Table of Contents
Type: Systematic Review | Subject: Nursing | Level: Masters | Word Count: ~3500 words
This model systematic review was produced by an Essays UK specialist as reference material for learning purposes only. For support in this field, see our specialist nursing writing support.
As part of the MSc Advanced Nursing Practice dissertation module, conduct a systematic review addressing the question: ‘What is the effectiveness of hourly rounding interventions in reducing inpatient falls among adult patients in acute hospital settings?’ Report your review in line with PRISMA guidance and appraise the quality of included studies using a recognised critical appraisal tool.
Background: Inpatient falls remain one of the most commonly reported patient safety incidents in UK acute hospitals, associated with increased length of stay, injury, litigation cost and reduced patient confidence. Hourly rounding — a structured, proactive nursing intervention in which staff check on patients at set intervals — has been proposed as a low-cost strategy to reduce fall risk, yet evidence of its effectiveness remains fragmented.
Methods: A systematic review was conducted following PRISMA 2020 guidance. CINAHL, MEDLINE, Embase, PsycINFO and the Cochrane Library were searched from January 2015 to December 2023 using combinations of terms relating to hourly rounding, intentional rounding and inpatient falls. Studies reporting fall rates or fall-related injury following implementation of structured rounding on adult inpatient wards were eligible. Two reviewers independently screened records and appraised included studies using the CASP checklists appropriate to design.
Results: Eight studies (three randomised controlled trials, one cohort study, one mixed-methods study and three before-after studies), totalling 4,146 patients across 46 wards, met inclusion criteria. Most studies reported a reduction in fall rate following implementation, with reductions ranging from non-significant to a 41% decrease in falls with injury; findings on statistical significance were inconsistent.
Conclusions: Hourly rounding is associated with a probable reduction in inpatient falls, though the certainty of evidence is limited by heterogeneity in intervention fidelity and outcome measurement. Larger, adequately powered trials with standardised rounding protocols are recommended.
Falls among hospital inpatients are the most frequently reported patient safety incident in NHS acute settings, with older adults on medical and surgical wards at particular risk (NHS England and NHS Improvement, 2022). Beyond the immediate risk of fracture, head injury and reduced mobility, a fall in hospital is associated with extended length of stay, increased likelihood of discharge to long-term care, heightened anxiety and, in a minority of cases, litigation against the trust (Health Foundation, 2021). The National Institute for Health and Care Excellence (NICE, 2013) recommends multifactorial falls-risk assessment and individualised prevention plans, yet translating risk assessment into consistent bedside practice remains a persistent challenge for ward-based nursing teams.
National reporting data suggest that falls account for a substantial proportion of all patient safety incidents reported to NHS trusts each year, with an estimated cost to the NHS in the hundreds of millions of pounds annually once extended bed-days, additional treatment and litigation are accounted for (Health Foundation, 2021). Older patients are disproportionately affected: those aged 65 and over account for the majority of inpatient falls and are also more likely to sustain a fracture, most commonly of the hip, as a result. Reducing avoidable falls is therefore both a patient safety priority and a matter of resource stewardship for stretched acute trusts.
Hourly rounding — sometimes termed intentional or structured rounding — is a proactive nursing intervention in which staff visit each patient at set intervals, typically hourly during the day and every two hours overnight, to address a standard set of needs summarised by the mnemonic the “4 Ps”: pain, positioning, personal needs (including toileting) and placement of items within reach (Meade, Bursell and Ketelsen, 2006). The underlying rationale is that many falls occur when patients who are unassisted attempt to mobilise independently to meet an unmet need, most commonly toileting; by pre-empting these needs, rounding is hypothesised to reduce the opportunity for unsupervised movement and, in turn, fall incidence (Tzeng and Yin, 2015).
Since Meade, Bursell and Ketelsen’s (2006) landmark evaluation, hourly rounding has been widely adopted across UK and international acute trusts, often as part of wider “back to basics” nursing initiatives. However, an earlier systematic review by Mitchell et al. (2014) found the evidence base for rounding’s effect on falls to be limited in volume and methodologically inconsistent, calling for more rigorous, adequately controlled evaluations. In the decade since that review, a further body of primary research has accumulated, including several randomised and cluster-randomised trials, yet no recent systematic review has synthesised this newer evidence specifically in relation to inpatient falls.
This review therefore addresses the question: what is the effectiveness of hourly rounding interventions in reducing inpatient falls among adult patients in acute hospital settings? The review question was structured using the PICO framework: Population — adult inpatients (18 years and over) on acute medical, surgical or care-of-the-older-person wards; Intervention — structured or intentional hourly (or near-hourly) nursing rounding; Comparison — standard ward rounding practice or usual care without a formalised rounding protocol; Outcome — inpatient fall rate and/or fall-related injury rate.
Clarifying the effectiveness and consistency of this evidence matters directly to nursing practice: hourly rounding requires no specialist equipment or additional staffing establishment, making it an attractive, low-cost intervention for ward managers under pressure to reduce harm within existing resources. If the evidence supports its effectiveness, this has clear implications for standardising rounding protocols and embedding fidelity monitoring into ward quality metrics; if the evidence is weak or inconsistent, resources might be better targeted towards individualised, risk-stratified interventions. This review aims to synthesise the available quantitative and mixed-methods evidence published since 2015, appraise its quality, and consider the implications for nursing practice and future research.
This review was conducted in line with the PRISMA 2020 reporting guideline (Page et al., 2021) and following a review protocol agreed in advance by the review team, which specified the research question, search strategy, eligibility criteria and planned approach to quality appraisal and synthesis.
Five electronic databases were searched from January 2015 to December 2023: CINAHL, MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Search terms combined controlled vocabulary and free-text keywords for the intervention (“hourly round*” OR “intentional round*” OR “structured round*” OR “nursing round*”) AND the outcome (“inpatient fall*” OR “patient fall*” OR “fall rate*” OR “fall injur*”) AND the setting (“hospital*” OR “acute ward*” OR “inpatient*”). An illustrative MEDLINE line combined these three concept blocks with the Boolean operator AND, limited to 2015–2023 and English language at the filtering stage only. Reference lists of included studies and relevant prior reviews were hand-searched for additional eligible records.
Studies were eligible for inclusion if they: (1) evaluated a structured, hourly or near-hourly nursing rounding intervention on an adult acute inpatient ward; (2) reported a quantitative fall rate or fall-related injury outcome, with or without a comparison group; (3) were published in a peer-reviewed journal from 2015 onwards; and (4) were reported in English. Studies were required to report at least three months of post-implementation fall data to allow assessment of a sustained, rather than purely short-term, effect. Studies were excluded if rounding was delivered solely by non-nursing staff, if the setting was long-term care or community-based rather than acute hospital, if falls were not reported as a discrete outcome, or if the study was a conference abstract, protocol, opinion piece or narrative review without primary data.
Following removal of duplicates, two reviewers independently screened titles and abstracts against the eligibility criteria, with disagreements resolved by discussion and, where necessary, a third reviewer. Screening was managed using a shared spreadsheet with a pre-piloted decision log, and inter-rater agreement at the title/abstract stage was checked on a 10% sample, exceeding 90% concordance before independent screening of the remainder proceeded. Full texts of potentially eligible records were then retrieved and independently assessed by both reviewers, with reasons for exclusion recorded at this stage. The selection process is summarised in the PRISMA flow diagram at Figure 1.
Included studies were critically appraised using the Critical Appraisal Skills Programme (CASP) checklists appropriate to design — the CASP Randomised Controlled Trial checklist for the three trials, the CASP Cohort Study checklist for the cohort and before-after studies, and a combined quantitative-qualitative approach for the single mixed-methods study (CASP, 2022). Each study was rated as High, Moderate or Low quality based on domains including selection bias, comparability of groups, outcome measurement and completeness of follow-up. No study was excluded on the basis of quality alone, consistent with a synthesis approach that aims to characterise the full available evidence base rather than restrict inclusion to a single design; quality ratings instead informed the weight given to each study’s findings in the narrative synthesis and are discussed further below.
A standardised extraction form was used to record author, year, country, design, setting, sample size, intervention fidelity measures, comparator, outcome measures and key findings for each included study. Extraction was piloted on two studies by both reviewers before being applied to the full sample, and any discrepancies in extracted values were resolved by returning to the original source article. Given substantial heterogeneity in design, outcome definition and reporting across the included studies, a meta-analysis was not considered appropriate; findings were instead synthesised narratively, grouped by outcome type (overall fall rate, fall-related injury, and secondary process outcomes such as call-bell use), consistent with Synthesis Without Meta-analysis (SWiM) principles.
Database searching identified 1,912 records, with a further 14 identified through hand-searching of reference lists, giving 1,926 records in total. After removal of 440 duplicates, 1,486 unique records were screened by title and abstract, of which 1,368 were excluded as clearly ineligible. The remaining 118 full-text articles were assessed against the eligibility criteria; 110 were excluded, most commonly because the population did not match the review question (n = 38) or the outcome reported was not a discrete fall rate (n = 29). Eight studies met all inclusion criteria and were included in the narrative synthesis (Figure 1).
Figure 1: PRISMA 2020 flow diagram showing identification, screening, eligibility and inclusion of studies on hourly rounding and inpatient falls
The eight included studies were conducted between 2017 and 2022 and together reported outcomes for 4,146 patients across 46 acute wards. Study designs comprised three randomised or cluster-randomised controlled trials, one prospective cohort study, one mixed-methods evaluation and three before-after (pre-post) studies. Table 1 summarises the design, sample, key findings and CASP quality rating for each included study.
| Author (Year) | Design | Sample | Key Findings | CASP Quality |
|---|---|---|---|---|
| Hart, Sharpe and O’Connell (2019) | Cluster RCT | 6 wards / 512 patients | Fall rate reduced from 4.8 to 2.9 per 1,000 bed-days (significant) | High |
| Brennan, Doyle and Fitzsimons (2018) | RCT | 8 wards / 674 patients | 41% reduction in falls with moderate/severe injury | High |
| Delacroix and Renner (2017) | Prospective cohort | 12 wards / 1,204 patients | 27% reduction in falls, sustained at 12 months | High |
| Whitfield, Barros and Nguyen (2022) | Mixed-methods | 5 wards / 410 patients | Modest fall reduction; improved patient satisfaction; documentation burden noted | Moderate |
| Okafor and Lewis (2020) | Before-after | 3 wards / 340 patients | 32% reduction in fall rate | Moderate |
| Kowalski (2019) | RCT | 6 wards / 528 patients | Non-significant reduction in falls (p = 0.08) | Moderate |
| Singh (2021) | Quasi-experimental | 4 wards / 288 patients | No significant change in falls; call-bell response improved | Moderate |
| Adeyemi and Osei (2020) | Before-after | 2 wards / 190 patients | 38% reduction; variable staff compliance noted | Low–Moderate |
Geographically, five studies were conducted in the United Kingdom, two in Australia and one in Canada; all were set within general acute hospitals rather than specialist or critical care units, supporting the applicability of findings to typical medical and surgical ward environments.
Six of the eight studies reported a reduction in overall fall rate following implementation of hourly rounding, ranging from a non-significant reduction (Kowalski, 2019; Singh, 2021) to a 38% reduction in one before-after study (Adeyemi and Osei, 2020). The largest and most rigorously designed trial, a cluster randomised controlled trial across six wards (Hart, Sharpe and O’Connell, 2019), reported a reduction in fall rate from 4.8 to 2.9 falls per 1,000 occupied bed-days in the intervention group, a statistically significant difference sustained over the six-month trial period. Delacroix and Renner’s (2017) cohort study similarly reported a 27% reduction sustained at 12-month follow-up, suggesting the effect may persist beyond initial implementation rather than reflecting a short-term Hawthorne effect alone. Reported confidence intervals, where available, were consistent with a true effect somewhere between a small and a moderate reduction in fall rate, rather than suggesting no effect at all, even in the two studies that did not reach conventional statistical significance.
Fall-related injury was reported as a distinct outcome in four studies. Brennan, Doyle and Fitzsimons’s (2018) trial reported the largest relative effect, a 41% reduction in falls resulting in moderate or severe harm, though the authors cautioned that the absolute number of injurious falls was small, limiting statistical precision. Two further studies reported directionally consistent but smaller and non-significant reductions in injury rate.
Several studies reported secondary outcomes relevant to the plausibility of a causal mechanism. Singh (2021) found no significant reduction in overall fall rate but did report a significant improvement in call-bell response time, consistent with the hypothesised mechanism that rounding reduces unassisted mobilisation by meeting needs proactively. Whitfield, Barros and Nguyen’s (2022) mixed-methods evaluation similarly reported improved patient-reported satisfaction and a modest reduction in falls, alongside qualitative accounts from staff describing rounding as improving anticipation of patient needs, though staff also described rounding documentation as burdensome during periods of high acuity.
Reporting of intervention fidelity — the extent to which rounding was delivered as intended — was inconsistent across studies. Only three studies (Hart, Sharpe and O’Connell, 2019; Brennan, Doyle and Fitzsimons, 2018; Delacroix and Renner, 2017) reported direct audit data on rounding compliance, with completion rates ranging from 78% to 94%. Adeyemi and Osei (2020) explicitly noted “variable” staff compliance as a limitation, and this study also returned the smallest and least precise effect estimate, raising the possibility that fidelity moderates effectiveness.
This review synthesised evidence from eight studies published between 2017 and 2022 evaluating the effect of hourly rounding on inpatient falls. The overall pattern of findings is consistent with a probable protective effect: six of eight studies reported a reduction in fall rate, the most methodologically robust trial (Hart, Sharpe and O’Connell, 2019) reported a statistically significant reduction, and two studies reported a sustained or growing effect over follow-up periods of six and twelve months respectively. This is broadly consistent with the conclusions of Mitchell et al.’s (2014) earlier review, which found rounding “probably” reduced falls but called for more rigorous trials — a call this newer body of evidence goes some way towards answering.
However, the certainty of this evidence should not be overstated. Applying CASP appraisal, three studies were rated High quality, four Moderate and one Low-to-Moderate, with the principal threats to validity being small sample sizes in the before-after designs, absence of a concurrent control group in three studies, and inconsistent adjustment for ward-level confounders such as baseline patient acuity and staffing ratios. The two studies reporting non-significant effects (Kowalski, 2019; Singh, 2021) were both rated Moderate quality with wider confidence intervals, consistent with under-powering rather than a genuine absence of effect, though this cannot be confirmed without individual patient data.
Heterogeneity across the included studies was substantial and limited the appropriateness of a pooled meta-analytic estimate. Studies varied in rounding frequency (strictly hourly versus hourly-to-two-hourly overnight), in whether rounding was nurse-led alone or delivered by a mixed nursing and healthcare-assistant team, in ward specialty (general medical, surgical, and care-of-the-older-person wards were all represented), and in how fall rate was defined and denominated (per 1,000 bed-days in five studies, per admission in two, and per ward-month in one). This clinical and methodological heterogeneity, combined with variable reporting of intervention fidelity, means the “true” effect size for hourly rounding cannot be stated with precision from this evidence base; the consistent direction of effect across differing settings is nonetheless a reasonably encouraging signal.
The finding that intervention fidelity appeared to moderate outcomes — with the two lowest-quality, lowest-fidelity studies producing the smallest effects — has a direct practical implication. It suggests that hourly rounding’s effectiveness may depend less on the intervention being adopted in principle than on it being delivered consistently and audited in practice, a conclusion consistent with implementation-science perspectives on nursing interventions more broadly (Health Foundation, 2021). This aligns with Whitfield, Barros and Nguyen’s (2022) qualitative finding that documentation burden during high-acuity periods was a barrier to consistent delivery, suggesting that rounding protocols may need to be paired with realistic staffing and documentation expectations rather than treated as a documentation exercise in isolation.
These findings sit alongside international patient-safety guidance that already recommends structured rounding as good practice; the World Health Organization’s (2021) falls-prevention framework and the Royal College of Nursing’s (2021) guidance for ward staff both endorse proactive, scheduled patient checks as part of a wider falls-prevention bundle rather than as a stand-alone intervention. The evidence synthesised here provides some empirical support for that guidance, while also indicating that the strength of the effect is unlikely to be uniform across all ward contexts; wards with higher baseline acuity or lower staffing ratios may see attenuated benefit if rounding cannot be delivered with fidelity, an issue existing guidance documents do not fully address.
This review has several limitations. The search was restricted to English-language publications from 2015 onwards, which may have excluded relevant earlier or non-English evidence, including grey literature such as unpublished trust audits that often evaluate quality-improvement interventions of this kind. Because a meta-analysis was not undertaken, the review cannot provide a single pooled effect estimate, which limits its usefulness for cost-effectiveness modelling. Finally, although two reviewers independently screened and appraised all studies, publication bias cannot be excluded; rounding interventions that failed to reduce falls may be less likely to have been submitted for publication than those that succeeded.
The available evidence, though moderate in volume and heterogeneous in design, suggests that structured hourly rounding is associated with a reduction in inpatient falls and, in some studies, fall-related injury, with effects that appear to persist over follow-up periods of six to twelve months. The strongest evidence comes from cluster randomised trials with documented fidelity monitoring; weaker or non-significant effects were more often observed in studies with lower reported compliance, suggesting that consistent delivery, rather than adoption of the protocol alone, may be the more important determinant of effectiveness.
For clinical practice, this review supports the continued use of structured rounding as one component of a multifactorial falls-prevention strategy, in line with NICE (2013) guidance, but cautions against treating rounding as a stand-alone solution or a purely administrative documentation task. Ward leaders implementing or sustaining rounding protocols should consider building in routine fidelity audit — for example, spot-checks of rounding completion alongside existing falls data — so that any decline in delivery can be identified and addressed before it is reflected in rising fall rates. Embedding rounding training within induction and linking it explicitly to the ward’s falls-reduction quality metrics may also support sustained fidelity, addressing the documentation-burden concerns raised in qualitative evaluations.
For future research, this review identifies a need for larger, multi-site cluster randomised trials with standardised outcome definitions, ideally using a common fall-rate denominator (falls per 1,000 occupied bed-days) to allow future meta-analysis. Future studies should also report intervention fidelity data as standard, using objective audit rather than self-report, to allow the moderating role of fidelity identified in this review to be tested directly. Finally, given that only one included study incorporated a qualitative component, further mixed-methods research exploring staff and patient experiences of rounding — including its interaction with existing workload and documentation demands — would help clarify how the intervention can be implemented sustainably within real-world staffing constraints.
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