Programme theory

All programmes (henceforth called ‘interventions’) will implicitly or explicitly have a programme theory or theories⁶⁸ about how the intervention is expected to cause its intended outcomes. When an intervention such as IR is implemented, it is testing a theory about what ‘might cause change’, even though that theory may not be explicit.⁶⁹ As previously explained, in the first phase of the research, the initial theories of IR, or mechanisms by which change might occur, were not very explicit (see Chapter 3). Thus, a key task in the realist synthesis was to make the theories in the intervention explicit, by developing clear hypotheses about how and for whom IR might ‘work’ and why. Data used to develop the initial programme theory included analysis of academic peer-reviewed articles, policy documents and grey literature, and discussion in an initial stakeholder consultation event involving service user representatives and NHS clinical staff. These approaches enabled the development of initial programme theories about how, for whom and under what circumstances IR helps nurses with their work (Box 4).

BOX 4

Initial programme theory

Revised evidence-informed programme theory

The revised evidence-informed programme theory is presented in Box 5. An iterative CMO configuration process was used, distilling from the CMOs how IR (the intervention) causes its intended outcomes, based on an analysis of the data. In particular, the degree of support for each CMO configuration was examined within different data sources (e.g. nurses, managers, patients, carers, other health-care professionals) and obtained by different data collection methods (e.g. interviews, observations, national survey).

BOX 5

Revised evidence-informed programme theory

There was some evidence to suggest that the ‘consistency and comprehensiveness’ and ‘accountability’ mechanisms were at least partially activated, in some contexts. Both CMOs were considerably more complex than the initial programme theories and CMOs had implied. Some nurses said IR helped them ‘communicate with their colleagues and within teams’, but this was not supported through the observations or any other source. When activated, the outcomes that were most closely linked to these mechanisms were as follows:

• All nurses knew what was required to deliver basic, fundamental patient care to a minimum standard.
• Nurses said that they could use IR documentation to provide evidence that they had delivered basic, fundamental patient care to a minimum standard.
• Nurses said that they thought that IR led to improvements in levels of patient comfort and safety.

The evidence was inconclusive around whether or not the ‘anticipation’ and ‘visibility and presence’ mechanisms were activated, because, in practice, it was often hard or impossible to separate IR from nurses delivering usual care. Finally, there was no evidence to support the activation of the ’nurse–patient relationships’, ‘allocated time to care’ or ‘patient empowerment’ mechanisms. No additional CMOs were identified during the national survey of senior nursing managers or in the case study fieldwork. The reasons for these findings will be explored in the remainder of this chapter.

Contextual factors influencing variation in implementation and outcomes of intentional rounding

In this section, four layers of context that activate mechanisms and lead to outcomes of IR are examined. Pawson⁷⁰ and Pawson et al.⁷¹ identified four contextual layers that influence variation in outcomes:

1. individual capabilities and characteristics of key actors
2. interpersonal relationships
3. organisational setting
4. intrastructural setting

This section builds on and refines the contextual factors previously identified in the realist synthesis, based on the case study fieldwork. In Chapters 6 and 7 the perspectives of patients, carers, front-line nurses, senior management and other health-care professionals on organising, delivering and receiving IR were presented. Here, these perspectives are synthesised to describe the enabling and inhibiting factors that determined whether or not mechanisms were activated, operating at each contextual layer. These contextual factors are based on data presented in preceding chapters and/or have been theorised on the basis of these data. For example, the patients and carers whom we interviewed had not received an information leaflet on admission to the wards (as recommended in some of the individual trust IR policy documents from the case studies), but if they had been, we would have inferred that it was more probable that they would have had an awareness of IR.

Fidelity to the original intervention

As stated in Observations of intentional rounding (nurse shadowing and non-participant observation of direct patient care), 188 hours of care delivery were observed by four research staff. A total of 240 IRs were observed in this time, delivered by RNs, HCAs, ward sisters, assistant practitioners and trainee assistant practitioners, and both bank and permanent members of staff. Observations were undertaken throughout the day and evening shifts (ranging between 07.00 and 01.15) on both weekdays and weekends. At every round, researchers recorded whether or not each member of staff conducted the core components of IR according to the Studer Group’s protocol. The following examination of fidelity has been conducted to explore how observations of IR delivered in the English case study sites compare to the original IR intervention as promoted by the Studer Group.

In each intentional round, researchers looked for an opening phrase, examples of the ‘4 P’s’ (pain, positioning, personal needs and placement of items), an environmental assessment, a closing phrase and information about when the staff member would return. Researchers noted whether or not each of these components was observed ‘fully’ (as per the Studer Group protocol), ‘partially’ (notable but not as defined as in the Studer Group protocol) or ‘not observed’. To increase inter-rater reliability between observers, we discussed and agreed how to define each of these categories in the research team; the definitions are provided in Appendix 16 for the sake of transparency.

Researchers also recorded details of when staff members completed the IR documentation (this referred to either ‘immediately after the round’; ‘retrospectively’, i.e. at a later time in the day; ‘prospectively’, i.e. before the round took place; or ‘not at all’. The ‘not at all’ category meant that researchers did not see the nursing staff complete the documentation for the duration of the observation session. The researchers can therefore not be sure that documentation was not completed after the observation session had ended, e.g. at the end of the nursing staff shift). Researchers also recorded any observations of RNs checking that IR had been completed by HCAs (i.e. checking IR documentation to see if HCAs had completed it). On occasion, researchers were unable to determine whether or not a component of IR had been delivered. This was usually because IR was being undertaken at the same time as personal care delivery and the patient and staff member were either behind a drawn curtain or in a single room with the door closed, leaving researchers unable to see or hear the care being delivered. When this was the case, the instances have been recorded in the fidelity table as ‘unable to observe’.

As Appendix 16 highlights, there are a number of caveats to these data. Just because researchers did not observe nursing staff asking patients directly about each of the IR components, one cannot assume that they were not internally assessing them and making clinical judgements as to their relevance. Nursing staff may have felt (rightly or wrongly) that they already knew the answer to some of these questions and, therefore, did not need to ask the patients directly. Similarly, nursing staff may have assessed that particular aspects of the IR protocol were not pertinent to some patients and, therefore, they did not vocalise them. Researchers did not ask nursing staff why they behaved as they did after each round, meaning that they could not be sure what nursing staff were thinking as they performed IR. This is a possible methodological limitation in the study, although it is probable that nursing staff would not have had the time or capacity to debrief with researchers after each round. A further point to remember is that, in some cases, nursing staff were delivering IR when patients were either asleep or away from their bed. In these instances, protocols stated that nursing staff should still complete the IR documentation even though they could not ask patients any of the questions. Instead, they were to mark on their documentation either ‘patient asleep’ or ‘off ward’. Similarly, there were occasions when nursing staff were unable to directly ask patients IR questions either because patients could not speak English/had health issues that made them incapable of responding or because patients had expressed a desire not to be disturbed, yet on these occasions nursing staff were still required to complete the IR documentation. These issues all explain part of the reason why the completion of documentation was observed more commonly than the asking of questions. With these caveats in mind, Table 20 demonstrates how regularly nursing staff were observed to ask patients about or, in the case of environmental assessment, undertake each aspect of the IR protocol.

TABLE 20

Observations of IR in practice: fidelity to the original intervention (i.e. the Studer Group protocol)

Table 20 shows that 240 individual IR interactions were observed over a period of 188 hours: 89 intentional rounds were observed at case study site 1 (during 68 hours of observation), 108 intentional rounds were observed at case study site 2 (during 60 hours of observation) and 43 intentional rounds were observed at case study site 3 (during 60 hours of observation). A number of other (non IR-related) interactions were also observed in this time frame; these are discussed in Chapter 6, Perspective of other health-care professionals, General contexts and outcomes. Although similar numbers of observational hours were undertaken at each site, far fewer IRs were observed at case study site 3 because clear examples of IR were very difficult to identify. Staff were often seen to incorporate aspects of IR into their general interactions with patients but not to refer to this as IR or document it as such.

Across all sites, the most frequently observed aspect of IR was the completion of IR documentation. Overall, 86% of all IR interactions were observed to be documented. Seventy-five per cent of rounds were documented immediately after they were undertaken, whereas 9% of rounds were documented retrospectively and 2% were documented prospectively. Case study sites varied markedly in their approach towards documentation of IR. Documentation was completed most regularly at case study site 1, where 92% of rounds observed were documented, usually immediately after the round had taken place (85%). In comparison, 67% of rounds observed at case study site 3 were documented and 51% were completed immediately after the round. More rounds were completed retrospectively at case study site 3 (16%) than at sites 1 (6%) or 2 (8%), and rounds were also more likely to go undocumented in site 3 (30%) than at site 1 (8%) or site 2 (10%). The majority of rounds were documented at case study site 2 (88%), although only 77% were completed immediately after the round and prospective completion was noted more often here than at other sites (3%, compared with 1% at site 1 and 0% at site 3). This was because case study site 2 consisted primarily of single rooms, with IR documentation stored outside a patient’s room. Staff were therefore occasionally observed to complete the IR documentation before they entered the room to undertake the round.

The only other aspect of IR that was more commonly observed than not was the use of an opening phrase. Nursing staff used an opening phrase in 53% of the intentional rounds observed. However, it was rare for nursing staff to introduce themselves by name (as per the Studer Group protocol); this occurred in only 16% of interactions. Nursing staff tended to introduce themselves by name when meeting a patient for the first time, when the patient had new visitors with them or when a period of time had lapsed since they had last seen the patient (e.g. if the staff member had not been on shift for a couple of days). It was far more common (in 36% of interactions) for nursing staff to simply use a generic opening statement, such as ‘Morning’, ‘Hello’, ‘Are you allright?’ or ‘How are you feeling?’ when they entered the room or approached a patient’s bed. Occasionally, nursing staff opened the conversation with a direct question, such as did they want to get back into bed or had they opened their bowels, rather than begin with a greeting, per se. However, in 47% of rounds observed, no opening phrase was used by nursing staff at all – they simply approached the patient and started undertaking their tasks. Again, there were notable differences between sites in the use of opening phrases. Nursing staff at case study sites 2 and 3 were far more likely to use any form of opening statement than those at site 1, with opening phrases observed in 74% of IR interactions at site 3, 65% of IR interactions at site 2 and 27% of IR interactions at site 1.

Findings for all ‘4 P’s’ of IR were similar, in that these issues were rarely observed to be asked about by nursing staff. ‘Positioning’, ‘personal needs’, ‘pain’ and ‘placement of items’ questions were observed to be asked in 27%, 26%, 26% and 23% of rounds, respectively. This pattern of not asking about the ‘4 P’s’ was noted across all sites, although staff at case study site 1 were less likely to ask any of the ‘4 P’s’ questions than staff at the other sites. One other notable difference was that staff at case study site 3 were more likely to ask about personal needs (49%) than staff at sites 1 (13%) or 2 (27%). Environmental assessments were also uncommon, with these being observed in only 8% of all IR interactions. Again, staff at case study site 3 were observed to undertake environmental assessments more often (14%) than staff at sites 1 (8%) or 2 (6%).

A closing phrase, in any form, was observed in only 9% of all interactions. According to the Studer Group protocol, nursing staff are required to ask the question ‘Is there anything else I can do for you?’, but the staff in this study were observed asking this question (or words to that affect, e.g. ‘Do you need anything?’) in only 3% of rounds. Staff at case study site 2 were more likely (5%) to ask this question than staff at sites 1 (1%) or 2 (0%), although there may be some reasonable explanations for this finding (e.g. a larger number of single rooms). As shown in Table 12, staff at case study site 3 were not required to ask this question; therefore, it is unsurprising that no one did. Furthermore, case study site 2 was the only site where staff were required to sign the IR documentation to confirm that they had asked this question, whereas staff at site 1 were supposed to ask it but did not need to document it. This requirement to document the closing phrase on the form may explain why staff at site 2 were more likely to ask this question than those from other sites. However, it is questionable why only 5% of nursing staff were observed to ask this question, given their requirement to document this on the IR form. Using a generic closing statement to end rounds was observed slightly more often (in 6% of all rounds observed) than asking the Studer Group closing question. Statements such as ‘thanks’, ‘bye’ or ‘shout me if you want anything’ were used and others informed patients to use their call bell if they required any assistance. However, in 90% of rounds observed, nursing staff used no closing statement at all; they simply completed the round and left. Occasionally, this was because the nurse had been interrupted by another member of staff at this point and had terminated the round prematurely in order to provide assistance elsewhere. However, leaving without saying anything was less common in case study site 2 (83%) than in sites 1 (97%) or 3 (95%); this may be because of the predominance of single rooms in this site. It may be that it feels less comfortable for nursing staff to leave a single room without giving a closing statement than it does for those leaving a bedside in a shared bay. The end of an intentional round delivered in a single room may feel more finite to staff when they have to physically leave the room, rather than for those working in a bay setting, who may simply be returning to their bay-based desk or moving to the patient in the next bed.

Finally, Studer Group protocols state that nursing staff should inform the patient when they will next return to them, but this was observed in < 1% of all interactions (0.8%). It was slightly more common (3%) for staff to give a vague suggestion that they would be returning to the patient (e.g. ‘see you later’ or ‘see you in a bit’) but far more common (95%) for staff not to mention anything about coming back. This propensity for staff to not mention when they would be returning to the patient was observed across all sites, but was slightly less common at case study site 3 (88%) than at sites 1 (98%) or 2 (96%). It was also rare for RNs to be observed checking HCA’s IR documentation, as this was observed on only three occasions (once at site 1 and twice at site 2).

Overall, Table 20 demonstrates that IR was not being delivered in the English case study sites in the same manner promoted by the Studer Group. In these sites, the main focus of IR appeared to be in the completion of IR documentation, regardless of whether or not the IR questions had been asked. What is clear from these findings is that the successful completion of IR paperwork is not necessarily indicative of fundamental care being delivered by nursing staff during the rounds. At case study site 1, where the regular completion of IR documentation was most successful (i.e. completed for 92% of observed interactions), nursing staff were the least likely to ask patients about any aspect of the four P’s and least likely to open their interactions with any form of greeting or inform patients when they would return. Indeed, staff at this site were observed more than at any other to simply complete IR documentation without asking patients any of the questions on the form. Comparatively, at case study site 3, where the regular completion of IR documentation was least successful (i.e. completed for only 67% of interactions), nursing staff were the most likely to be observed undertaking a number of aspects of IR (e.g. using an opening phrase, asking about personal needs, undertaking an environmental assessment and informing patients when they would return) – they just did not always document to say that they had done so. These findings suggest that health-care managers should exercise some caution when relying on IR documentation for audit purposes or in response to incidents or complaints: the completion of IR documentation does not necessarily mean that fundamental care has been delivered and vice versa.

Reach

In theory, if IR was conceptualised, broadly and simply, to mean checking regularly to ensure that patients were comfortable, safe, not in pain and had everything they needed, all patients would benefit from IR and this would mean that no one would be missed or neglected. Towards the end of this study, we learned that this was all that was originally intended by UK policy-makers when introducing IR in England. In practice, however, the Studer Group protocol for IR is more specific and less relevant for some patients and in some settings.

Frequency

The regularity of IR varied according to:

• patient characteristics
• patient ‘risk’ assessment
• time of day/night.

Content

During English implementation, the Studer Group protocol content had been adapted in the following ways:

• Irrelevant questions had been omitted (e.g. mobile/independent patients were not asked if they needed a change of position or to go to the toilet).
• Patient-relevant questions/checks were added (e.g. vital signs, food–fluid charts, skin checks, wound care, i.v. lines and infusions, pressure ulcer risk assessment, incontinence check, nutrition check, falls prevention).
• Response format had changed (e.g. Y = yes, N = no, UC = unable to communicate, NA = not applicable vs. tick for yes, cross for no, etc.).

Style

Intentional rounding could be carried out using a script and asking closed questions or by being incorporated into a general conversation and asking open questions. For a variety of reasons, some nurses undertook IR in a task-orientated, tick-box way, rather than using it as an opportunity to engage the patient in conversation to find out more about them and develop a rapport/relationship.

Responsibility

The responsibility for completing IR was shared between HCAs and RNs (and sometimes student nurses), but the proportion of IR that was done by each group varied. Furthermore, the strategies for ensuring that RNs took overall responsibility for IR differed (e.g. one site changed their documentation layout to ensure that RNs signed to say they had taken overall responsibility, even if some IR checks were completed by HCAs).

Documentation

Adaptations were made to IR documentation in a variety of ways:

• Layout – whether staff had to enter the specific time the round was completed or if time slots of every 1 or 2 hours were already recorded on the form; certain components of the form were colour coded to ensure that they were completed by RNs, etc.
• Clarity of instructions/guidance – for example where there was the inclusion of a body map to note pressure damage areas and the presence of devices.
• Instructions on the regularity of specific aspects of IR adaption – where pressure ulcer checks were included in IR the frequency of these checks was dependent on patients’ assessed risk, for example ‘high risk’ (every 2 hours minimum), ‘medium risk’ (every 4 hours) or ‘low risk’ (daily).
• Complexity – for example, with regard to documentation, ‘keys’ such as ‘position or links to other screening tools embedded in IR (e.g. Nutrition Malnutrition screening tool).
• IR follow-up identified and documented – whether or not there was space for nursing staff to record any variation/deviance or any actions resulting from rounding (e.g. pain control, medication administered).
• Ease of access – whether or not IR documentation was kept at end of patients’ beds, outside their room or at the nursing station.
• Where IR is recorded – for example, was it recorded on a separate form or in a nursing document bundle of other assessments and records, etc.?
• Form – whether IR documentation was kept in an electronic or paper format.

Using theories to develop contexts–mechanisms–outcomes

The national survey of senior nursing managers, interviews (with front-line nurses, senior nursing managers, other health-care staff, patients and carers), observation of patients (to complete Qualpacs) and shadowing of individual nurses all provided data to support and refute the CMOs. The findings of this study support other work that suggests that some mechanisms operate on a continuum, rather than simply the mechanism ‘firing’ or ‘not firing’.⁷² In this section, the existing literature and theories are drawn on to develop two of the eight mechanisms that we have concluded were partially activated, namely CMO 1, ‘consistency and comprehensiveness’, and CMO 3, ‘accountability’.

Context–mechanism–outcome 1: consistency and comprehensiveness

Context–mechanism–outcome 3: accountability

Another tension underpinning IR is its contribution to supporting accountability for nursing care. This exists at several levels, including from the point of care to senior management and commissioning.