feature article

Implementing Nursing
Grand Rounds in a
Community Hospital
KATHLEEN M. FURLONG, MSN, RN, ANP-C;
LUBELLE D’LUNA-O’GRADY, MSN, RN;
MARGARET MACARI-HINSON, MSN, RN, CCRC;
KAREN B. O’CONNEL, MN, RN, CNS; ELIA L. PEREZ, MSN, RN, GNP-C;
GINGER S. PIERSON, MSN, RN, CCRN, CNS

urpose: The purpose of this article is to describe the process of implementing Nursing
P Grand Rounds in a community hospital. Methods: The Advanced Practice Council of
clinical nurse specialists and nurse practitioners used Benner’s theoretical framework of
skill acquisition to guide the process. The development and implementation included the
following: (1) conducting a convenient interest survey, (2) establishing targeted marketing
strategies and a delivery format template for Nursing Grand Rounds, (3) mentoring clinical
nurses, and (4) evaluation. Conclusion: Our institution has established Nursing Grand
Rounds as a forum ‘‘For our Nurses, By our Nurses.’’ The forum was held quarterly with
survey feedback demonstrating increased awareness by clinical nurses and growing
attendance. Implications: As a designate Magnet hospital, our Advanced Practice Council
established a forum to promote and demonstrate excellence in nursing. The attributes of
advanced practice nursing are the cornerstone to successful implementation of Nursing
Grand Rounds. The involvement of clinical nurses across the 5 stages of proficiency in skill
acquisition is a means to retain clinical experts and foster the development of nurses from
novice to expert.
KEY WORDS: nursing grand rounds, advanced practice nurses, staff development,
evidence-based practice

T he Advanced Practice Council (APC), established in 2003, was created to foster a

collegial environment for networking and peer support. The APC membership
included nurse practitioners (NP), clinical nurse specialists (CNS), bedside/staff nurses
who held a clinically focused master’s degrees in nursing, and nursing graduate students

Author Affiliations: Hoag Memorial Hospital Presbyterian, Newport Beach, California.

Corresponding author: Kathleen M. Furlong, MSN, RN, ANP-C, Hoag Memorial Hospital Presbyterian,
Neuroscience Center, One Hoag Drive, PO Box 6100, Newport Beach, CA 92658-6100 (kfurlong@
hoaghospital.org).

Clinical Nurse SpecialistA Copyright B 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

VOLUME 21 | NUMBER 6 2 87

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pursuing clinically focused advanced nursing degrees. The interest survey was conducted. An APC subcommittee,
APC mission is to improve outcomes by promoting evidence- compromised of CNSs and NPs from diverse clinical
based practice through leadership, education, and research. specialty areas, developed the interest survey instrument,
The APC introduced the concept of Nursing Grand Rounds which was distributed to a convenience sample of the
(NGRs) as a means for promoting excellence in evidence- clinical nurses. The survey instrument was a 1 page and
based practice and improving outcomes of nursing care. distributed by NGR subcommittee members to unit nurse
Very little has been published about either the process educators who distributed it to clinical nurses for comple-
or outcomes of NGR.1–4 It is apparent, however, that, tion. The survey was collected by the educators and re-
currently, NGRs are intended to link the evidence-based turned to the NGRs subcommittee. Overall, the staff was
practice literature to the clinical practice of nursing, having very supportive of NGRs and the survey results (Table 1)
been described as ‘‘an organized learning activity in which were used to help structure NGRs. The next step was to
relatively large numbers of nurses gather in a central develop goals for the NGRs. The goals, viewed as the
location to hear a topic or case presented.’’5 The NGRs cornerstone, include the following: to assist staff in
environment is intended to foster advancement of nursing
practice by addressing the learning needs of nurses in
clinical practice. Nursing Grand Rounds provide a forum Table 1. 2004 NGR Interest Survey
for peers to recognize individuals for clinical expertise, to Resultsa
foster networking among diverse clinical nursing specialty
areas, and to promote the value of each nurse’s contribu- Question Results
tion. The purpose of this article is to describe the process
used by CNSs and NPs working collaboratively in an APC Probability you would For sure!!! 24%
to successfully implement NGRs in a community hospital. attend grand rounds Probably 53%
on your scheduled No way 23%
day off?
(n = 100)
GUIDING FRAMEWORK What length of time 2h 68%
Benner’s6 novice to expert framework served as the guiding would Grand Rounds 3h 6%
conceptual framework for the development of NGRs. be appropriate for 1h 25%
Benner’s framework was being used in the hospital to you?
(n = 95)
guide the conceptualization of nurses’ professional develop- What time of day? Early morning 20%
ment through different stages of clinical knowledge and Mid-morning 55%
judgment, skill acquisition, and experience, which NGRs
Mid-afternoon 17%
were designed to also support.
Late afternoon 9%
Benner’s6 framework describes 5 levels of skill acquisi-
tion: (1) novice, (2) advanced beginner, (3) competent, (4) (n = 115)
proficient, and (5) expert. It was assumed that involving How often would you Monthly 39%
nurses of different levels knowledge and skill in a collabo- suggest Grand Every other month 31%
Rounds be Quarterly 30%
rative project such as NGR would promote problem solving
presented?
and further skill acquisition among more novice nurses as (n = 105)
expert nurses made their judgments transparent by discus- What format would Patient case study 41%
sing the nuisances of each case. Nursing Grand Rounds you prefer? presentations
focused on situation-based interpretive learning by identi- Nursing guest speaker 30%
fying and describing knowledge for clinical practice and presentations
incorporating evidence into practice. Thus, the clinical Unit-based Bedside 29%
nurse was guided by experts in the process of applying Rounds (RN/CNS/NP)
evidence in real-time situations. (n = 165)
Topic Suggestions for Neurology
Grand Rounds Evidenced-based practice
NURSING GRAND ROUNDS Pain management
Hoag Memorial Hospital Presbyterian is a 511-bed, not- Women and heart disease
for-profit acute care hospital located in Newport Beach, COPD
California. The hospital earned Magnet accreditation from Cardiovascular
the American Nurses Credentialing Center). Achieving Sepsis
Magnet accreditation is a recognition that a healthcare or- Heart failure
ganization demonstrates leadership in excellence in nursing Diabetes
practice while adhering to national standards for nursing
Cancer
practice and patient outcomes.
Abbreviations: CNS, clinical nurse specialist; COPD, chronic obstructive
pulmonary disease; NGR, Nursing Grand Rounds; NP, nurse practitioner;
Assessment RN, registered nurse.
a
Some responded to more than 1 choice for length of time, time of day, and
It was important to engage clinical nurses in the early NGR frequency and format. Percentages may not equal 100 due to rounding.
planning phase. To obtain nurses’ interest in NGRs, an

288 CLINICAL NURSE SPECIALISTA

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developing knowledge and skills, to foster a learning
environment, to highlight the work of expert nurses, and
to support knowledge and skill acquisition among novice
and beginner level nurses and nurture nurses’ professional
development (Table 2).
The Blueprint
The NGRs’ subcommittee developed the blueprint for the
NGRs format, incorporating the survey results. As a Magnet
hospital, the focus was to demonstrate excellence in nursing
practice, thus the descriptive motto for our NGRs was
developed a forum ‘‘For our Nurses, By our Nurses.’’ The
impetus for this motto was to communicate the environment
and focus of the NGRs as a collegial nursing forum.
To assure attendance, the planning process included
marketing strategies. The subcommittee met with the
hospital’s corporate communications department and
developed a formal announcement that included the
presentation topic and registration information. To rein-
force the purpose of NGRs, all printed announcements
included the motto ‘‘For our Nurses, By our Nurses.’’
Printed announcements were distributed to the units by
APC council members. Charge nurses and nurse educators
were encouraged by the NGRs subcommittee to be NGR
Ambassadors and to spread the word among staff and
encourage attendance. This concept was embraced by these
individuals and ongoing positive reinforcement, and NGRs
updates were shared with them. In addition, an e-mail
announcement was sent to all registered nurses from the
Vice President of Nursing Services.
The hospital has an online education option through its
Internet Web site. A member of the planning committee
worked with the information systems department to have a
description of NGRs and a registration process placed in the
online education option. The advantage of using this
internal structure included the ability to monitor the num-
ber of registrants for NGR-related programs, to increase visi-
bility of the program, and to facilitate ease of registration.
Benner’s framework was used to guide the selection of
individual clinical nurses for participation in the NGRs. An
operational definition of novice, advanced beginner, and
competent levels of nursing practice were developed.
Definitions are presented in Table 3. An APN served as
the expert mentor for clinical nurse presenters and would
guide clinical nurse presenters and responders though the
NGR process. The APN mentored the staff by providing
Table 2. Goals of Nursing Grand Rounds
1. To develop clinical knowledge and skills of nurses across
a diverse spectrum of care
2. To apply socialization to the learning process
3. To provide a venue to showcase our own resident nursing
experts
4. To provide a forum for the APC to cultivate nurses from novice
to expert
5. To support clinical nurse’s professional development
Abbreviation: APC, Advanced Practice Council.
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a
Table 3. Benner Framework Definitions
Stage Level Definition
Stage 1 Novice Beginners have had no experience of the
situations in which they are expected
to perform.
Stage 2 Advanced Able to demonstrate marginally
beginner acceptable performance, who have
copied with or been mentored in
enough real situations
Stage 3 Competent Experienced the same situations for 2
or 3 y; the nurse begins to see their
actions in terms of long-range goals
Stage 4 Proficient Perceives situations as a whole rather
than in terms of aspects. Perception
is key.
Stage 5 Expert Operates from a deep understanding of
the total situation. Ability to have an
intuitive grasp on situations and able
to identify the important issue at hand
a
Adapted from Benner.6(20–32)
nonthreatening communication, encouraging critical think-
ing, and reviewing clinical case studies with staff nurses
selected as panel respondents. The education strategy of
clinical pearls was incorporated into the case studies; that
is, salient related information was encapsulated into a short
succinct take-away message. The APN also provided
support in the technical development of audiovisual
materials, especially PowerPoint. As the expert, the APN
served as an important resource and role model for the
more novice nurses, meeting frequently to review and
discuss. As time for NGR neared, the presenters were
prepared with a final review of their presentations includ-
ing a dress rehearsal if they so choose.
Implementation
Using the results of the interest survey, the schedule for
NGRs was established as quarterly for 2 hours during the
mid-morning. The setting was on the hospital campus in
the conference center that was not directly connected to the
hospital. This setting was chosen to promote a learning
environment that included collegial interactions and peer
socialization. The room was set up in classroom style for
75 people. Informal sharing time before the program was
promoted by offering a continental breakfast that stimu-
lated peer networking among clinical nurses from diverse
areas of practice.
The day of NGRs, the attendees were greeted by an
APN from the NGR subcommittee at the sign-in table.
Participants received presentation-related material and
documentation for 2 continuing education contact hours.
An APN was designated ‘‘Master of Ceremonies,’’ and it
was his or her responsibility to facilitate the presentation.
Nursing administration offered support by attending the
presentations and shared opening remarks that under-
scored the importance of the program. The feature speaker
2 89
was an expert clinical nurse that specialized in the area of
the topic being presented. The expert had several years of
clinical experience and demonstrated a passion and
ongoing clinical experience within that specialty area. The
expert presented the selected topic overview, pathophysi-
ology, and evidence-based management guidelines for the
topic of discussion. Case studies were interwoven through-
out the presentation by a novice to competent level nurses,
highlighting personal experiences in patient care. An aver-
age of 3 clinical nurses would participate at each NGRs.
An Audience Response System (ARS) was used to stimu-
late dialogue among presenters and participants incorpo-
rating socialization into the learning process. The ARS is
an interactive wireless device that tallies and displays
participant’s anonymous responses and helps to generate
continuing dialogue. It is an excellent mechanism to assess
the audience’s knowledge and level of understanding of the
problem in a real-time format. The audience responded
positively to the ARS; it added to the interest and mean-
ingfulness of the presentation. The Information Technology
and Audio-Visual departments provided support for the
audiovisual elements of the program.
The topic chosen for the initial kick-off NGRs was
‘‘Your Patient is Septic. . .Now What?’’ The topic was
timed to correspond with the hospital’s ‘‘Surviving Sepsis’’
campaign, which coincided with the national ‘‘Saving
100,000 Lives Campaign.’’ The featured speaker was a
clinical expert in sepsis, well respected and recognized
expert by the staff; thus, interest was high because many
staff nurses were eager to attend her presentation. As
planned, the NGRs format incorporated a discussion of the
broader issues related to sepsis including pathophysiology
and treatment interventions. Consistent with the goal to
include nurses across the continuum of competencies, the
first NGR included responses from clinical nurses ranging
from advanced beginner to expert. The selection of the
clinical nurse panelist was based on their interest in the
topic, experience with septic patients, and participation in
the clinical care of the patient selected as the case study.
The case studies included patient assessment, patient-
centered plan of care, critical thinking, and outcomes.
Outcomes
Fifty-one participants attended the first NGR program.
Thirty-two nurses had preregistered using the online option
and 22 registered on site, for a total attendance of 54
nurses. Of the 32 online preregistrants, 19% did not
attend. A follow-up survey was not done to inquire about
the reason. Forty-four (81%) of the 54 attendees completed
program evaluations. The evaluations were summarized
and have served as a guide for restructuring NGRs and
selecting future topics. The results demonstrated that 89%
of those who completed the evaluation noted that the
subject material was appropriate and applicable to their
work; 91% reported the speaker held their interest; 95%
found the handout materials useful; 89% found the
audiovisuals and ARS beneficial. One respondent wrote,
‘‘extremely helpful—enjoyed the case studies.’’ The ARS
was described in the evaluations as a ‘‘great tool’’ and
attendees believed like the live participation and discussion
ARS facilitated. Anecdotally, a staff nurse contacted the
290
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presenter after NGRs to share a clinical situation in which
she was immediately able to apply the knowledge she
learned at the presentation. She stated that the patient’s
clinical presentation and laboratory values were changing
consistent with early signs of sepsis, so she notified the
physician, and the patient was immediately transferred to a
higher level of care. This novice nurse credited the NGR
presentation with enabling her to recognize the early
clinical indicators of sepsis and giving her the confidence
to act before the patient’s condition deteriorated.
The APC determined that a forum ‘‘For our Nurses, By
our Nurses’’ was needed to assist nurses in sharing expe-
riences. The initial NGRs were designed to meet this need.
Participating clinical nurses were interviewed to obtain
feedback. The nurses reported that the NGRs presented an
opportunity to share expertise as well as participate in
professional development. One nurse stated, ‘‘It was a
compliment to be able to participate in and showcase my
clinical experience. This professional opportunity allowed
my clinical expertise to be recognized by my peers.’’ An
advanced beginner nurse noted that NRGs were her first
opportunity for public speaking as a nurse. The recognition
of her clinical expertise by her peers was rewarding. The
opportunity to share clinical knowledge and experiences
beyond the immediacy of daily care was a way to
acknowledge and sustain the clinical practice of nursing.
EVALUATION
Post–NGR evaluation feedback was consistently positive
across the 3 NGR programs held thus far. However,
repeated issues with poor preregistration compliance has
resulted in insufficient numbers of materials and seating. In
addition, the number of nurses attending was considered
low given the number of nurses employed at the hospital,
so the APC decided to survey the entire nursing staff for
factors influencing decision regarding NGRs. Also included
in this follow-up NGR survey was an opportunity for
nurses to suggest future NGR topics.
The hospital had recently acquired the inquisite web
survey system (B Copyright 1997–2005 Inquisite, Inc), a
Web-based, interactive survey software system. The plan
was to send the NGR survey via e-mail to all nurses in
the hospital regardless of job title. Based on consultation
with the institutional review board, it was determined
that because this was an internal nursing survey and with-
out a protocol, it was exempt from institutional review
board review.
A pilot survey was sent to 30 registered nurses to assess
readability of the survey instrument questions and trouble-
shoot any technical difficulties that may occur with the
instrument distribution and response. To publicize the
survey, printed announcements were distributed to depart-
ment directors for posting on each nursing unit and at key
locations in clinical areas. The survey announcement was
also posted on the hospital’s nursing Web site. All pilot
responses were cleared and the instrument was distributed
to all nurses.
The instrument was distributed via e-mail to 1,296 nurses
in the hospital with the request to respond within 2 weeks.
Of the 1,296 surveys sent, 469 responses were received
(36% response rate). Most respondents were staff nurses
CLINICAL NURSE SPECIALISTA
(51%), worked day shift (65%), and worked full-time (73%).
Of the respondents, 83% (n = 392) had not attended any
of the NGR programs. Lack of awareness of NGRs was
ranked as the number 1 reason for not attending, followed
by scheduling issues. An impressive percentage (88%)
indicated a willingness to attend NGRs.
The findings of the survey provided the NGRs sub-
committee with feedback that was used to improve the
NGRs programs. The following changes have been imple-
mented: (1) all nurses are notified of scheduled programs
by e-mail; (2) the e-mail notification includes a link to the
preregistration Web site on the hospital intranet; (3)
upcoming NGRs are highlighted in the hospital’s biweekly
newsletter in addition to continued print advertising
materials such as with posters and flyers; and (4) selection
of future topics reflects suggestions from staff nurses.
EVALUATION OF GOALS
In our efforts to develop and implement NGRs, we es-
tablished the goals listed in Table 2. Through discussion
and consensus building, the sub-committee supports the
following achievement toward goal accomplishment.
1. Develop clinical knowledge and skills of nurses across a
diverse spectrum of care. Through the presentation of a
variety of clinical topics and through the selection of
case studies involving patients at differing levels of
acuity, the knowledge and skill level of nurses has
increased. This increase is evidenced by the hospital’s
ranking in the top 5% to 10% locally and nationally in
a variety of clinical specialties. The hospital would not
receive this type of recognition across a variety of
specialties if not for the clinical knowledge and skill
level of our nurses and the collaborative effort of the
medical and nursing staff.
2. Apply socialization to the learning process. By holding
NGRs away from the nursing unit, providing refresh-
ments and offering continuing nursing education con-
tact hours, a social learning environment was created.
The 2-hour grand round program provided an oppor-
tunity for the nurse to step back from the immediacy of
a busy patient unit and take care of his or her
professional-educational needs—to feed the self emo-
tionally and intellectually for 2 hours.
3. Provide a venue to showcase our own resident nursing
experts. Speakers for all of the grand rounds were
members of the hospital staff; no outside speakers were
involved. The grand rounds provided our expert staff
nurses the opportunity to develop the public speaking
skills while sharing their nursing expertise.
4. Provide a forum for the APC to cultivate nurses from
novice to expert. Although the expert nurse developed
his or her presentation and peaking skills, NRGs also
provided novice nurses with useful clinical information
from a fellow nurse. In addition to being educational,
this format provided novice nurses with visioning career
VOLUME 21 | NUMBER 6
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development in nursing including options for advanced
nursing practice roles.
5. Support clinical nurse’s professional development. As a
Magnet-accredited hospital, our goal was to support
clinical nurse’s professional growth. Attendance at
NGRs provided staff nurses an opportunity for ongoing
professional development.
IMPLICATIONS FOR PRACTICE
The multiple competencies of APNs were important in
implementing NGRs in the community hospital setting.
Clinical nurse specialists and NPs collaborated to prepare
NGR programs. Depending on the topic, CNSs and NPs
shared responsibility for facilitating programs, providing
expertise ranging from information about pathology and
disease to application of evidence-based nursing practice,
and mentoring clinical nurses. Consistent with Benner’s
framework of skill acquisition, NGRs provide recurrent
meaningful situations where the components of care are
learned and incorporated into the practice of novice nurses
as they move to higher levels of skill.6
CONCLUSION
The premise on which NGRs blueprint was developed was
to bring the expertise of nurses in all practice settings into
the spotlight. The NGR format provided an excellent
opportunity for collegial exchange of nursing expertise
directed at patient outcomes. Sharing knowledge fostered
professional growth among nurses. Clinical nurse special-
ists and NPs collaborating together as expert nurses
provided the impetus to move the idea of NGRs from
concept to reality.
ACKNOWLEDGMENT
The authors would like to express their heartfelt appreci-
ation to Susan Goldberg and Rick Martin for their support
of Nursing Grand Rounds and to Karen Brooks and
Dominic Shields for their support and assistance in the
conduct of the online survey.
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