Phase 1: theory development – a realist synthesis of the evidence

Ruth Harris; Sarah Sims; Mary Leamy; Ros Levenson; Nigel Davies; Sally Brearley; Robert Grant; Stephen Gourlay; Giampiero Favato; Fiona Ross

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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. Southampton (UK): NIHR Journals Library; 2019 Oct. (Health Services and Delivery Research, No. 7.35.)

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

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Chapter 3Phase 1: theory development – a realist synthesis of the evidence

This chapter describes the first phase of the study: the realist synthesis of the evidence for IR. The aim of this phase was to generate hypotheses on what the mechanisms of IR may be, what particular groups may benefit most or least, the contextual factors that might be important to its success or failure and the associated outcomes. This theory development drew on principles of realist synthesis¹⁸ and the subsequent framework was to be tested in phases 2 and 3 of the study.

Method

In stage 1, a search of academic, policy and grey literature was undertaken to develop initial programme theories of IR. Expert advice was sought from library and information science specialists around generating relevant search terms, and between June and July 2014 four electronic databases were searched [Allied and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE and the Royal College of Nursing Archive] alongside searches of Google and Google Scholar (Google Inc., Mountain View, CA, USA), InterNurse, Social Care Institute for Excellence (SCIE) and NHS Evidence using the strategies highlighted in Table 1. Relevant documents were independently examined by two researchers to identify any purported mechanisms of IR (i.e. theories or assumptions about why/how IR worked/was expected to work).

TABLE 1

Search strategy

Between October and November 2014, stage 2 of the synthesis was undertaken, with the aim of identifying empirical research that either supported or refuted the mechanisms identified in stage 1, or identified any new mechanisms. A comprehensive search for empirical research was undertaken using the search strategy highlighted in Table 1. Snowball searches and citation searches in CINAHL and Scopus were also conducted. A structured data extraction form was completed for every paper, recording either salient details on the study design, objectives and participants, or the reason for its exclusion. Broad inclusion criteria were used, meaning that a paper was included if it described nursing rounds occurring every 2 hours or less and highlighted empirical evidence of any associated context, outcome or mechanism. In line with realist synthesis methodology, conventional approaches to quality appraisal were not used;²¹ instead, each study’s ‘fitness for purpose’ was assessed by considering its relevance and rigour. The evidence collected from these papers was synthesised by drawing together all information on contexts, mechanisms and outcomes. Similarities and differences in findings were sought in order to build a comprehensive description of each mechanism and its role in IR. Focused literature searches were also conducted for mechanisms for which little evidence was found.

A third and final search of the literature was undertaken in February 2016 to ensure that the synthesis was up to date and that no research published in the interim period had been missed. Searches were repeated as in stage 2, but focused only on research published between December 2014 and February 2016. Snowball searches and hand-searches were also undertaken. In addition to the review of the relevant literature, a stakeholder consultation event was held in February 2015, at which key figures associated with IR (e.g. Directors of Nursing of NHS hospitals, health-care staff) plus members of the study’s advisory group were asked to discuss their understanding of IR and their reasoning for its implementation, to further elicit realist theories on the mechanisms.

Findings

This section presents the findings of the realist synthesis. A total of 44 papers were included in the realist synthesis, drawn from a variety of sources [i.e. the professional press (n = 21),³^,⁷^–⁹^,²²^–³⁸ peer-reviewed journals (n = 18),³⁹^–⁵⁶ study reports (n = 4)⁴^,⁵⁷^–⁵⁹ and one doctoral thesis].⁶⁰ The research was primarily undertaken in the USA (n = 25)³^,⁷^–⁹^,²²^,²⁵^–²⁷^,³²^,³³^,³⁵^–⁴²^,⁴⁴^,⁴⁷^,⁴⁸^,⁵²^–⁵⁴^,⁶⁰ but also included research from the UK (n = 12),⁴^,²³^,²⁴^,²⁸^,³⁰^,³¹^,³⁴^,⁴⁶^,⁵¹^,⁵⁷^–⁵⁹ Australia (n = 5),⁴³^,⁴⁵^,⁴⁹^,⁵⁰^,⁵⁵ Canada (n = 1)²⁹ and Iran (n = 1).⁵⁶ Studies were conducted in a variety of settings, including accident and emergency, intensive care, mental health, maternity, orthopaedics and medical-surgical units and used both qualitative and quantitative research methods. The papers were published between 2006 and 2017, with a peak in publication in 2012. The two earliest published papers (2006 and 2007) were authored by Meade (and colleagues),²²^,³⁹ who was directly connected to the Studer Group; these papers were heavily cited by authors publishing at later dates. The 44 papers were written by a total of 168 authors, with only three authors (Meade,²²^,³⁹^,⁴⁰ Braide²³^,²⁴ and Neville²⁵^,⁴¹) authoring or co-authoring more than one paper. This suggested that there had not been a major programme of research by one group of researchers in IR.

Eight potential mechanisms of IR were identified in the first stage of the literature search; these are highlighted in Table 2, along with their provisional descriptions. In Table 3, the programme theories for each of the eight mechanisms are presented in descending order according to the number of papers addressing them and the CMOs are summarised. A number of individual CMO configurations were identified and examples of these have been provided for selected mechanisms in Boxes 2 and 3. It must be noted that these programme theories were not mutually exclusive, with one context and/or mechanism feeding into another or becoming an outcome of a third. However, they have been separated here for clarity.

TABLE 2

Hypothesised mechanisms of IR (stage 1)

TABLE 3

Summary of eight CMO configurations

BOX 2

The CMO configuration associated with the presence of the consistency and comprehensiveness mechanism

BOX 3

The CMO configuration associated with the absence of the allocated time mechanism

Programme theories

Context–mechanism–outcome 1: intentional rounding ensures that consistent and comprehensive care is delivered to all patients by all nurses

A total of 21 papers⁴^,⁹^,¹¹^,²⁴^,²⁶^–³²^,⁴¹^–⁴⁷^,⁵⁷^,⁵⁸^,⁶⁰ highlighted the link between IR and consistent and comprehensive care. The structured, systematic approach to IR prompted and guided the delivery of care to a required standard, helped staff to remember to conduct all aspects of care on each round⁴^,⁵⁸ and identified tasks that might otherwise be missed.⁹ The format helped ensure continuity of care across staff members, which was thought to be particularly important for guiding junior/unqualified staff and those less familiar with patients.⁴ IR enabled staff to speak regularly to all patients, which helped prevent quieter patients from being overlooked.⁴

However, in most studies there was recognition that a dependence on standardisation did not always ensure successful IR and that a flexible approach may be more appropriate.²⁸^,⁴¹^,⁴³^–⁴⁵^,⁴⁷ Nurses were reported to use their clinical judgement and professional autonomy to modify the rounding process, assessing patients on an individual basis and making informed choices about how frequently to conduct rounds and what questions to ask.⁴^,²⁴^,²⁷^,³²^,⁴¹^,⁴²^,⁴⁴^,⁴⁵^,⁶⁰ Others highlighted how the breadth of care elements covered in IR could be modified in order to comprehensively address all potential patient needs and make it relevant to individual settings.⁴^,²⁶ The setting of care was an important influencing context for this mechanism. For example, in mental health wards, there were reports of IR being disproportionate for ‘low-risk’ patients⁴ or too intrusive for those experiencing psychotic symptoms.³² Other influencing contexts were time limitations, low staffing levels and conflicting priorities; all of these made IR more difficult.³¹^,⁴¹^,⁵⁷^,⁶⁰ Understanding of the principle and practice of IR was also reported to vary according to individual staff characteristics.⁴

Context–mechanism–outcome 2: intentional rounding gives nurses allocated ‘time to care’

A total of 19 papers⁴^,⁹^,²²^,²⁴^,²⁸^,²⁹^,³¹^,³³^,³⁹^–⁴¹^,⁴³^,⁴⁵^,⁴⁸^–⁵⁰^,⁵⁷^,⁵⁸^,⁶⁰ discussed the ‘allocated time’ mechanism. There was no indication that nurses were given specifically allocated time in which to conduct IR (i.e. no discussion of other aspects of nursing workload being reduced or extra resources being provided). There was, however, some evidence that IR could have time-saving benefits for nurses, enabling them to better organise their workload and free up more ‘time to care’.⁴^,⁹^,⁵⁷ No other descriptions of the mechanism were highlighted and reported outcomes were limited, although some reported improved staff satisfaction²²^,³⁹ reflective staff practice⁴ and positive patient feedback.⁵⁷

There was more empirical evidence regarding the absence of the mechanism, with some staff stating that IR was ‘nothing new’, that it was akin to what they were already doing or that made no difference to their practice.⁴^,²⁸^,³¹^,⁴⁰^,⁴⁵^,⁵⁰ There was also evidence that staff believed that IR resulted in less ‘time to care’ and added to, rather than reduced, their workload.²⁴^,²⁸^,⁴³^,⁴⁵^,⁵⁰ It was felt by some that the documentation associated with IR took nurses away from delivering patient care²⁸ and others talked about having to fit in rounds around the rest of their workloads.²⁹^,⁴³^,⁶⁰ In these situations, higher-priority duties could take precedence³³ and more complex patients could be prioritised.²⁴^,⁴¹^,⁴⁹^,⁶⁰ The need for cultural change in an organisation was an important influencing context for this mechanism,⁴^,²⁴^,²⁸^,⁴⁸^,⁴⁹ as was successful teamworking.⁴¹

Context–mechanism–outcome 3: intentional rounding increases nurses’ accountability for the standard of care provided

A total of 19 papers⁴^,⁹^,²⁴^,³⁰^–³³^,⁴¹^–⁴⁵^,⁴⁷^,⁴⁸^,⁵⁰^,⁵¹^,⁵⁷^,⁵⁸^,⁶⁰ discussed this mechanism. Accountability was perceived by some to underpin IR;⁴^,⁹^,³³^,⁴³^,⁴⁸^,⁶⁰ however, there was no evidence that increased personal accountability led to the delivery of higher standards of care, as the accountability of staff generally related only to responsibility for ensuring that they completed the IR documentation, rather than responsibility for carrying out high-quality rounds. Similarly, although the documentation associated with IR did enable care delivery to be audited, there were concerns that such audits provided information only about staff compliance with documentation procedures and not evidence of rounding quality or confirmation that any action(s) required had taken place.⁴^,²⁴^,³¹^,⁵⁸ There were also concerns that such audits may provide an incentive for staff to simply ‘tick boxes’ on the documentation, rather than completing the task in full,³⁰ and incidents were reported of nurses completing all documentation at the beginning/end of their shift⁴^,⁴³^–⁴⁵^,⁴⁸ or falsifying information on IR documentation when they had forgotten to complete it.⁴³

The suitability of rounding documentation was an important context for this mechanism, with evidence that, where documentation was not ‘fit for purpose’ or duplicated nursing effort, non-compliance with IR protocols was more likely to occur.⁴^,³¹^,⁴¹^,⁴²^,⁵⁷ The visibility and placement of rounding documentation was also an important context,⁹^,⁴⁴ with evidence that keeping documentation physically close to patients helped to ensure that it was completed as required.⁹^,⁴⁵ Finally, leadership and management support was also an influencing factor.⁴^,⁹^,⁴²^,⁴⁵^,⁴⁷^,⁶⁰ Few studies discussed the outcomes of the mechanism, but some reported that nurses felt patronised, insulted or untrusted,³¹^,⁴³^,⁵⁰^,⁶⁰ and one study⁴³ reported that it was believed that IR devalued nursing work by focusing on processes rather than professional judgement.⁴³

Context–mechanism–outcome 4: intentional rounding enhances nurse–patient communication and/or relationships

A total of 17 papers highlighted the positive impact that IR could have on nurse–patient communication.⁴^,²²^,²⁴^,²⁸^,³⁰^,³⁴^,³⁵^,⁴⁰^,⁴¹^,⁴³^,⁴⁵^–⁴⁷^,⁵⁷^–⁶⁰ It was widely reported that IR increased the frequency of nurse–patient communications;⁴^,²⁸^,³⁴^,⁴⁰^,⁴⁷^,⁵⁷^,⁵⁸ staff believed that this was welcomed by patients and their carers,²⁴^,²⁸^,⁴⁰^,⁴⁶ making them feel more involved in their care,²⁸ more likely to voice concerns⁴⁰ and less likely to feel ignored/neglected.⁵⁷ There was less evidence that IR improved the quality of nurse–patient communication, although some staff felt that it was the final question (‘Is there anything else I can do for you?’) that was crucial, perceiving this to demonstrate respect and compassion.⁴⁵ There was little discussion of the impact of IR on nurse–patient relationships. Some staff felt that IR helped them to get to know patients better⁵⁷ and made them more aware of patients’ conditions and needs,²⁸^,⁴⁰^,⁴⁵ which could potentially affect patient outcomes²⁸ and lead to better teamworking,⁵⁷ fewer patient complaints and increased nurse satisfaction.²⁴^,²⁸^,⁴⁵^,⁵⁷ However, not all outcomes were positive and there were reports of patients being irritated or annoyed by IR.²⁸ Some staff felt that using predetermined scripts stripped communications of authenticity and made nurse–patient contacts a matter of routine,⁴³ whereas some patients highlighted the importance of quality interactions with staff, noting the value of meaningful contacts and feeling connected.³⁰^,⁵⁷^,⁵⁹

Context–mechanism–outcome 5: intentional rounding increases nurse visibility and/or presence

A total of 11 papers⁹^,²³^,²⁴^,²⁸^,⁴⁰^,⁴⁵^,⁴⁷^,⁴⁹^,⁵⁷^,⁵⁸^,⁶⁰ discussed this mechanism. Some staff believed that IR increased the visibility of nurses on a unit;⁴⁰^,⁴⁵ this was generally viewed positively, with perceived benefits such as enhanced nurse–patient communication,²⁸ helping patients to feel well cared for and increasing staff satisfaction.⁴⁷ However, some negative outcomes of increased visibility were also reported by staff, including an increase in non-urgent requests from patients.⁴⁹ It was noted that rounding could be particularly challenging in rehabilitation settings, with reports that increased visibility of staff led to patients doing less for themselves and instead waiting for staff to assist them during their rounds.²⁸ Some staff questioned any association between IR and increased visibility, believing that they were visible to patients even when they were not undertaking rounds. They could not, however, confirm whether this was also the patients’ perception.⁵⁷ In the few studies that did explore patient and carer perceptions, it was generally agreed that increased visibility of nursing staff was valued by both patients and their carers.⁹^,²³^,²⁴

Context–mechanism–outcome 6: intentional rounding enhances a nurse’s ability to anticipate and proactively address patient needs

A total of 11 papers⁴^,⁹^,²⁵^–²⁷^,⁴³^,⁴⁶^,⁴⁸^,⁵⁷^,⁵⁸^,⁶⁰ addressed this mechanism. A number of staff identified IR as an intervention that enabled them to be proactive in anticipating patient needs, as opposed to being reactive to patient call bells or requests for help.⁹^,²⁷^,⁴³^,⁴⁶^,⁴⁸^,⁶⁰ There were a number of staff-reported outcomes associated with this mechanism, including increased patient satisfaction,²⁷ reduced anxiety,⁴⁶ increased reassurance,⁴^,⁴⁶ reduced call bell usage⁴^,⁵⁷ and an overall sense of calm on the ward.⁴ IR was also reported to enable nurses to intervene earlier when a patient’s medical condition was deteriorating⁴⁶ and to prevent quieter patients from being overlooked.⁴^,⁴³^,⁵⁷ Few studies reported patient experiences of the mechanism, although patient questionnaires demonstrated an improvement in patient satisfaction²⁵ and patient perceptions of nursing proactivity following the implementation of IR.⁵⁷ One influencing context was the type of patient on the ward where IR was being carried out and their particular needs. For example, changing position and getting in and out of bed were identified as activities that could be anticipated and addressed by hourly rounding, whereas pain management and toileting could not be anticipated by hourly rounding. The layout of the ward was also an influencing context, with IR helping to ensure that patients in side rooms were not forgotten.⁵⁸

Context–mechanism–outcome 7: intentional rounding enhances staff communication and/or teamworking

A total of nine studies⁹^,²⁷^,²⁹^,³²^,⁴⁰^,⁴¹^,⁴⁷^,⁵⁷^,⁶⁰ discussed this mechanism. Several studies⁹^,²⁹^,³²^,⁴⁷^,⁵⁷ discussed staff communication and its interconnecting relationship with IR (i.e. strong staff communication was perceived to be crucial for effective rounding, and rounding was perceived to improve staff communication). In addition to communication, some studies also noted the relationship between IR and staff teamworking (both unidisciplinary and mulitidisciplinary);⁹^,⁴⁰^,⁴¹^,⁶⁰ once again, an interconnecting relationship was noted between the two (i.e. teamworking was perceived to be crucial to successful IR⁶⁰, and effective rounding was perceived to improve staff teamworking).⁹ Some staff believed that rounding improved ‘camaraderie’ on a unit; led to a calmer, less ‘chaotic’ atmosphere; and helped prevent tasks being missed.⁹ When staff communication and teamworking were deemed to be ineffective, this caused frustration and concern among staff and reduced the effectiveness of IR. Some highlighted nurses’ reluctance to ask other team members for help as a barrier to effective IR;⁶⁰ other influencing contexts were staff involvement, ownership of practice²⁹^,⁴⁷ and the busyness of the ward.²⁷

Context–mechanism–outcome 8: intentional rounding fosters patient empowerment

Overall, the evidence related to this mechanism was weak, with only four studies⁴^,²⁵^,²⁸^,⁵⁷ identified and no detailed descriptions provided. The brief definition of the mechanism was supported only by limited empirical evidence, primarily drawn from one UK study.⁴ This reported that individuals in care homes became more ‘forthcoming’ when they knew that staff were coming to see them regularly, empowering them to ask for what they needed.⁴ As in the original definition, this study⁴ also found patient empowerment to be closely entwined with nurse–patient communication and relationships. Tentative evidence related to patient empowerment as an outcome of IR was identified by three other studies.²⁵^,²⁸^,⁵⁷

Influencing contexts and outcomes of intentional rounding

Although the aim of realist syntheses is to better understand the interplay of how a particular context affects a specific mechanism to produce outcomes,⁶¹ this review has found that such detailed theoretical explanations of IR are rarely provided in the literature. A list of potential ‘backdrops’ believed by authors to influence IR and a list of potential outcomes reported to arise from it were, however, identified and are highlighted in Appendices 1 and 2. The findings of this synthesis echo those of a systematic review of the barriers to effective implementation and sustainment of IR on medical and surgical wards,⁶² as well as identifying additional barriers. In Table 3, the theories by which IR may work are made explicit, and CMO configurations that are to be tested and refined in later phases of the study are summarised.

Discussion

The absence of any theoretical development of IR was notable in the synthesis, as many studies reported only the outcomes of implementing IR without providing any explanation of how or why these outcomes occurred. Similarly, many studies discussed the contexts that influenced IR but failed to explain how these conditions interacted with mechanisms to produce specific outcomes. This poor understanding of how IR works poses a major challenge to learning, replication and sustainability of the intervention.

The synthesis identified a number of discrepancies between how IR is purported to work and how it operates in practice, as well as international differences in how the intervention has been implemented. For example, guidance from the US states that the intervention should be utilised in a standardised manner so that all patients receive the same input.² Yet other countries, including the UK, appear to have adopted a more flexible approach, based on nurses’ clinical judgements of patient needs and preferences. The intervention has, therefore, not been consistently implemented across settings, but has been adapted and extended to suit local circumstances. This leads to an important question of how flexible the approach to the delivery of IR can be before it can no longer be considered IR.

Managing risk has also been acknowledged as an important driver for the introduction of IR. Assumptions have been made that IR will increase the personal accountability of nurses and raise the overall standard of nursing care. However, this synthesis has identified that this is not necessarily the case. IR may assist organisations to monitor and audit the care provided by their nursing staff, but evidence suggests that these audits focus on compliance with documentation procedures rather than on the quality of the rounds. This illustrates another ambiguity in the purpose of IR: is it to support nurses to improve the care they deliver, or to provide nursing managers with detailed evidence of nursing activity? Or is it an assurance tool for nurse directors seeking to report the quality of care to their boards and the public?

Summary

Despite the widespread use of IR, there is ambiguity surrounding its purpose and limited evidence of how it works in practice.
Differences in the implementation of IR demonstrate the importance of care delivery context and highlight that IR has been adapted in different contexts and as time has progressed.
This synthesis generated eight CMO configurations (see Table 3), which were tested and refined in subsequent phases of the study.

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.

Bookshelf ID: NBK547481

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