Intensive and Critical Care Nursing (2013) 29, 256260

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/iccn

APN-led nursing rounds: An emphasis on

evidence-based nursing care
Dea Mahanes a,, Beth D. Quatrara b, Katherine Dale Shaw b
a

Nerancy Neuroscience Intensive Care Unit, University of Virginia Health System, Box 801436, Charlottesville,
VA 22908, United States
b
University of Virginia Health System, Charlottesville, VA 22908, United States

KEYWORDS
Advanced practice
nursing;
Evidence-based
nursing;
Guideline adherence;
Hygiene;
Quality indicators,
healthcare;
Staff development

Summary In todays healthcare environment, nursing staff are challenged to care for patients
with increasingly complex needs in an ever-changing environment. Nurses are expected to stay
up to date on a tremendous number of institutional initiatives, best practice guidelines, and
policies and procedures. These practice imperatives are often disseminated through passive
means of information-sharing such as staff meetings and electronic mail. In this setting, it is
difcult for nurses to simultaneously focus on incorporating practice updates while continuing
to value basic nursing functions such as oral care, skin care, and incontinence management. The
concept of Interventional Patient Hygiene emphasises that basic nursing functions are not only
tasks, but also important evidence-based interventions that contribute to improved health for
the patient. Interventional Patient Hygiene facilitates the integration of science and practice.
This article describes a quality improvement intervention, Advanced practice nurse-led nursing
rounds, which supports Interventional Patient Hygiene and be used to help staff integrate best
practices while balancing the multiple priorities inherent in nursing care.
2013 Elsevier Ltd. All rights reserved.

Implications for Clinical Practice

APN-led nursing rounds assist nurses in integrating best practices and institutional initiatives into the complex care
environment.
APN-led nursing rounds aid staff in connecting basic nursing tasks, such as evidence-based hygiene measures, to
patient outcomes.
Staff feedback and available quality data can be used to adapt nursing rounds to meet the needs of individual units
or care settings.

Corresponding author. Tel.: +1 434 924 2164; fax: +1 434 243 2779.
E-mail address: sdm4e@virginia.edu (D. Mahanes).

0964-3397/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.iccn.2013.03.004

APN-led nursing rounds

257

Introduction
Interventional Patient Hygiene (IPH) is a concept introduced
by Vollman et al. (2005) to bring attention to the importance
of performing basic nursing care activities according to
evidence-based standards. Although initially focused on oral
care, bathing and incontinence management, the concept of
IPH has expanded to include other essential nursing functions such as mobility, catheter care and hand hygiene.
These activities contribute signicantly to improved patient
outcomes by decreasing the risk of healthcare-acquired
conditions such as pneumonia, pressure ulcers and skin
breakdown (Carr and Benoit, 2009; McGuckin and TorresCook, 2009; Vollman, 2006).
Clinical leaders are challenged to create a culture in
which basic nursing care is evidence-based and appropriately prioritised within the myriad of tasks that nurses face.
Evidence-based guidelines, protocols and procedures are
often written to integrate science into practice but are
rarely implemented to the fullest extent. One reason for
less than full implementation is that a passive approach is
used to introduce the best practice. Passive dissemination
of information is insufcient to change practice whereas
a multi-faceted, interactive approach is more likely to be
successful (Grol, 2001; Gross et al., 2001).
Nursing rounds have been used in a number of settings to
provide education and enhance patient care. In some settings, rounds focus primarily on staff education and critical
thinking (Brault et al., 2009; Guin et al., 2002; Segal and
Mason, 1998). In other settings, the primary purpose is to
develop or enhance the nursing plan of care (Catangui and
Slark, 2012; Coleman and Henneman, 1991). Nursing rounds
have not been explicitly linked to empirical outcomes, in
part because nursing rounds do not focus on one intervention, but rather the integration of multiple interventions
into bedside practice. Outcomes reported include mostly
process measures, such as participation and staff willingness
to present information.
Advanced practice nurses (APNs) are viewed as resources
that can assist staff in linking direct care to current evidence
(Gerrish et al., 2011). APNs are well-poised to bring evidence
to the nurse clinician, and to develop innovative strategies to assist nurse clinicians in integrating the evidence
into practice. One quality improvement initiative that may
impact nurse-sensitive indicators is APN-led nursing rounds.

Methods
In response to quality data, a group of APNs at a large
academic medical centre in the Mid-Atlantic United States
developed the concept of APN-led nursing rounds to focus
on the application of evidence-based nursing practice at
the bedside. Three APNs covering four units were involved
in the initial roll-out of the project. By emphasising the
basics of good nursing practice, the group hoped to improve
nurse-sensitive patient outcomes. The APNs on the participating units used quantitative data collected as part
of the hospitals standard quality framework to determine the initial focus of nursing rounds in their areas.
The APNs continue to review these data monthly to determine trends and adapt practices. This is an ongoing quality

Nursing Rounds
Presenting RN Guide
Age, sex, diagnosis
Current situation
Relevant Past Medical History
Relevant details of hospital course
Current priorities of care
Medical Management (brief overview)
Safety and Quality of Care (choose two)
o Fall risk/prevention
o Aspiration risk/prevention
o Pressure ulcer risk (Braden)/prevention
o Restraints/alternatives
o CAUTI risk/prevention
o VAP risk/prevention
o CLABSI risk/prevention
o Surgical site infection risk/prevention
o Delirium risk/prevention (CAM-ICU)
o Pain assessment/treatment/documentation
o Patient/family satisfaction
Whats keeping the patient in the ICU?
Worst case scenario?
Other concerns?

Key:
CAUTI = catheter-associated urinary tract infection
VAP = ventilator-associated pneumonia
CLABSI = central line-associated blood stream infection
CAM-ICU = Confusion Assessment Method for the ICU
Figure 1

Presenting guide for nursing rounds in the NICU.

improvement intervention and thus the format for nursing

rounds is not strictly dictated; the APNs are encouraged to
adapt Rounds to meet individual unit needs. A description
of the structure and process of nursing rounds follows.
Neurosciences Intensive Care Unit: Emphasising the
Basics and Encouraging Critical Thinking
In the 12-bed Neuroscience Intensive Care Unit (NICU),
nursing rounds led by the unit-based Clinical Nurse Specialist
(CNS) occur on Sunday afternoons. Additional nursing rounds
are integrated into the units Neurocritical Care Course, a
ve-week series attended by all newly hired nurses without
previous NICU experience. A template is provided for the
presenting nurse (see Fig. 1). After presenting the patient,
the nurse is asked to identify two quality indicators for discussion. For example, the nurse might identify the patient
as at risk for ventilator-associated pneumonia. Discussion
would then focus on the Ventilator Bundle, including the
importance of evidence-based interventions such as head
of bed elevation and comprehensive oral care. Electronic
resources are utilised; if a question arises about oral care,
the staff is coached in locating the on-line nursing procedure. Head of bed elevation is assessed and raised if not
already elevated at least 30 . Everyone present participates
in the discussion, both to keep everyone engaged and to
increase their comfort level with providing and receiving
peer feedback.

258
Because the NICU has many inexperienced nurses, identication and management of the worst case scenario
is also emphasised to develop critical thinking skills. For
example, a nurse caring for a patient with a subarachnoid
haemorrhage might identify neurological deterioration due
to cerebral vasospasm as the worst-case scenario. An interactive discussion of the management of vasospasm would
follow with an emphasis on immediate nursing actions.
Other topics addressed include collaborative management
of seizures, herniation syndromes and cardiorespiratory
emergencies.
In the NICU, staff nurses have the opportunity to serve as
champions or on-unit experts for a variety of nursesensitive quality indicators. When present on rounds, the
champions are identied and asked to provide input. This
helps the staff identify available resources, and builds the
champions condence in providing guidance and coaching.

Neurosciences acute care units: sharing ideas to

improve outcomes
APN-led nursing rounds occur twice weekly on the
acute/intermediate neurosurgery unit, and once weekly on
the acute care neurology/neurovascular unit. Rounds are
coordinated by an experienced Acute Care Nurse Practitioner. The stated purpose of nursing rounds on these units is
to highlight nursing indicators for each patient and provide
a time for sharing of ideas to improve outcomes. On
the neurosurgical unit, nursing rounds occur early on Monday mornings (4:45 a.m.) to facilitate participation by night
shift staff in addition to times later in the day. Commonly
addressed themes include management of constipation,
incontinence care, pain management and mobility. Nurses
are asked to identify their most vulnerable patient. Discussion focusses on what makes the patient vulnerable;
examples include fall risk, non-English speaking, or altered
mental status. The group discusses and determines individual nursing interventions to eliminate potential harm
and promote patient autonomy, safety, and recovery. Discussion is based on the needs of the patient and nurses,
and may be centerd on ethics, evidence-based practice,
pathophysiology and/or discharge planning. For example,
one such discussion focused on the research that led to
the development of a new protocol for the management
of indwelling bladder catheters in the surgical patient.
The APN takes advantage of the opportunity to show the
nurses tools to access evidence-based practice via the health
systems library, culture and ethics information, and community resources.
Six months after nursing rounds started, the APN on
the Acute Care Neurosciences Units sought feedback from
the staff via an informal survey. Information was solicited
regarding the value of nursing rounds as well as specic preferences such as date and time. This information was used
to make changes to meet staff needs better.

Medical-surgical acute care unit: rounding with a

new lens
APN-led nursing rounds are not limited to the neuroscience
areas. On one acute care medical-surgical unit, the CNS

D. Mahanes et al.
leads rounds that focus on nursing care to prevent complications. Nursing rounds on this unit occur weekly. Rounds
are designed to emphasise participation by newer clinicians
and new graduate nurses. The presenting nurse determines
which patient will be highlighted. Identied patients are
discussed in terms of their overall medical and nursing
care needs but an emphasis is placed upon prevention of
hospital-acquired pressure ulcers, catheter-associated urinary tract infections (CAUTI), central-line associated blood
stream infections (CLABSI) and falls. Appropriate nursing
interventions and best practices are discussed. For example, pressure ulcer prevention is addressed by reviewing
the Braden scale and the subscale measures that place
the patient at risk for an ulcer. Interventions such as
turning, moisture protection, nutrition and mobility are
reviewed. If necessary, consults with interdisciplinary team
members occur. Similarly, if the patient has been identied as at risk for falls (either before or in the process
of nursing rounds), the group insures that evidence-based
practice interventions are in place. They check that the
patient is wearing a fall bracelet, the bed is in low
position with the bed exit alarm engaged, and that the
patient can reach necessary items such as tissues and
the call bell. Patients and families are incorporated into
nursing rounds as appropriate. Patients and families are educated about strategies to prevent healthcare complications
and are encouraged to help support best practices. This
engages patients and families as members of the healthcare partnership and provides an opportunity for the CNS
to role model effective communication with patients and
families.

Results
Evaluation of the effectiveness of APN-led nursing rounds
is ongoing, and includes qualitative feedback from participants and trending of nurse-sensitive quality indicators.
Because APN-led nursing rounds are by design adapted
to meet the needs of participants and address unitspecic data, it is not possible to directly correlate
this intervention with specic outcomes. In addition, the
impact of nursing rounds cannot be isolated from the
impact of other concurrent initiatives. However, positive trends in indicators such as CAUTI, CLABSI, falls
and pressure ulcers have been noted on the units
actively participating in APN-led nursing rounds. Nursing rounds are being implemented in additional areas
of the hospital because of their perceived value and
impact on the pilot units. Other measures used to evaluate APN-led nursing rounds include participation by
staff, perceived value, and practice changes made in
response to information gathered during rounds, as noted
below.
Nursing rounds in the NICU typically include 311 care
providers. Most are nurses, but patient care assistants,
respiratory therapists and students also participate. In addition to nurse-sensitive quality indicators and critical thinking
skills, practice issues addressed on rounds have included
consistent neurological assessment, appropriate use of tactile stimuli, assessment of spinal cord function and nursing
documentation. Nursing rounds are gradually becoming a

APN-led nursing rounds

part of the units culture, with staff sometimes initiating
them.
When surveyed, over 60% of respondents on the
acute care neurosciences units rated nursing rounds as
extremely valuable. Comments from staff indicate
that nursing rounds promote learning and interaction
and enhance knowledge of pathophysiology. The neurology/neurovascular unit has asked the NP to increase nursing
rounds from once to twice weekly on that unit, which is an
indicator of the perceived value.
On the acute care medical-surgical unit, several process
issues have been identied and addressed as a result of
APN-led nursing rounds. For example, the CNS identied
that a chlorhexidine-impregnated sponge used for CLABSI
prevention was not being properly applied. This was not
only due to decits in staff knowledge but also because
the catheters were sutured too tightly to permit appropriate placement. Education was provided to the nursing staff,
and feedback was provided to practitioners involved in line
placement. Similarly, staff noted difculty avoiding dependent loops when caring for patients with indwelling bladder
catheters. This information helped the CNS target an educational strategy using pictures to demonstrate proper tubing
securement.

Discussion
APN-led nursing rounds have been implemented on several
units at this large academic medical centre. The facilitators identify exibility and persistence as key contributors
to success. Each unit has its own culture and the approach
to rounds has been individualised to meet unit needs. For
example, the nurses in the NICU prefer in-depth discussion
of selected indicators on a few patients, while the acute
care neuroscience oors nd more benet in focused review
of those patients perceived to be at risk. The process of
nursing rounds is also adapted based on stafng mix, with
complexity increasing when more experienced nurses are
present.
A primary challenge identied by the facilitators is
decreased participation in times of high acuity or low
stafng. Strategies to alleviate this challenge include
altering the time of rounds and encouraging staff to participate for whatever time they are available, even if they must
periodically leave rounds to attend to patient needs. It is
also important to acknowledge that there will be days when
rounds will not occur or when the APN will round individually
with staff nurses because of unit activity.
Staff discomfort with presenting patients to a group
is also a potential barrier to effective nursing rounds.
Strategies to address this barrier include providing a consistent format for presentations, allowing staff to choose the
patients presented and encouraging group contributions to
discussion of the plan of care. For example, when discussing
skin care strategies, the facilitator may ask the presenting
nurse to describe the patients current skin condition, and
then ask the group to provide input on pressure ulcer prevention strategies.
Finally, some units do not have an APN available to lead
nursing rounds, either because the unit does not employ
APNs or because the APNs lack time for or interest in staff

259
development. This barrier can be addressed by emphasising the connection between improved nursing practice and
patient outcomes (and thus the importance of staff development), and by utilising APNs from other areas as Guest
Facilitators. APNs are ideal facilitators for nursing rounds
because of their educational preparation and competencies.
However, other clinical leaders such as Nurse Educators,
charge nurses, and experienced staff nurses can also be
effective.

Conclusion
It is difcult to isolate the impact of APN-led nursing rounds
on the quality of nursing care, but that does not diminish the potential benets. Nursing rounds contribute to
prevention of blood stream infections, catheter-associated
urinary tract infections, hospital-acquired pressure ulcers,
ventilator-associated pneumonia and falls. These nursesensitive quality indicators are impacted by attention to
basic care needs such as hand hygiene, antisepsis with
catheter manipulation, skin care, incontinence care, mobility and oral care. Nursing rounds enhance the effectiveness
of education and practice improvement strategies by guiding staff in applying knowledge in practical situations.
Nursing rounds contribute to a culture of inquiry, ongoing peer review and collaboration, and pride in nursing
practice. By focusing on Interventional Patient Hygiene
while also discussing other aspects of care, Nursing rounds
emphasise that IPH is as important as other nursing responsibilities. A sense of responsibility and accountability is
instilled by linking IPH to the overall quality and safety of
care.

Acknowledgement
The authors acknowledge Suzanne M. Burns, RN, MSN, RRT,
CCRN, ACNP, FAAN, FCCM, FAANP for her guidance and support in developing and implementing this project.

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