged. It’s hard to make changes when people are comfortable with the status quo. Some staff members worried that Nurse Integrated Rounds would be too time consuming. The opposite has proven true.
Support from Leadership
Previously, the nurses’ role in rounds was fulfilled by medical residents. “The division head of critical care is very passionate about the nurses in the unit. She holds the physicians accountable and got them to understand why this is so important,” Byrne explained. “There is a tremendous amount of respect from the medical team.”
Physician buy-in is necessary to a successful integrated rounding program. The nurses need to know they have support from everyone.
In the new program, nurses are held accountable at a high level. They have to learn more about the pathophysiology and complex diseases processes of their patients. The medical team supports the nurses by encouraging them to speak up and ask questions of the team. “Getting them to stand at the bedside and speak was a challenge for some of them,” Byrne acknowledged. “We kept validating that this is the right thing to do.”
In addition to staff nurses, nursing leadership is also a presence at rounds, providing support and education. “We want to be a unit in which you’re never afraid to speak up,” Byrne explained. Nurses feel like strong contributors in the management of success for the children. She added: “I see my nurses being more confident.” Seniority does not matter within rounds; it’s more about maintaining the nurses’ comfort level to share their expertise.
Not only did Lurie Children’s change the makeup of the rounds team, it also changed the location of daily rounds. The PICU moved from hallway meetings to bedside meetings and included the patients and their families in the process.
By rounding at the bedside, team members can physically evaluate the patient in real time. They can keep their eyes on a patient’s vitals. When everyone on the team is making the same observations, it turns into a teaching opportunity. “It’s for inclusion and safe practice,” noted Kathleen Seerup, MSHA, BSN, RN, NE-BC, senior director of critical care. “There are so many things a critical care team has to line up.”
Bedside discussions also are beneficial for HIPAA compliance, since hallways are not ideal places to maintain patient confidentiality.
Including the families is another factor that makes this style of rounds different. “We’re here to take care of their child, and we believe they are part of the team,” Byrne said. “We want them to participate in all levels of care.”
Added Seerup: “It’s difficult for the family to feel included when they’re out in the hall.”
Parents listen, ask questions and offer suggestions during rounds. The children can participate too.
“Families are grateful that we engage the children who are old enough to communicate. It’s important for us not to ignore them,” Seerup explained. The family knows the staff functions as a team and that each member has an open mind to what everyone has to offer. Weekly multidisciplinary rounds with the nonmedical team, including social work, music therapy, child life and the hospital chaplain, make the families aware of these resources for their children.
In addition to the family presence during daily rounds, the Patient and Family Engagement team plays a large part in educating the families about their child’s care.
When Nurse Integrated Rounds developed, a former bedside nurse was promoted to the position of Patient and Family Engagement Manager for the entire hospital. She partners with the facility’s patient and family experience champions, two nurses from each unit who engage with families in a greater way than other bedside nurses.
Nurse Integrated Rounds have produced positive results. “We have seen a significant decrease in catheter-associated urinary tract infections and central line-associated bloodstream infections,” Seerup said. It’s routine practice for nurses to question the necessity of central lines during rounds. As a result, fewer central lines have been used, contributing to the drop in infections.
From the perspective of patients and their families, the rounds have been a success. The National Research Corporation Survey asked: “How often during your child’s stay did the nurse listen carefully to you?” Lurie Children’s results were higher than the national Children’s Hospital Association of America average.
Families were also asked: “How often during your child’s stay did the nurse listen carefully to the child?” For Lurie Children’s, parents answered “always” 100% of the time.
Lurie Children’s asked another question not on the survey: “While your child was in the hospital, did a nurse leader visit and ask about your child’s stay?” Before introducing Nurse Integrated Rounds, the answer was “yes” 72.6% of the time. After nurse managers started rounding daily as part of Nurse Integrated Rounds, the answer became “yes” 98.9% of the time.
Byrne explained the roots of nurses taking a greater role in daily rounds. “I had the vision, and I needed to get the bedside nurses to see that vision.” The hospital provided the platform for the staff to engage in greater participation with patient care.
“Having satisfied nurses who enjoy their job and feel empowered is a great thing,” Byrne remarked.