Quantitative design – Meade study

As discussed previously the study by Meade et al. (2006) provides not only a comprehensive description of the ‘modern day’ process of rounding but the earliest published results from a large scale experimental/comparative design methodology. The study examined the before and after effects of implementing rounding. The influence of Meade et al. (2006) study and the subsequent publication of the Meade work by the Studer Group (2007) is very significant within the practice of rounding. It led to several other replicant studies which have resulted in an evidence base dominated by quantitative methodology and methods. The Meade methodology and methods therefore has to be forensically examined because of its seminal positioning with rounding practice.

Meade et al. (2006) use a quasi-experimental design with non-equivalent groups and non- randomisation of hospital units to experimental and control groups, the experimental groups performed either one or two hourly rounding. The study was a large scale covering 27 medical, surgical and medical-surgical units in 14 American hospitals although originally 46 units in 22 hospitals were included in the study, poor data quality excluded 19 units in 8 hospitals. The authors state the study is nationwide and included small, large, rural and

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urban hospitals, summary details of participating hospitals are available directly from the author.

Being a quantitative study the hypothesis being tested states that nursing rounds conducted on a regular schedule by nursing staff who perform a specific set of actions would:

 Reduce call bell use

 Increase patient satisfaction

 Improve patient safety by reducing falls

The time period for the study was relatively short, a two week baseline measurement period and then for the experimental groups a four week period of rounding with two sets of call bell data collection. Data collection for patient satisfaction measures were provided by commercial vendors working for each hospital and although broadly similar they are potentially not strictly comparable, particularly as in the study the results do not appear to be cross checked or verified. Hospitals also produced their own data on falls rates which although they sent to the research studies principle investigator this could potentially reduce the reliability of the study due to differing definitions of what may be considered a patient fall within the different hospitals. It was difficult to delineate a consistent definition used for falls within the study were all falls recorded or if only falls resulting in harm were recorded. A further potential problem with the methods of Meade et al. (2006) was the lack of equivalence between experimental and control groups. Although Meade et al. (2006) acknowledged this in their quasi-experimental design their lack of randomisation in their empiric design does question if their comparative outcomes between their experimental and control units were fully valid.

A further problem was that there was no mention in the study that any changes in patient satisfaction may have been a placebo effect. The results may have been no different if the nurses had just seen the patient and said ‘hello’ without providing any intervention described in the checklist as this is not observed/measured within the study as the researcher has to be remote/detached from the study. A further constraint of the design methodology of not observing rounding in practice, and the short time frame for data

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collection was the consideration of the ‘Hawthorne’ effect that may have led some nursing staff to change their behaviour for the study duration without it necessarily being related to rounding, but because they were involved in a study.

The study by Meade et al. (2006) does go some way to explain their control of variables, an important part of quantitative studies, as the experimental setting was required to be as regulated as possible in order to isolate the cause and effect of the experiment. For example the hospitals involved in the study had to have a less than 5% use of agency nurses, the units had to have strong nurse managers to oversee the study and supervise staff. All participating hospitals had to have one unit in the experimental group and one unit with similar types of patients in the control group. Within the research protocol Nurse Managers had to review ‘rounding logs’ and ‘call bell logs’ on a daily basis to ensure compliance with the research protocol. The principal investigator for the study visited all the hospitals during the various stages of the research to ensure compliance with the research design and methods. Specific training was delivered to the experimental group to explain the purpose of the experiment and demonstrate the actions to be performed while rounding. Nurses from the control group were not exposed to any training to prevent inadvertent implementation of the specific actions of rounding which were being performed by the experimental wards.

Meade et al. (2006) linked their rationale, for what could be viewed as a short time frame, to measure the effects of a significant change to practice, a 4 week study design, to cognitive-behavioural and learning literature based on humanistic approaches to psychotherapy. They basically felt it would take nurses four weeks to fully integrate this new process into their practice but they divided this time into two periods of two weeks for the purpose of the study to see how quickly the intervention of rounding affected patient call bell usage.

However, Meade et al. (2006) documents a one year follow up to their study in which they further prove the benefits and sustainability of rounding. Twelve hospitals remained in their study, with all of those hospitals expanding rounding to more units. Patient satisfaction

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scores continued to increase by a mean score of 8.9 on a 100 point scale. There also appeared to be a further reduction in the falls rate, Meade et al. (2006).

Despite potential problems with the methods used by Meade et al. (2006) to prove the effectiveness of rounding on patient satisfaction and safety, their methods have been integral to other studies. The study crucially forms the cornerstone of the rounding evidence base. It potentially appears to have methodological flaws that could question the impact of the findings in relation to providing a robust link to the practice of rounding with improved patient experience and safety. The possible persuasive argument for the deductive study by Meade et al. (2006) despite its methodological flaws was the number of wards/hospitals which participated in the study. The study consisted of 27 units in 14 hospitals although the study originally covered more units/hospitals (the data from 19 units/8 hospitals was excluded from data analysis due to poor reliability and validity of data collection due to poor consistency of compliance with rounding as identified in the ‘rounding logs’). However, the study does collate large numbers, data was collected on 108,882 instances of call bell use. There was a statistically significant reduction in falls in the one hour rounding group and a statistically significant reductions in call bell usage in both the one and two hour rounding groups.

Meade et al. (2006) acknowledged their study does have limitations and recommended the need for a longitudinal approach requiring at least six months of data collection. Data collection on pressure ulcers was also recommended and a more systematic measurement of patient and staff satisfaction. Meade et al. (2006) also recommended understanding if rounding reduced call bells then how did this impact on nursing time.

The two systematic reviews (Halm 2009; Snelling 2013) had opposing views on the methodological merits of Meade et al. (2006). Halm (2009) as discussed previously found the study the best quality evidence available about rounding. Snelling (2013) entirely disagreed finding several methodological flaws as well as raising concerns about misrepresentation of evidence. Snelling (2013) particularly highlighted how the Meade et al. (2006) study had been distorted to promote rounding as reducing pressure ulcer formation when this was not correct as it was not part of the methodological design of the

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study. Forde-Johnston (2014); Mitchell et al. (2014); Hicks (2015) and Lyons et al. (2015) acknowledged the seminal position of Meade et al. (2006) rating the methodological design of the study to be comparatively good compared to other studies but both also noted the limitations of the pressure ulcer evidence.