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Headline
Evidence for the effectiveness of intentional rounding is weak, with concerns that it oversimplifies nursing, creates a prescriptive approach and prioritises the completion of documentation as evidence of care delivery.
Abstract
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.
© Crown copyright 2013. Contains public sector information licensed under the Open Government Licence v3.0
Copyright © Queen’s Printer and Controller of HMSO 2019. This work was produced by Harris et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
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.
Future work:
It is suggested that the insights and messages from this study inform a national conversation about whether or not intentional rounding is the optimum intervention to support the delivery of fundamental nursing care to patients, or if the time is right to shape alternative solutions.
Funding:
The National Institute for Health Research Health Services and Delivery Research programme.
Contents
- Plain English summary
- Scientific summary
- Chapter 1. Introduction
- Chapter 2. Methods
- Chapter 3. Phase 1: theory development – a realist synthesis of the evidence
- Chapter 4. Phase 2: a national survey of NHS acute trusts in England
- Chapter 5. Phase 3: in-depth case studies – ward profile data, patient outcomes, and costs and benefits
- Chapter 6. Professional perspectives of intentional rounding and observations of its delivery
- Chapter 7. Patient and carer perspectives of intentional rounding
- Chapter 8. Realist evaluation of intentional rounding: data synthesis
- Chapter 9. Conclusions
- Acknowledgements
- References
- Appendix 1. Influencing contexts of intentional rounding
- Appendix 2. General outcomes of intentional rounding
- Appendix 3. Analysis of trusts’ additional free-text responses to national survey questions
- Appendix 4. Contextual mapping interview topic guide
- Appendix 5. Detailed ward profiles
- Appendix 6. Example of intentional rounding documentation at case study site 1
- Appendix 7. Example of intentional rounding documentation at case study site 2
- Appendix 8. Example of intentional rounding documentation at case study site 3 (for patients with a Waterlow score of < 10)
- Appendix 9. Example of intentional rounding documentation at case study site 3 (for patients with a Waterlow score of ≥ 10)
- Appendix 10. Cost analysis
- Appendix 11. Interview schedule: ward managers
- Appendix 12. Interview schedule: nursing staff
- Appendix 13. Interview schedule: health-care staff (non-nursing)
- Appendix 14. Interview schedule: patients
- Appendix 15. Interview schedule: carers
- Appendix 16. Definitions for observation categories
- Glossary
- List of abbreviations
About the Series
Article history
The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 13/07/87. The contractual start date was in September 2014. The final report began editorial review in April 2018 and was accepted for publication in January 2019. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.
Declared competing interests of authors
Robert Grant reports grants from King’s College London during the conduct of the study.
Last reviewed: April 2018; Accepted: January 2019.
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