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CE2_Oct REV 11/6/10 1:38 PM Page 16 aged care reimbursement contracts. Other hospitals have cut spending for support personnel, thereby increasing the workload of RNs. One reason for changing nursing processes and systems is to strongly embed management control to ensure the development of behaviors and skills that reflect the institutional business strategy. Key elements of the restructuring of the hospital environment from a nursing process model to a corporate care model are driven by the economic incentives of institutional providers and the commercial mandates of the healthcare industry. Along with shared governance schemes and new technologies, many hospitals are now introducing scripted "rounding" schemes. These schemes require RN loyalty to the business enterprise. This is hostile to the fiduciary responsibility of the RN to provide care in the exclusive interests of their patients. For example, the Studer Group, a proprietary proponent of these schemes, published a newsletter/press release article titled "Rounding for Outcomes: How to Increase Employee Retention and Drive Higher Patient Satisfaction." It's written by a nurse who is identified as a "Studer Group Coach." The author states, "While many organizations struggle with issues related to pain management, response to call lights, attention to personal needs, and increasing their sensitivity to patient's inconvenience, rounding is a powerful way to shape the experience for patients and increase patient perception of care." From an evidence-based standpoint, this author has a vested and biased interest in promoting the program. The references for the article used to support her claims are Studer Group press releases, promotional materials, and Press-Ganey opinion surveys from 2000 and 2003. Other so-called "studies" and articles reviewed on rounding reveal a similar lack of rigorous scholarly study and empirical scientific evidence to support what appear to be preconceived and purported claims of satisfaction and quality outcomes. There are serious concerns about the validity and reliability of rounding/scripting studies due to oversimplification of the conceptual design and inaccurate correlation of questionable "nursing sensitive" indicators to quality patient outcomes, including the use of voluntary, proprietary, and confidential data. There is a critical lack of systematic and ongoing monitoring and evaluation of the effects of organizational redesign and staffing reconfiguration on patient outcomes. There has been drastic clinical restructuring of nursing processes, and the acuity of patients has been rising steadily for years. Patient care is more complex, causing an increase in nurses' workloads, especially with the imposition of additional burdens of data collection that is unrelated to initial and ongoing patient assessments, documentation of the actual care provided to the patient, and the evaluation of patient's response to the treatment, patient education, and nursing advocacy activities. Research designs can lead to meaningless "findings" if care is not taken in the selection of variables and in avoiding the temptation to assume that because a variable is associated with a particular outcome, that it is therefore a cause of that outcome. The results of several rounding and patient satisfaction "studies" are highly suspect as measures of quality. It's important to note that the National Quality Forum (NQF) lists 15 voluntary consensus standards for nursing-sensitive care (standards based on patient outcomes, nursing interventions and system level measures) and consensus-based performance measures 16 N AT I O N A L N U R S E for nursing care. A reduction in the patient's use of call lights is NOT one of them! Undaunted, a number of misguided champions of change have embraced scripting and rounding initiatives and other transforming-care-at-the-bedside initiatives. In the race to "publish or perish," several clever and even amusing titles have washed up along the periphery of our nursing literature shoreline like so much debris that's cast off from the sea of serious and credible research. These papers all but ignore the results of more rigorous scientific studies on the relationship between the significance of increased nurse-to-patient ratios with staffing that is flexed up from the minimums based on patient acuity, and their well-documented impact on improved patient safety, nurse and patient satisfaction, and therapeutic outcomes that address the NQF standards in a more comprehensive and meaningful way. Most of the published results of rounding and scripting schemes are as substantive as sea foam due to their lack of identification of critical problems such as deliberate short-staffing and its relation to preventable complications and patient deaths, and the implementation of effective solutions, such as increasing the number of direct-care RNs at the patient's bedside. Below is a selected listing of article titles: ■ Ring for the Nurse! Improving Call Light Management ■ Hourly Rounding for Positive Patient and Staff Outcomes: Fairy Tale or Success Story? ■ Rounding for Outcomes Using Scripts ■ Call Light Study: A Summary Abstract from the Studer Group ■ You Called? Hourly Rounding Cuts Call Lights ■ Rounding for Outcomes: A Practical Tool to Increase Patient and Staff Satisfaction ■ Effects of Nursing Rounds on Patient Call Light Use, Satisfaction, and Safety ■ How to Increase Employee Retention and Drive Higher Patient Satisfaction ■ Hourly Rounding: How One Nurse Reduced Call Lights to Almost Zero ■ Patient Rounding: A Prescription for Satisfaction Critical thinking and analysis: Food for thought some of the authors of these articles on rounding are refreshingly upfront about the weaknesses and limitations of their findings. Common threads and concerns begin to emerge, and the prudent nurse should be apprised of them in order to more critically and properly evaluate the lofty claims made by proponents and authors with undisclosed biases that are often unsubstantiated. According to one such article by Kocis and Miksch (2007), "A search for written evidence revealed a paucity of literature regarding the direct use of rounding as a strategy." Yet another commentary, by Melnyk (2007), with regard to a study titled, "Nursing Rounds and Patient Safety" (Meade, Bursell, and Ketelsen, 2006) is instructive. Melnyk describes a rating system for evaluating the hierarchy of research evidence (Melnyk and Fineout-Overholt, 2005). She encourages clinicians to evaluate the strength of the evidence presented in a study before initiating a change in practice. A Level I study presents "evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice guidelines based on systematic reviews of RCTs." Randomized controlled trials are the strongest W W W. N A T I O N A L N U R S E S U N I T E D . O R G O C TO B E R 2 0 1 0