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Nurse Rounds

NIHR Signal Structured nurse ward rounds support accountability and risk management but not nurse-patient communication

Published on 26 February 2020

doi: 10.3310/signal-000886

Scheduling regular nurse bedside ward rounds (called ‘intentional rounding’) may not improve nurse-patient communication, as most interactions occur outside of these rounds. The rounds are intended to improve accountability and provide evidence that risks are being managed when correctly documented.

Intentional rounding was introduced as a UK Government policy imperative to facilitate regular interactions between nurses and patients following high profile care failures at the Mid Staffordshire NHS Foundation Trust.

Implemented in 97% of English hospital trusts, these rounds are viewed by senior staff and front-line nurses as a checklist to prevent staff forgetting to undertake important tasks.

However, this NIHR-funded mixed-methods study suggests that intentional rounding may result in more brief task-orientated nurse-patient interactions rather than better quality interactions tailored to patient needs.

The role of intentional rounding needs to be carefully considered, to see whether the approach can be improved or whether alternative approaches may be better for improving patient care.

Share your views on the research.

Why was this study needed?

Following investigations into poor patient care at the Mid Staffordshire NHS Foundation Trust, the Francis Report called for regular engagement and interactions between nurses and patients. Intentional rounding, also known as comfort rounds, care rounds or hourly rounds, was the method adopted to facilitate this.

Intentional rounding was developed in the US to provide a timed and structured way of systematising regular nursing ward rounds. It is designed to proactively identify and meet a patient’s fundamental care needs. The focus is on the 4Ps - patient positioning, personal needs, pain and placement of items (such as water).

This NIHR project is the first large-scale evaluation of intentional rounding in England, which aimed to assess its impact and effectiveness.

What did this study do?

This study used a mixed-methods approach. A realist synthesis of 44 papers identified eight potential mechanisms by which intentional rounding might work and these formed a framework to test emerging findings. The framework included: consistency and comprehensiveness; allocated time to care; accountability; nurse-patient relationships and communication; visibility; anticipation; staff communication and/or team working; and patient empowerment.

A national online survey received responses from 108 (70%) of all NHS hospital trusts. Six wards in three acute trusts were selected for in-depth case studies. These consisted of semi-structured interviews with 17 senior trust and ward managers, 33 front-line nursing staff, 28 multidisciplinary team members, 34 patients and 28 carers. They also performed 188 hours of observation (including 240 intentional rounds), shadowing of 29 nursing staff and retrieval of ward outcome data.

Realist evaluation was used to synthesise the findings.

What did it find?

  • One hundred and five (97%) of 130 hospital trusts in England have implemented intentional rounding, 85 (81%) using a structured protocol. However, the details of implementation varied and tended not to follow the original intentional rounding protocol from the US.
  • A mixture of registered and unregistered nursing staff conduct most intentional rounding (89%). In almost all trusts (96%) documentation is completed as part of the round.
  • Views from senior staff and front-line nursing staff suggested that they felt that the rounds did have an impact on consistency, comprehensiveness, and accountability.
  • There was inconclusive evidence of any impact on nurse visibility and anticipation, minimal evidence of an impact on multidisciplinary teamwork and communication (e.g. in terms of better handovers of patient information), and no evidence of impact in the other areas assessed (nurse-patient relationships and communication, allocated time to care and patient empowerment).
  • Most nurse-patient interactions occur outside of intentional rounding and with greater frequency than intentional rounding protocols recommend, calling into question the efficacy of intentional rounding.

What does current guidance say on this issue?

There is NICE 2018 guidance on the use of structured ward rounds, but this acknowledges few low-quality studies on explicit rounding. This guidance advises that the format and way in which ward rounds are structured should be determined by local experience.

NICE recommends that gap analysis should be undertaken prior to the implementation of changes to rounding to identify where maximum process improvements can be achieved.

What are the implications?

Implemented with the intention of improving staff-patient communication, evidence of the effective translation of intentional rounding to an English context is weak. Concern also exists that encouraging nurses to adopt a very prescriptive, transactional approach to patient care is overly simplistic, and could unintentionally result in de-skilling of nurses.

This study suggests that intentional rounding may not be meeting all of its goals, and consideration needs to be given to whether it needs to be adapted or replaced.

Citation and Funding

Harris R, Sims S, Leamy M et al. Intentional rounding in hospital wards to improve regular interaction and engagement between nurses and patients: a realist evaluation. Health Serv Deliv Res. 2019;7(35).

This project was funded by the NIHR Health Services and Delivery Research Programme (project number 13/07/87).

Bibliography

Forde-Johnston C. Intentional rounding: a review of the literature. Nurs Stand. 2014;28(32):37-42.

Francis R. Report of the Mid Staffordshire NHS Foundation Trust public inquiry. London: The Stationery Office; 2013.

NICE. Chapter 28: structured ward rounds. Emergency and acute medical care in over 16s: service delivery and organisation. NG94. London: National Institute for Health and Care Excellence; 2018.

Studer Group. Best practices: Sacred Heart Hospital, Pensacola, Florida. Hourly rounding supplement. Gulf Breeze, FL: Studer Group; 2007.

Why was this study needed?

Following investigations into poor patient care at the Mid Staffordshire NHS Foundation Trust, the Francis Report called for regular engagement and interactions between nurses and patients. Intentional rounding, also known as comfort rounds, care rounds or hourly rounds, was the method adopted to facilitate this.

Intentional rounding was developed in the US to provide a timed and structured way of systematising regular nursing ward rounds. It is designed to proactively identify and meet a patient’s fundamental care needs. The focus is on the 4Ps - patient positioning, personal needs, pain and placement of items (such as water).

This NIHR project is the first large-scale evaluation of intentional rounding in England, which aimed to assess its impact and effectiveness.

What did this study do?

This study used a mixed-methods approach. A realist synthesis of 44 papers identified eight potential mechanisms by which intentional rounding might work and these formed a framework to test emerging findings. The framework included: consistency and comprehensiveness; allocated time to care; accountability; nurse-patient relationships and communication; visibility; anticipation; staff communication and/or team working; and patient empowerment.

A national online survey received responses from 108 (70%) of all NHS hospital trusts. Six wards in three acute trusts were selected for in-depth case studies. These consisted of semi-structured interviews with 17 senior trust and ward managers, 33 front-line nursing staff, 28 multidisciplinary team members, 34 patients and 28 carers. They also performed 188 hours of observation (including 240 intentional rounds), shadowing of 29 nursing staff and retrieval of ward outcome data.

Realist evaluation was used to synthesise the findings.

What did it find?

  • One hundred and five (97%) of 130 hospital trusts in England have implemented intentional rounding, 85 (81%) using a structured protocol. However, the details of implementation varied and tended not to follow the original intentional rounding protocol from the US.
  • A mixture of registered and unregistered nursing staff conduct most intentional rounding (89%). In almost all trusts (96%) documentation is completed as part of the round.
  • Views from senior staff and front-line nursing staff suggested that they felt that the rounds did have an impact on consistency, comprehensiveness, and accountability.
  • There was inconclusive evidence of any impact on nurse visibility and anticipation, minimal evidence of an impact on multidisciplinary teamwork and communication (e.g. in terms of better handovers of patient information), and no evidence of impact in the other areas assessed (nurse-patient relationships and communication, allocated time to care and patient empowerment).
  • Most nurse-patient interactions occur outside of intentional rounding and with greater frequency than intentional rounding protocols recommend, calling into question the efficacy of intentional rounding.

What does current guidance say on this issue?

There is NICE 2018 guidance on the use of structured ward rounds, but this acknowledges few low-quality studies on explicit rounding. This guidance advises that the format and way in which ward rounds are structured should be determined by local experience.

NICE recommends that gap analysis should be undertaken prior to the implementation of changes to rounding to identify where maximum process improvements can be achieved.

What are the implications?

Implemented with the intention of improving staff-patient communication, evidence of the effective translation of intentional rounding to an English context is weak. Concern also exists that encouraging nurses to adopt a very prescriptive, transactional approach to patient care is overly simplistic, and could unintentionally result in de-skilling of nurses.

This study suggests that intentional rounding may not be meeting all of its goals, and consideration needs to be given to whether it needs to be adapted or replaced.

Citation and Funding

Harris R, Sims S, Leamy M et al. Intentional rounding in hospital wards to improve regular interaction and engagement between nurses and patients: a realist evaluation. Health Serv Deliv Res. 2019;7(35).

This project was funded by the NIHR Health Services and Delivery Research Programme (project number 13/07/87).

Bibliography

Forde-Johnston C. Intentional rounding: a review of the literature. Nurs Stand. 2014;28(32):37-42.

Francis R. Report of the Mid Staffordshire NHS Foundation Trust public inquiry. London: The Stationery Office; 2013.

NICE. Chapter 28: structured ward rounds. Emergency and acute medical care in over 16s: service delivery and organisation. NG94. London: National Institute for Health and Care Excellence; 2018.

Studer Group. Best practices: Sacred Heart Hospital, Pensacola, Florida. Hourly rounding supplement. Gulf Breeze, FL: Studer Group; 2007.

Intentional rounding in hospital wards to improve regular interaction and engagement between nurses and patients: a realist evaluation

Published on 9 October 2019

Harris R, Sims S, Leamy M, Levenson R, Davies N, Brearley S, Grant R, Gourlay S, Favato G & Ross F.

Health Services and Delivery Research Volume 7 Issue 35 , 2019

Background The government response to the care failures at the Mid Staffordshire NHS Foundation Trust led to the policy imperative of ‘regular interaction and engagement between nurses and patients’ (Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013. © Crown copyright 2013. Contains public sector information licensed under the Open Government Licence v3.0) in the NHS. The pressure on nursing to act resulted in the introduction of the US model, known as ‘intentional rounding’, into nursing practice. This is a timed, planned intervention that sets out to address fundamental elements of nursing care by means of a regular bedside ward round. Objectives The study aims were to examine what it is about intentional rounding in hospital wards that works, for whom and in what circumstances. Design A multimethod study design was undertaken using realist evaluation methodology. The study was conducted in four phases: (1) theory development; (2) a national survey of all NHS acute trusts in England; (3) in-depth case studies of six wards, involving individual interviews, observations, retrieval of routinely collected ward outcome data and analysis of costs; and (4) synthesis of the study findings. Setting The study was conducted in acute NHS trusts in England. Participants A total of 108 acute NHS trusts participated in the survey. Seventeen senior managers, 33 front-line nurses, 28 non-nursing professionals, 34 patients and 28 carers participated in individual interviews. Thirty-nine members of nursing staff were shadowed during their delivery of intentional rounding and the direct care received by 28 patients was observed. Review methods A realist synthesis was undertaken to identify eight context–mechanism–outcome configurations, which were tested and refined using evidence collected in subsequent research phases. Results The national survey showed that 97% of NHS trusts had implemented intentional rounding in some way. Data synthesis from survey, observation and interview findings showed that only two of the original eight mechanisms were partially activated (consistency and comprehensiveness, and accountability). The evidence for two mechanisms was inconclusive (visibility of nurses and anticipation); there was minimal evidence for one mechanism (multidisciplinary teamwork and communication) and no evidence for the remaining three (allocated time to care, nurse–patient relationships and communication, and patient empowerment). A total of 240 intentional rounds were observed within 188 hours of care delivery observation. Although 86% of all intentional rounding interactions were observed to be documented, fidelity to the original intervention [i.e. the Studer Group protocol (Studer Group. Best Practices: Sacred Heart Hospital, Pensacola, Florida. Hourly Rounding Supplement. Gulf Breeze, FL: Studer Group; 2007)] was generally low. Limitations Intentional rounding was often difficult for researchers to observe, as it was rarely delivered as a discrete activity but instead undertaken alongside other nursing activities. Furthermore, a lack of findings about the influence of intentional rounding on patient outcomes in the safety thermometer data limits inferences on how mechanisms link to clinical outcomes for patients. Conclusions The evidence from this study demonstrates that the effectiveness of intentional rounding, as currently implemented and adapted in England, is very weak and falls short of the theoretically informed mechanisms. There was ambivalence and concern expressed that intentional rounding oversimplifies nursing, privileges a transactional and prescriptive approach over relational nursing care, and prioritises accountability and risk management above individual responsive care.

Expert commentary

This study demonstrates the problematic nature of implementing un-evidence based, reactionary policy initiatives as a substitute for evidence-based practice.

This study should be the catalyst for an open conversation regarding the value of intentional rounding and other alternative ways of delivering timely and person-centred nursing care.

It also calls for nursing leaders and policymakers to examine how and why such policies are implemented in the real world.

Professor Alison Leary, Chair of Healthcare and Workforce Modelling, London South Bank University

The commentator declares no conflicting interests