Implementation of intentional rounding
Within trusts
A total of 105 (97%) trusts stated that they had implemented IR in some way, although details around how and when it was implemented varied widely. For example, the vast majority of trusts implemented IR between 2011 and 2014. Seven trusts could be considered ‘pioneers’ or ‘innovators’, having implemented IR before 2011, and six could be considered late adopters, stating that IR had been adopted after 2014. Further breakdown is shown in .
Once IR had been implemented, few trusts [n = 18 (17%)] reported that it had been interrupted for any length of time. Those that did gave the following reasons for the interruption: difficulty in implementing/sustaining IR, with several changes to documentation and pilots (n = 9); to review that IR was meeting its objectives (n = 3); staff shortages (n = 2); winter bed pressures (n = 1); ward managers deciding to stop IR and then re-introduce it (n = 1); poor understanding of the structured approach (n = 1); and to transfer documentation to an electronic record (n = 1).
Most trusts used the term ‘intentional rounding’ [n = 54 (53%)], although a large number of other different terms were also used, with ‘comfort rounds’ being the most common alternative [n = 14 (14%)] ().
The majority [n = 67 (64%)] had implemented IR on all wards in the trust, although 18 trusts (17%) had implemented it on specific wards only and 20 (19%) had other more specific arrangements ().
On which wards was IR implemented?
A few trusts had implemented IR in only a small number of clinical areas (e.g. in surgical wards only). Other trusts had implemented IR in specific areas, such as intensive therapy units (n = 1), operating theatres (n = 1), surgical assessment units (n = 1) and outpatient waiting areas (n = 1). Some trusts indicated that there was variation in where and how IR was implemented in their organisation. For example, one trust chose not to mandate IR but to leave it up to ward managers to decide. Another trust had initially implemented IR on all wards for all patients, but revised this to select patients ‘at risk’ (e.g. those with confusion or dementia, those post surgery or those at a high risk of falling).
Within wards
A total of 84 (80%) trusts reported that, on the wards where IR had been implemented, it occurred for all patients. Where IR did not occur for all patients [n = 21 (20%)], this was mainly based on patient need, with nine responses indicating that patients who were assessed as being at higher risk/vulnerable received IR and seven responses stating that patients who were self-caring or mobile did not receive IR. One respondent said that some patients opted out of IR.
Staff conducting intentional rounding
In 93 trusts (89%), a mix of RNs and unregistered nursing support staff conducted IR. In one trust (1%), only RNs conducted IR, and in two trusts only unregistered staff (2%) conducted IR. Nine (9%) trusts responded that allied health professionals (AHPs) were also involved in IR, with two trusts adding that doctors had occasionally been involved.
Frequency of intentional rounding
There was some variation among trusts regarding the frequency with which IR was carried out during the day on wards where IR was implemented. Twenty-three (22%) trusts implemented IR hourly, 21 (20%) implemented IR every 2 hours on all wards and 29 (28%) implemented IR hourly for some wards and every 2 hours on other wards. Thirty-two (30%) trusts had some variation in frequency, usually dependent on individual patient risk/needs. One trust specified that frequency was prescribed by a RN and another that need was assessed daily. Six trusts did not specify a frequency but said that it was dependent on patient need. Other variations were indicated, for example that IR should be conducted five or six times per day (n = 1), that it should be conducted hourly for high-risk patients and three times in 7 hours for other patients (n = 1), or that it was ward specific (n = 1).
A similar varied pattern was found for the frequency with which IR was conducted during night-time on wards where IR was implemented. Ten trusts (10%) implemented IR hourly, 26 (25%) implemented IR every 2 hours on all wards and 26 (5%) conducted IR hourly for some wards and every 2 hours for other wards. A total of 43 (41%) trusts had some variation in frequency, usually dependent on individual patient risk/needs, as during the day. Several respondents indicated that staff made hourly checks but that patients would not be disturbed or woken up to do IR.
Structured protocol, script and procedure of intentional rounding
A total of 85 (81%) trusts said that they had a structured protocol, script or procedure in place during IR. shows the aspects of care included as part of IR. The most frequently included items were personal needs, positioning and pain assessment, which are in keeping with the accepted definition of IR. The majority of trusts also included placement of patient items, environmental safety checks and checking pressure areas. However, there were a significant number of items not usually considered part of IR that were also included [e.g. interactions with carers and checking fluid balance and intravenous (i.v.) lines and infusions], suggesting that the IR protocol was adapted by many trusts to address additional patient needs. Additional items that other trusts included were continence, nutrition, falls risk assessment, cognitive status and mouth care.
Aspects of care included as part of IR
A total of 50 (48%) trusts reported that individual wards had flexibility about what they included in the IR. This flexibility included wards adding to the standard content of IR for their specific patient group or specialty (n = 9), staff using ‘common sense’ to ask only relevant questions (n = 7), adaptation of IR questions for specific patient groups (n = 8) and having a free-text option to record additional information.
Documentation of intentional rounding
Most trusts documented IR [n = 101 (96%)]. The majority used paper documentation kept by the patient’s bedside [n = 90 (86%)] or at the nurses’ station (n = 6). Some used electronic documentation at the bedside using a mobile device (n = 4) or at the nurses’ station (n = 1). One trust documented IR on a whiteboard and 10 trusts used a combination of paper and electronic documentation. Documentation was supposed to occur after every round in most trusts [n = 91 (87%)] or at the end of the shift at five trusts (5%). Timely documentation after every round was seen as better, but five trusts acknowledged that, in reality, staff documented IR at the end the shift some or most of the time.
Intentional rounding was audited by the majority of trusts [n = 68 (65%)], although five respondents did not know if IR was audited or not. Audits tended to be part of monthly general nursing compliance and metrics audits (n = 13), weekly or fortnightly senior nurse/ward manager quality rounds or documentation audits (n = 8) or spot-checked on daily ward manager/matron rounds (n = 9). Other, less frequent, responses included that IR was not audited formally, but was used in the management of incidents and complaints (n = 3); that IR was looked at as part of 6-monthly or annual reviews (n = 7); that IR was assessed as part of patient experience surveys (n = 2); and that it was reviewed in ‘Back to the Floor’ senior nurse reviews (n = 1).
Perceived changes resulting from the implementation of intentional rounding
The majority of respondents perceived that IR had a positive impact on patient experience (82%) and safety (79%) or had made no difference (). They thought that IR had less of an impact on carers’ experiences, but that the impact it did have was positive (55%). IR was thought to have some positive impact on staff experience (44%), although 10 respondents thought that IR had a negative impact on staff experience. The majority thought that IR had a positive impact on accountability (66%), although 34% thought that it made no difference to staff accountability. Some trusts perceived improvements in the number of falls and pressure ulcers; however, 19 trusts thought it was very difficult to say whether or not any improvements were due to IR, as other initiatives undertaken may also have had an impact.
Perceived changes resulting from the implementation of IR
Staff education about intentional rounding
Sixty-three (60%) trusts provided education for staff when IR was introduced and 52 (50%) trusts made IR education mandatory as part of the induction of new staff. Only 18 (17%) trusts provided education about IR as an ongoing requirement for all staff, although 27 trusts (26%) said that education was locally arranged in ward areas/specialties. Some trusts provided more than one approach to education and 15 trusts (14%) had no planned programme to educate and prepare staff for using IR. Two (2%) respondents did not know whether or not IR education was provided for staff.
Qualitative analysis of the open, free-text questions in the survey
The survey included opportunities to provide additional information about how IR was implemented. A total of 108 trusts responded to the survey; of these, 94 provided a free-text response to at least one question. These responses were analysed to search for examples of contexts, mechanisms or outcomes associated with IR; this is reported in Appendix 3.
