JONA
Volume 50, Number 6, pp 355-362
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL OF NURSING ADMINISTRATION
Exploring Practices of Bedside Shift
Report and Hourly Rounding. Is There an
Impact on Patient Falls?
Carolyn Sun, PhD, RN, ANP-BC
Caroline J. Fu, MPH
Jessica O'Brien, MS, RN, AGCNS-BC, PCCN
OBJECTIVE: To describe the relationship of inpa-
tient falls to bedside shift report (BSR) and hourly
rounding (HR).
BACKGROUND: Falls are a major healthcare con-
cern. Although measures such as BSR and HR are
reported to reduce falls, studies are often based on
self-reported data related to nurse compliance with
protocols for HR and bedside report.
METHODS: Observational data were collected on
nursing tasks, including BSR and HR.
RESULTS: Nine thousand six hundred ninety-three
observations were recorded on 11 units at 4 hospitals
over 281 shifts. Falls were associated with shift and
day of the week but not BSR, HR, or the frequency
of encounters with the patient. The regression model
included frequency with patient, shift, day of week,
and HR.
CONCLUSIONS: Increased nurse frequency with pa-
tient may signal increased fall risks. Bedside shift
report and HR may require robust and sustained in-
terventions to provide lasting effects.
Author Affiliations: Assistant Professor (Dr Sun), Hunter-Bellevue
School of Nursing, Hunter College; Adjunct Faculty (Dr Sun), Research
Coordinator (Ms Fu), and Assistant Professor (Dr Cato), Department
of Research, Columbia University School of Nursing; and Nurse Re-
searcher (Dr Sun), Clinical Nurse Specialist (Ms O'Brien), and Director
of Nursing (Ms Stoerger), New York–Presbyterian, New York; Assis-
tant Professor of Clinical Informatics (Dr Cato), Columbia University
Department of Emergency Medicine; and Vice President and Chief
Nursing Officer (Mr Levin), New York–Presbyterian Queens, Depart-
ment of Nursing, Flushing, New York.
Conflicts: None to declare.
Correspondence: Dr Sun, Hunter-Bellevue School of Nursing,
Hunter College, 425 E 25th Street, New York, NY 10010
(cjs.cumc@gmail.com).
DOI: 10.1097/NNA.0000000000000897
JONA  Vol. 50, No. 6  June 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Kenrick D. Cato, PhD, RN, CPHIMS, FAAN
Lauren Stoerger, MSN, RN, NEA-BC, CCRN, CNRN
Alan Levin, MSN, MBA, RN, CPHQ, NEA-BC
While healthcare costs in the United States rank lower
compared with other high-resource countries, many
Americans lack high-quality care and suffer poor out-
comes.1 In 2005, in an effort to improve healthcare
quality and concomitantly reduce costs, Congress
identified hospital-acquired conditions that would
no longer be paid for by the Centers for Medicare &
Medicaid Services.2 Falls were among the list of
nonreimbursable hospital-acquired conditions citing
falls as a “serious preventable event.”2 Worldwide,
falls are the 2nd leading cause of death from acciden-
tal injury, and in the United States alone, the cost of
falls is estimated at $50 billion annually.3,4 Thus,
there is constant pressure on hospitals to improve pa-
tient safety and reduce costs from adverse events.
Nurse leaders are charged with cost containment
but are challenged with fall-prevention programs that
may be more costly than potential cost savings.5 Inter-
ventions including hourly rounding (HR), bedside
shift report (BSR), gait belts, and the use of chair or
bed alarms have been cited as effective.6-10 It has been
suggested that program development, including HR,
without leadership engagement, is not an effective fall
prevention strategy.7
While there has been a plethora of fall-prevention
strategies globally in a variety of settings,11,12 evidence
suggests that nursing presence is directly related to the
incidence of falls, with each additional RN hour
per patient day associated with a reduced fall rate.13
Whereas increased time with patients has been linked
with improved patient and nurse satisfaction and re-
duced falls, lack of nursing time and interaction with
patients have been associated with higher risks of ad-
verse events such as patient falls and medication errors
355
both in the United States and abroad.14-18 Nurses are
critical to improving healthcare quality and reducing
costs19,20 as nurses spend more time with patients than
any other healthcare worker, and the quantity of that
time spent is directly correlated with patient safety.14,15
Nurses can play a critical role in preventing falls and
other negative patient outcomes by quickly identifying
patients at risk as they care for patients, evaluating
these risks, and acting upon the changing status of
the patient, a process termed, “nurse surveillance.”21
Nurse surveillance has been seen as integral in reduc-
ing errors and improving patient outcomes, and
nurses are seen as key contributors to overall patient
surveillance.22,23
HR is the process by which a member of the nurs-
ing staff performs proactive, intentional rounds on ev-
ery patient, every hour to help identify and tend to the
patients' needs. The main components of HR include
addressing patients' needs for pain control, position-
ing, personal hygiene, and possessions, as well as
assessing the environment for safety and ensuring all
patient needs are met prior to leaving; however, the
exact definition of components and timing vary
widely.24 HR is purported to reduce patient anxiety,
set patient and family expectations, and decrease pa-
tient falls.25
BSR is the transfer of patient information, ac-
countability, and authority from nurse to nurse at a
patient's bedside to encourage patient participation
and continuity of care.26 A main objective of BSR is
to provide structured communication, which offers
additional benefits such as patient satisfaction and
improved outcomes, including reductions in patient
falls.26,27
With a push from organizations such as the Agency
for Healthcare Research and Quality and the Joint
Commission to involve the patient and the family dur-
ing BSR,28,29 as well as many studies recommending
HR by nurses, there has been little research to assess
how or whether BSR or HR is actually carried out,
or their subsequent effects on patient falls.8,30 A sys-
tematic review on the utility of HR to decrease falls re-
ported only 3 of 16 studies demonstrated a statistically
significant reduction in falls, and the method and defi-
nition of HR varied widely from study to study.31 A
scoping review on BSR reported that 18 of 22 studies
were about the implementation of these measures,
rather than looking at the longitudinal outcomes that
such interventions would affect.32 This could be due
to the difficulty assessing nurses' activities; direct ob-
servation is often costly, but methods such as video
surveillance can present ethical difficulties.33 The sem-
inal study by Meade et al34 suggested HR could im-
prove patient falls, decrease call bell use, and increase
patient satisfaction; however, all information about
356
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
whether HR was completed was self-reported data
by nurses. Less is known about the effects of these in-
terventions after the implementation period has ceased
to assess whether these changes are sustained and the
ultimate impact on patient-related outcomes.10
Previously, methodologies such as time-and-motion
and work sampling have been used to assess nurse and
patient interactions.35-38 While time-and-motion studies
involve constant, prolonged observation of participants,
work sampling is a method that has been used in
health-services research to more cost-effectively utilize
research staff by recording observations at intervals
(rather than constant observation) and analyzing these
observations with statistical modeling to allow a study
to capture longitudinal workflow habits.39 To date,
there is a paucity of observational nursing studies of
these types focused on BSR and HR.40
Therefore, the purpose of this study was to de-
scribe the frequency with which BSR and HR are car-
ried out and describe their relationship to patient falls
in a setting where these practices have been in place
for a period and to assess the sustained effect of these
interventions. This was to be accomplished through
the following aims:
1. Aim 1: Describe the frequency of BSR and HR
in inpatient medical/surgical units using work-
sampling technique.
2. Aim 2: Explore the relationship between nurse
surveillance including BSR and HR and pa-
tient falls.
H2: BSR and HR may be negatively associated
with patient falls.
Methods
Design
Work sampling was used to quantify nursing tasks
and detect relationships between those tasks.41 Nurses
were recruited to the study via direct verbal communi-
cation, and they verbally consented to participating in
the study. Each nurse was observed in intervals of
15 minutes at all hours of the day and all days of the
week; their activities were recorded at these intervals
using a previously published instrument, adapted for
the needs of this study.39 The nurses were not told spe-
cifically which tasks were being recorded, but that they
were common tasks one would perform in the nursing
profession. Supplemental training on BSR and HR was
not provided for this study.
Instrument
Using a previously published and validated tool for
work sampling in a nursing setting for observation,39
JONA  Vol. 50, No. 6  June 2020
researchers conducted tests for face validity among a
group of 7 RNs who worked in inpatient settings with
at least 1 year of full-time experience. The instrument
lists the tasks that nurses routinely perform through-
out their shift on an inpatient medical/surgical unit;
however, not all activities of interest in this study were
listed. Therefore, adaptations to the instrument were
guided by their input and existing literature to meet
the needs of the current study with the authors' per-
mission.39 We also included a single question about
the nurses' self-ranked level of expertise according to
Benner's42 “Novice to Expert” model to allow for ad-
justment for variations of experience level between
nurses in the statistical model.
Conceptual Definitions
Hourly Rounding
The healthcare system in which the study took place
does not have organizational policies that communi-
cate the expectation of staff to perform HR per proto-
col; however, patient experience guidelines are in
place that suggest nursing staff complete hourly
rounds during each shift. There are no regulations
set to define when HRs are expected to occur during
the hour, the format by which they should occur, or
the specific elements that should be included in HR.
Because of this and the fact that previous studies have
depicted a wide range of definitions of HR, we opted
to make our definition as broad as possible to give the
greatest chance of capturing HR. Therefore, we de-
fined HR as anytime a nurse was observed with the
patient at least once in an hour period.
Bedside Shift Report
The healthcare system the study took place has orga-
nizational policies that outline expectations for nurs-
ing staff to participate in BSR for every patient,
every shift. During the transfer of care, nurses use a
standardized handoff process to communicate rele-
vant patient information, introduce the oncoming
nurse, answer any patient and/or family questions
and concerns, and perform an environmental safety
check. The environmental scan includes ensuring the
patients' call bell is within reach, any equipment is
functioning properly, the bed is in the lowest position
with appropriate side rails up, and all clinical alarms
are functioning and properly set (ie, bed alarm). Sim-
ilarly, the nurse going off duty is responsible for com-
municating patients' fall risk factors and fall prevention
interventions specific for each patient. However, as
above, we opted to make our definition as broad as
possible to give the greatest chance of capturing BSR.
Therefore, for the purpose of this study, we counted
BSR as any observation where a nurse was giving re-
port to another nurse at the bedside (regardless of time
of shift) during a shift.
JONA  Vol. 50, No. 6  June 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Setting
Institutional review board (IRB) and site approval were
obtained at all study sites. The study was conducted at
4 hospitals: 2 large urban medical centers and 2 com-
munity hospitals. Two to 5 medical/surgical units at
each site were selected. All 4 hospitals were a part of
the same healthcare system and followed the same pol-
icies, procedure guidelines, and patient experience ex-
pectations; at the time of data collection, HR policies
were in place for at least 5 years and BSR for at least
3 years.
Variables
The dependent variable was the total number of falls
on the shift (inclusive of all types of falls). Indepen-
dent variables included nurse activities (as recorded
by the observer including BSR and HR), census, and
staffing data (Table 1).
Analysis Plan
The sampling plan was consistent with strategies rec-
ommended by Sittig41 for work sampling studies. A
sample size of 2100 observations (“observations” re-
ferring to the number of times an activity is docu-
mented rather than a unit of time) was calculated,
using 30% of nursing time spent on direct care activ-
ities based on historical studies, to detect a small effect
size using the methods described by Sittig.41 Observa-
tional data collected by the research assistant (RA) were
entered into IBM SPSS Statistics for Macintosh, version
25.0 (IBM Corp, Armonk, New York) for analysis.
Aim 1: Describe the Frequency of BSR and HR in
Inpatient Medical/Surgical Units Using
Work-Sampling Technique
Descriptive statistics were calculated to assess the fre-
quency of BSR and HR. HR was a categorical vari-
able (completed = yes or no) counted as any time a
nurse was observed with the patient during 1 of the
4 observations per hour (therefore, if a nurse was ob-
served with a patient at 8:15, HR was recorded as
“yes” for the 8:00, 8:15, 8:30, and 8:45 observa-
tions). For the purpose of this study, we counted
BSR as any observation where a nurse was giving re-
port to another nurse at the bedside (regardless of
time of shift).
Aim 2: Explore the Relationship Between Nurse
Surveillance Including BSR and HR and Patient Falls
H2: BSR and HR May Be Negatively Associated
With Patient Falls
Data on falls collected by the hospital were obtained
and tested for associations with BSR and HR via the
2-sample t test (or Wilcoxon rank-sum test) and the
w2 test (or Fisher exact test), as appropriate.
357
 Table 1. Variable Sources and Definitions
Variable Functional Definition Variable Type

Source: Observational data collected using work-sampling technique

Nurses' activities Nursing tasks recorded by observer (see SDC 1) Continuous (no. per
12-h shift)
BSR by nurses Two nurses observed at bedside giving report on the patient at least Continuous (no. per
once per 12-h shift. 12-h shift)
HR by nurses Nurse observed with patient at least once per hour Continuous (no. per
12-h shift)
Frequency of nurse interactions No. of times nurse is at bedside during 12-h shift Continuous (no. per
with patients 12-h shift)
Source: Existing hospital quality data collected through NYP Quality Department, reported according to national reporting
standards
Patient falls Existing assisted and unassisted falls data as defined by National Categorical (yes or no) per
Database of Nursing Quality Indicators 12-h shift
Census data No. of patients on the unit during the shift Continuous (number
per 12-h shift)
Source: Existing hospital data collected through Hospital Personnel Department
Nurse staffing data No. of unique nurses during the shift Continuous (no.
Staffing ratios on the unit per shift per 12-h shift)

Because the fall data were at the shift level, corre-
lations between BSR and HR and falls were con-
ducted at the shift level. A score to represent level of
nursing expertise was created by using the average
of the nurse level of expertise per shift. Identified pre-
dictor variables with P < .30 on univariate analysis
(ie, for univariate relationship between predictor var-
iable of interest and fall binary outcome) were entered
into a multivariable logistic regression model.43,44
Collinearity between predictors in the model were
evaluated prior to the formulation of the final multi-
variable model, and outliers were removed from the
final model. A Hosmer and Lemeshow test was per-
formed to test goodness of fit of the final model.45 Ad-
justed odds ratios (ORs) and 95% confidence intervals
(CIs) for all predictor variables of interest were esti-
mated from the multivariable model. All P values were
2-sided with statistical significance evaluated at the .05
a level.46,47 Ninety-five percent confidence intervals for
all parameters were calculated to assess the precision
of the obtained estimates.
Recruitment
Before the observation, the RA consented and en-
rolled nurses to participate in the study. The purpose
of the study and the study procedures were explained,
and the RA answered any questions. A handout was
provided with information about the study and con-
tact information of the principal investigator (PI)
and IRB; nurses were asked to self-rank their level of
expertise.
Results
Six RAs collected a total of 9696 observations from
11 units and 168 nurses between November 2017 to
November 2018 over 281 shifts. The RAs consisted
of 3 RNs, 2 certified nurse specialists at the sites
(but who did not work on the units), and 1 RA with
a master's degree in public health; 2 were hired, and
the others were volunteers. All hours of the day and
days of the week were observed. To ensure that data
were collected consistently, we trialed the data collec-
tion process by having the PI and all the RAs at each
site collect data simultaneously on the same nurses
to compare results for interrater reliability between
data collectors. We discussed differences and pro-
ceeded until we achieved 100% agreement among
raters (because the observations occur at an exact mo-
ment in time, and nurses move quickly from one task
to the next, there was some variability between ob-
servers because of differences in timepoints, but no
variability in assessment of what the activities were).
We subsequently retrialed the data collection process
and compared results for interrater reliability between
data collectors; 78% agreement was achieved, which
describes strong agreement.48 The vast majority of
the observations were collected by a single observer
(one of the paid RAs, n = 8626 [88.9%]) over a period
of about a year.
Description of Nurse Surveillance
Nurses conducted HR in 57.7% (n = 5595) of the pos-
sible instances to do so. BSR was observed in 18.9%
(n = 53) of the shifts. The nurse was observed with
the patient in 23.1% of the observations (n = 2244).
Associations With Falls
Tests for associations between falls and predictor var-
iables revealed statistically significant differences be-
tween day and night shift associations between falls

358 JONA  Vol. 50, No. 6  June 2020

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Table 2. w2 Categorical Variable Association
With Falls
Variable 2
w Statistic
Unit 7.49
Day shift/night shift 5.34
Day of the week 17.26
Weekend/weekday 0.07
Site 3.55
BSR 0.01
Significant at P = .05 level (2-sided). Those with a P < .3 were en-
tered into the logistic regression.
and day shift/night shift (w2 = 5.34, P = .02) with falls
more often occurring on night shift; and day of the
week (w2 = 17.26, P < .01) with falls most often occur-
ring on Monday (Table 2). Other predictor variables
were not statistically significant (Tables 2 and 3).
Because census and staffing levels were found to
have high multicollinearity, these factors were not in-
cluded in the final model; retesting after removal of
these factors resulted in a variance inflation factor
(VIF) <2 for all independent variables. A binomial lo-
gistic regression was performed to ascertain the effects
of variables with P < .3 (shift, day of the week, fre-
quency with patient and HR) on the likelihood of a fall
during the shift; 8 cases were identified as outliers and
removed from the final logistic regression. The final
model was statistically significant w2 = 41.802, P <
.01). The Hosmer and Lemeshow test for goodness
of fit was w2 = 0.439, P > .99, indicating a good fit.
The Nagelkerke R2 test was 0.666, indicating 66.6%
of the variance in falls can be explained by the model.
In the final model, only the number of times the nurse
was observed with the patient remained significant
(B = 0.564, P = <0.01), indicating for 1-unit increase
in falls we expect a 0.564 increase in the number of
observations with the patient (OR, 1.76; CI, 1.148–
2.690). However, HR was near significance; for each
reduction in the number of times the patient had HR,
the odds of a fall increased by a factor of 1.20 (OR,
0.831; CI, 0.674–1.024; P = .08) (Table 4).
Table 3. Independent t Test for Mean of Continuous Variables With Number of Falls
Variable
Average level of nursing expertise
No. of observations with patient
No. of times observed doing HR
Average census
Average staffing
Significant at P = .05 level (2-sided). Those with P < .3 were entered into the logistic regression.
JONA  Vol. 50, No. 6  June 2020
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Discussion
In this study, we observed HR in 57.7% of the obser-
P vations; because of the paucity of direct observational
studies of this type, it is unknown if this represents
.68 higher or lower than average HR. Likewise, BSR
.02
.01 was observed in 18.9% of the observations, but it is
.79 unknown how this compares nationally because there
.31 are few objective data on this topic. In addition to
.91
these metrics, we found the nurse was observed pro-
viding direct patient care in 23.1% of the observations.
This is consistent with but slightly higher than previous
studies, which have suggested nurses spend between
19.3% and 20.4% on direct patient care in medical/
surgical units.49,50
Interestingly, this study suggested that while HR
could potentially reduce patient falls, the frequency
of interactions at the bedside alone may not reduce
patient falls. Intuitively, nurses at the bedside more
frequently may signal that the patient is a higher fall
risk; future studies could adjust for this through the
use of electronic health records to identify diagnoses,
comorbidities, and so on, to elucidate this phenomenon.
While this study included both community and
academic medical center hospitals, falls rates were
comparable between the 2 settings. It is important to
note that all hospitals in this study are in urban areas.
Further investigation of the relationship of nurse
rounding and falls in the rural versus urban setting
is needed. Researchers have observed regional differ-
ences in falls51 that have been attributed to differences
in the environment, hospital characteristics, and local
practices.52 A study of 3 rural hospitals in Australia
found mixed results in patient falls following imple-
mentation of BSR.10 More research focusing on the
setting-specific factors for falls in urban versus rural
hospitals is also needed.
This study is limited by the fact that the data were
collected in 15-minute intervals rather than through
constant observation; these intervals may not have
captured every BSR or incidence of HR. The use of
technology to conduct studies to provide continuous
95% CI
Sig (2-Tailed)
t Test Statistic P Lower Upper
0.45 0.65 −0.44 0.71
−1.88 0.08 −11.62 0.74
−1.33 0.21 −18.94 4.43
−1.70 0.11 −5.78 1.46
−0.87 0.41 −0.74 0.34
359
 Table 4. Statistically Significant or Near-Significant Variables in Final Logistic Regression Model With
Falls as the Outcome Variable
Variables in the Equation
B SE
No. of times nurse observed with patient 0.564
No. of times HR = yes −0.185
Constant −42.114
Test for significance of model w2 = 41.802, P < .01, indicating a statistically significant model. Hosmer and Lemeshow test w2 = 0.439, P > .99, indicating
a good fit. Nagelkerke R2 = 0.666, indicating 66.6% of the variance in falls can be explained by the model.
monitoring (eg, obfuscated computer vision or radio-
frequency identification) could improve this study
and further clarify the utility of BSR and HR, and
the overall influence of nurse surveillance. Moreover,
this study did not assess the quality of the interactions
with patients; future studies could examine this aspect
of nurse-patient interactions. Finally, because of the
low number of falls during the data collection period,
a longer study or sites with higher fall rates may be
able to better capture the effects of BSR and HR on
patient falls. Future studies could also consider adding
patient characteristics to better describe the nature of
the falls and associated characteristics. While this study
objectively examines the frequency of nursing interac-
tions of patients, further research is needed to improve
the understanding the quality of the interactions, as
well as the component of interactions that actually af-
fect patient outcomes in order to justify the cost for
nursing management to implement measures such as
HR and BSR.
Conclusion
Reducing inpatient falls is a major concern of hospi-
tals nationally and globally. There may be continued
opportunities to redistribute nursing workload or to
redesign workflow such that the nurse has increased
opportunities for direct patient contact, including
BSR and HR; future studies could help elucidate
whether these measures are necessary or helpful in
1. McGlynn EA, Asch SM, Adams J, et al. The quality of health
care delivered to adults in the United States. N Engl J Med.
2003;348(26):2635-2645.
2. Centers for Medicare & Medicaid Services. (2007). CMS-
1533-FC. Medicare program; changes to the hospital prospec-
tive payment system and fiscal year 2008 rates. (pp. 352-357).
3. Centers for Medicare & Medicaid Services. Falls. https://www.who.
int/news-room/fact-sheets/detail/falls. Accessed February 10, 2020.
4. Florence CS, Bergen G, Atherly A, et al. Medical costs of fatal
360
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
95% CI for Exp(B)
Wald df P Exp(B) Lower Upper
0.217 6.734 1 0.009 1.757 1.148 2.690
0.107 3.015 1 0.083 0.831 0.674 1.024
5982.930 0.000 1 0.994 0.000
improving patient outcomes. Continued studies to illu-
minate the utility of measures such as BSR and HR
could help understand the most cost-effective use of
time and resources, as well as how to maintain the qual-
ity of nurse-patient interactions. Institutions should ex-
amine the possibility that factors such as day of the
week and shift may play a role in falls, and nursing
management should also consider ways to increase
the sustainability of BSR and HR after rollout.
While there have been an increasing number of
studies conducted on the implementation of BSR
and HR, less is known about the long-term sustain-
ability of these measures or subsequent effects on re-
ducing falls. This study contributes to the literature
by examining the effects of these measures long after
the initial rollout and suggests hospital leadership
should consider how to ensure sustainability of these
practices to increase the long-term benefits.
Acknowledgments
The authors thank the reviewers and editor for their
comments, which helped them refine and strengthen
their manuscript. They also acknowledge with grati-
tude funding that supported this study: Columbia
University School of Nursing Intramural Grant and
a gift from Inspiren, Inc. Finally, they thank all of
the nurses who participated in the study, not only
for helping them with this study but also for all the
work these nurses do every day.
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