Collaborative Morning Rounds: Nurses Joining Physician Daily Rounds

Clinical/Organizational Problem

Inadequate communication between physicians and nurses can contribute to medical errors and work dissatisfaction, which can be detrimental to the quality of care provided to patients.  Medication errors also translate into patient risks, including increased costs in healthcare (Riga, Vozikis, Pollalis, & Souliotis, 2015). Inefficient nurse-physician communication has created unsatisfactory and stressful work environments, as well as reduced autonomy for nurses (Saber, 2014).  With poor professional work relations, nurses have changed careers, further exacerbating issues in the retention and recruitment of nurses (Zhang, Huang, Liu, Yan, & Li, 2016). 

Currently, the organization discussed does not have a system in which nursing is included in the physician’s daily bedside rounds, and a solution will be proposed in this paper. The proposed solution will facilitate the information flow between nursing and providers, as well as from patient to healthcare professionals in order to prevent miscommunications, errors, and to reduce repetitions in healthcare functions and duties.

Traditionally, physicians do their morning rounds with residents, and nurses do their morning rounds with oncoming nurses (Keeling, Kirchgessner, & Hehman, 2018).  After physicians do their rounds, orders for each patient are transmitted through the electronic health system and made visible to the nurses who will carry out the majority of the doctor’s orders.  This practice can be tedious as nurses and physicians do their separate rounds, which can cause additional stress on the patients (Keeling et al. 2018).  This practice can also be repetitive and redundant in the healthcare system.  From the transmission of information from the patient to the physicians and on to the nurses, crucial data may not be transmitted efficiently, sometimes resulting in unclear or inadequate information reaching the nurses.  The need to simplify physician and nurse rounds is, therefore, imperative (Saber, 2014).  As such, the new practice of including nurses in the physician morning rounds is one which will be considered, one which can potentially produce favorable results in improving the quality of patient care quality and preventing medical errors.

Description of Problem 

            The problem is the failure of physicians and nurses to coordinate their tasks efficiently, to collaboratively perform patient morning rounds so that input from both disciplines is exchanged.  The practice of doing independent rounds, versus nurse provider rounds, places patients at risk of medical errors and poor quality of care (Beaird, 2019).  It also creates a work environment that is not satisfactory for nurses.  Some physicians may not understand and appreciate the work of nurses as they do not interact with them much (Saber, 2014).  As a result, they may not have much respect and acknowledgment for nurses.

Explanation of Causes

The causes of poor collaboration and coordination between physicians and nurses are attributed to the long-established culture and practice in the healthcare setting (Burdick, Kara, & Ebright, 2019).  Physicians have traditionally led the healthcare practice in terms of providing care for patients (Keeling et al. 2018).  Nurses seem to be considered the helpers or assistants to physicians. Physicians also perceive nurses as health professionals who need to take orders from them, who do not have independent thinking (Beaird, 2019).  As a result, nurses are often not invited in discussions related to the patient’s plan of care, such as during morning rounds. 

At present, the practice of nurse-physician rounds at Womack Army Medical Center is not routinely practiced.  Womack Army Medical Center currently has a residency program and with the presence of resident physicians, including medical interns, the value for nurses joining rounds has been reduced.  This, however, has created poor communication and collaboration between nurses and physicians, with nurses and physicians often doing their own bedside rounds and nurses often not being confident enough to collaborate with physicians.  As a result, the risks for medical errors arising from poor communication have increased.

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Identification of Stakeholders

            Stakeholders of this project include physicians (and medical students/residents), nurses, and patients.  Physicians would encompass both attendings and residents/medical students since the facility is a teaching hospital.  Nurses here include the head nurses, the staff/ward nurses, and nursing students.  Patients are also stakeholders because, in the end, they are the recipients of the care provided and an active participant in the decision making related to the care they receive. 

Identification of Stakeholders	Stakeholders’ interest, power, and influence
Stakeholder 1: Physicians	Interest: Ensure that the plan of care is carried out efficiently and safely, that any orders they prescribe are understood and communicated effectively to the nurses and the patient so that patients receive appropriate care.
Power: Yes, because they are part of hospital committees and are also voting members when policies or protocols are revised or created.
Influence: Yes, because they have enough respect in the hospital and as respected leaders, they can persuade peers in the benefits of this practice change.
Stakeholder 2: Nurses	Interest: Ensure that they can share patient information and participate in decision making in a face to face setting.  Ability to improve communication related to the patients’ plan of care and improve the relationship with physicians, reducing work stress, and improving patient outcomes.
Power: Yes, because they are part of hospital committees and are also voting members when policies or protocols are revised or created.
Influence: Yes, because they are essential members of the medical team and highly respected.  This policy will directly affect them, and they can unite to help drive this policy change.
Stakeholder 3: Patients	Interest: To be able to receive quality, error-free, and efficient medical care while they are in the hospital
Power: No because it is not within their ability to get nurses to join morning rounds with doctors
Influence: Yes, because they are end-users of medical services, and this practice change will directly affect them. Patients can be active participants in the committee driving this change and share their perspective with hospital staff, which will help provide patient-centered care.

Purpose of the Project / Explanation of Project

            The purpose of the project is to create a process in which Physicians and Nurses collaborate in bedside morning rounds, therefore improving the coordination and collaboration of physicians and nurses on matters of patient care. It is meant to provide specific guidance for physicians and nurses on what will be bedside rounds include in terms of personnel and information exchanged.

Proposed Solution

            The proposed solution is the creation of a policy for morning rounds that would address the inclusion of bedside nurse, whenever possible, during the physician morning rounds. This solution is a means to prevent medical errors as well as to improve the quality of patient care.  It is a solution that would also promote a more satisfactory work environment for nurses and providers.

Evidence Summary

Improved communication and reduced errors

            As discussed in the study by Shirreff, Husslein, Lefebvre, and Shore (2019), implementing combined physician-nurse rounds helps improve the interdisciplinary communication between nurses and physicians.  The study noted how improved communication helps validate orders and helps mitigate errors in relation to the implementation and interpretation of doctors’ orders.  This was also supported by Wickersham et al (2018), who indicated how combined physician-nurse rounds helps improve communication between physicians and nurses, often allowing for nurses to clarify orders and on matters of patient care.  

Improved job satisfaction

            Job satisfaction also improves significantly with combined physician-nurse rounds.  As discussed by Henkin, Chon, Christopherson, Halvorsen, Worden, and Ratelle (2016), interprofessional rounds help promote job satisfaction, especially for nurses who feel that their work in the hospital is appreciated by doctors and that they have a voice and opinion in the healthcare setting.  Henkin and colleagues (2016) also mention how combined rounds with physicians helps open lines of communication with physicians and other health professionals.  This ultimately contributes to improved job satisfaction for the nurses in the healthcare setting. 

Patient satisfaction/quality care following interprofessional rounds

            With open lines of communication and favorable relations between nurses and physicians, several studies also indicate how interprofessional rounds ultimately help promote patient satisfaction and quality care.  Beaird et al. (2016) note how patients indicated a more favorable outlook on interprofessional collaboration as well as rounding.  These patients put a premium on getting quality care and being satisfied in the care they receive from health professionals. 

Barriers

            Nedfors et al. (2015) discuss the barriers to interprofessional rounding and the difficulty in setting schedules for these rounds, especially with the inclusion of nurses in the physician rounds.  Some nurses may not be available when physicians do their rounds, and this may prevent them from joining such rounds.  The authors noted that this can cause issues in the implementation of interprofessional rounds. 

Based on the evidence gathered for this study, it can be noted that coordination and collaboration between physicians and nurses can be poor. This can affect the quality of patient care and the work satisfaction of health professionals (Beaird et al. 2016).  The studies indicate that interprofessional rounds improved coordination and collaboration between nurses and physicians, helping ensure patient-centered care (Shireff et al. 2019; Wickersham et al. 2018).  The studies also note that interprofessional rounds helped create work settings that are not hostile for nurses as well as other health professionals (Henkin, et al. 2016).  The evidence also suggests that interprofessional rounds eventually help ensure quality healthcare for patients, with errors prevented and redundancies in tasks reduced (Beaird et al. 2016). 

Plan of Action

1. Initial conversations

• With Chief Medical Officer
  • Discussion with physician leadership on the identified problem and planned change
  • Election of a physician representative/stakeholder to participate in the policy change process
• With Chief Nursing Officer
  • Discussion with nursing leadership on the identified problem and planned change
  • Election of a nursing representative/stakeholder to participate in the policy change process
• With Patient Relations supervisor
  • Discussion with patient relations supervisor on the identified problem and planned change
  • Election of a patient to be the patient representative/stakeholder and participate in the meetings leading to the policy change

2. Literature review

• Team members will perform a literature review to include searching databases and scholarly sources for evidence-based practices on multidisciplinary rounding and nurse-physician bedside rounding.
• Team members will secure the change theory they’ll utilize during this process.

3. Development of deliverable

• Team members will create a policy that addresses the inclusion of nurses in physician’s morning rounds.  The policy will address:
  • Which nurses will join the morning rounds
  • What information will nurses share with physicians during morning rounds.
  •  Standard script for sharing information in an organized fashion

4. Presentation of deliverable

• The team members will present the proposed policy to the Chief Nursing Officer and Chief Medical Officer
  • Feedback will be given by leadership on the proposed policy, and adjustments made collaboratively between leadership and team members.
  • Education on the policy change may be set depending on the outcomes of the presentation of the policy proposed change.

Timeline

Week 1	Initial conversations With Chief Medical OfficerDiscussion with physician leadership on the identified problem and planned changeElection of a physician representative/stakeholder to participate in the policy change processWith Chief Nursing OfficerDiscussion with nursing leadership on the identified problem and planned changeElection of a nursing representative/stakeholder to participate in the policy change processWith Patient Relations supervisorDiscussion with patient relations supervisor on the identified problem and planned changeElection of a patient to be the patient representative/stakeholder and participate in the meetings leading to the policy change
Week 2	Literature review Database search (using search terms) – Team members will perform a literature review to include searching databases and scholarly sources for evidence-based practices on multidisciplinary rounding and nurse-physicianan bedside rounding.The team will secure a change theory and apply it to the proposed change
Week 3	Development of deliverable The team will develop a policy that addresses the inclusion of nurses in physician’s morning rounds.  The policy will address: Which nurses will join the morning roundsWhat information nurses will share with physicians during morning rounds.  Standard script for sharing information in an organized fashion
Week 4	Presentation of deliverable The team of nursing, physicians and a patient representative will present the proposed policy to the Chief Nursing Officer and Chief Medical OfficerFeedback will be given by leadership on the proposed policy, and adjustments made collaboratively between leadership and team members.Education on the policy change may be set depending on the outcomes of the presentation of the proposed change.

Required Resources and Personnel

            For this proposed change, the required personnel will include a multidisciplinary team composed of at least one Physician, one Nurse, one policy committee representative from the quality department, one administrative assistant, and one patient.   Adjustments in scheduling will need to take place to cover patient care in areas where these professionals would otherwise be working at.    Authorization for overtime will be requested as needed.

            A conference room will be reserved.  The conference room will have a laptop, a projector, a whiteboard, and will also have enough tables and chairs to accommodate the team members for the time allotted.

Proposed Change Theory

Lewin’s Change Theory of Nursing can be applied for this proposed change.  Kurt Lewin developed this change theory, and he is very much known for his work on social psychology (Petiprin, 2016).   His Change Theory highlights three stages of change, namely, the unfreezing, then the change, and the refreezing process (Petiprin, 2016).  This calls for previous learning or practice, which has to be rejected and replaced.  The previous practice is that of physicians carrying out their morning rounds without nurses, often leading to miscommunication and errors in the delivery of care.  Lewin believes that this model is a dynamic model that can balance the different forces which are headed for different directions (Petiprin, 2016). 

This Change Theory covers three different concepts, including driving forces, restraining forces, and equilibrium (Petiprin, 2016).  Those who push towards the direction which can lead to change are the driving forces.  They help secure change as they push the practice and the patient towards a place of quality care (Petiprin, 2016).  They also lead to a change in the equilibrium of change.  In this case, the driving force is the need to promote and ensure quality and error-free patient care (Petiprin, 2016).  Restraining forces are the forces that counter the driving forces.  They can sometimes prevent change.  In this planned change, the restraining force would be the refusal of the physicians and nurses to cooperate or support the planned change.  Finally, equilibrium is the condition whereby the opposing and the driving forces push against each other (Petiprin, 2016).  This state of equilibrium may go either way towards change or towards no change.  Concerning the three stages in Lewin’s change model, the unfreezing change refers to the stage where the usual practice in the organization is stopped or ended or “unfrozen” in preparation for a new practice.  In this case, it is the usual practice of nurses not being included in physician rounds.  This is followed by the introduction of the change, which in this paper means the nurses joining the physician rounds.  After such change is implemented in the organization, this new practice becomes frozen or set as the new norm or practice in the organization. 

            Barriers to Implementation

            Barriers to implementation include resistance from the physicians and nurses, specifically, their refusal to participate in the planned change. Other barriers include difficulties in establishing schedules for the morning rounds which nurses can attend.

References

Beaird, G. (2019). CE: a historical review of nurse–physician bedside rounding. The

American Journal of Nursing, 119(4), 30-38.

Beaird, G., Dent, J. M., Keim-Malpass, J., Muller, A. G. J., Nelson, N., & Brashers, V. (2017).

Perceptions of teamwork in the interprofessional bedside rounding process. The Journal for Healthcare Quality (JHQ), 39(2), 95-106.

Burdick, K., Kara, A., Ebright, P., & Meek, J. (2017). Bedside interprofessional rounding: the

view from the patient’s side of the bed. Journal of Patient Experience, 4(1), 22-27.

Henkin, S., Chon, T. Y., Christopherson, M. L., Halvorsen, A. J., Worden, L. M., & Ratelle, J. T.

(2016). Improving nurse–physician teamwork through interprofessional bedside rounding. Journal of Multidisciplinary Healthcare, 9, 201.

Keeling, A. W., Kirchgessner, J. C., & Hehman, M. C. (Eds.). (2017). History of professional

nursing in the United States: toward a culture of health. Springer Publishing Company.

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Petriprin, A. (2016). Lewin’s change theory.

Retrieved January 28, 2020 from https://nursing-theory.org/theories-and-models/lewin-change-theory.php

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Shirreff, L., Husslein, H., Lefebvre, G. G., & Shore, E. M. (2019). Introduction of physician-

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Wickersham, A., Johnson, K., Kamath, A., & Kaboli, P. J. (2018). Novel use of communication

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