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

Study design and conceptual basis

A multimethod study design was undertaken using realist evaluation methodology17 to evaluate the implementation of IR in England. Realist evaluation is a theory-driven approach designed for evaluating complex social interventions, such as IR. 18,19 It does not seek to answer the question ‘does this intervention work?’ but instead acknowledges that complex social interventions only ever work for certain people in particular circumstances. The key task of a realist evaluation is to therefore understand and explain the patterns of success and failure by asking the exploratory question: ‘what is it about this intervention that works, for whom and in what circumstances?’17,19 It achieves this through the identification of causal explanations of how an intervention or programme is anticipated to work, known as context–mechanism–outcome (CMO) configurations.

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 in three NHS acute trusts involving individual interviews with health-care staff, patients and their carers, observations of IR and nurse shadowing, retrieval of routinely collected ward outcome data and analysis of costs; and (4) synthesis of study findings. Figure 1 shows the study flow diagram. More detailed descriptions of the methodology for each phase is provided in individual phase chapters.

FIGURE 1.

Study flow diagram. Reproduced from Harris et al. 8 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

Reproduced from Harris et al. 8 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

Programme theories

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.

Sample and respondent characteristics

Responses were received from 108 (70%) of the 155 English NHS hospital trusts that were sent the survey, of which 76 (70%) were acute trusts, 23 (21%) were integrated acute and community trusts and nine (8%) were specialist trusts. The mean number of beds in the responding trusts was 709 (range 39–2000) and 98 (91%) trusts had wards that were structured as predominantly smaller bays (typically 4–6 beds in a bay); 44 (41%) had wards that were made up of predominantly single rooms and 26 (24%) had wards that were predominantly Nightingale wards (i.e. the majority of beds in one large ward area). A total of 102 respondents provided their job title, which showed that the majority of the surveys [N = 89 (87%)] were completed by corporate-level nursing leaders in the trust, that is chief nurses (n = 31), deputy chief nurses (n = 43) or another corporate-level senior nurse (n = 15). The remaining 13 questionnaires were completed by divisional or directorate level heads of nursing. At the beginning of the survey, a brief definition of IR was given:

. . . a structured process whereby nurses in hospitals carry out regular checks, usually hourly, with individual patients using a standardised protocol to address issues of positioning, pain, personal needs and placement of items.

A total of 103 respondents (95%) indicated that this was their understanding of IR; there were four missing responses, and one respondent thought that the definition made the interaction sound mechanistic and failed to capture the essence of IR (i.e. showing patients, at regular intervals, that staff are concerned about meeting their needs).

Descriptive statistical analysis

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 Figure 2.

FIGURE 2.

When was IR implemented?

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%)] (Table 4).

TABLE 4 - Alternative terms for IR

Alternative name	Trusts, n (%)
Comfort rounds	14 (14)
Care round or Care rounding	11 (11)
Hourly rounding or Hourly rounds or Hourly care rounds	4 (4)
Essential care rounds	2 (2)
Care and comfort rounding	2 (2)
Patient contact round	1 (1)
Rounding	1 (1)
Intentional safety care bundle	1 (1)
Better-care rounding tool	1 (1)
Patient-focused rounding	1 (1)
Time to care	1 (1)
I-Care	1 (1)
Safety and comfort checks	1 (1)
Care and comfort checks	1 (1)
Around-the-clock care	1 (1)
Patient-focus rounding	1 (1)
Well-being standards	1 (1)
Caring around the clock	1 (1)
Rounding with a reason	1 (1)
Quality rounds	1 (1)

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 (Table 5).

TABLE 5 - On which wards was IR implemented?

Clinical area	Trusts, n (%)
All adult inpatient areas	101 (96)
Acute admissions	91 (87)
Emergency department	80 (76)
Maternity areas	74 (70)
Day-care areas	74 (70)
Paediatric wards	72 (69)

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. Table 6 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.

TABLE 6 - Aspects of care included as part of IR

Aspect of care	On all wards, n (%)	On some wards, n (%)	On no wards, n (%)
Items in Studer version of IR
Placement of patient items	62 (83)	9 (12)	4 (5)
Positioning	77 (92)	8 (10)	0 (0)
Checking of pressure areas	61 (81)	12 (16)	2 (3)
Pain assessment	75 (90)	6 (7)	0 (0)
Personal needs (e.g. toileting)	78 (93)	6 (7)	0 (0)
Environmental safety checks	61 (82)	8 (11)	6 (7)
Items in trust adaptations of IR
Checking vital signs	13 (25)	12 (23)	28 (53)
Checking i.v. lines and infusions	19 (33)	15 (26)	24 (41)
Checking fluid balance	36 (55)	12 (18)	17 (26)
Interactions with carers	37 (58)	10 (16)	17 (26)

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 (Table 7). 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.

TABLE 7 - Perceived changes resulting from the implementation of IR

Area of change	Change, n (%)
	Positive impact	Negative impact	No difference
Patient experience	77 (82)	0 (0)	17 (18)
Patient safety	75 (79)	0 (0)	20 (21)
Carer experience	48 (55)	0 (0)	39 (45)
Organisation of care	61 (66)	1 (1)	30 (33)
Staff experience	39 (44)	10 (11)	39 (44)
Accountability	61 (66)	0 (0)	31 (34)

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.

Participant characteristics

Seventeen senior nurses and ward managers participated in individual, semistructured interviews (see Appendix 11). Table 13 highlights their participant characteristics, in terms of their role. It should be noted that none of the senior nurses interviewed personally delivered IR and so often talked in interviews about how they thought IR was delivered or how they expected it should work.

Findings

General contexts and outcomes

Summary

• All senior trust and ward managers mentioned accountability in some way during the interview. Accountability was seen to be demonstrated primarily by documentation of IR. Senior staff felt that one of the benefits of IR was the documented evidence it provided, although they acknowledged that this evidence was not always sufficient/reliable.

• Most senior staff described IR as a checklist, aide memoire or a framework that supports nursing staff to deliver care. However, there were concerns that it could be used in a prescriptive, task-orientated way, when it should be delivered in a conversational way, tailored to individual patient needs. None of the senior staff interviewed thought that IR should be delivered in a standardised, rigid way at every round.

• Intentional rounding was thought to facilitate some communication between nursing staff, although this tended to focus on whether or not patients had been checked.

• Few senior staff believed that IR increased the frequency or quality of staff communications with patients.

• Senior staff did not see IR as providing nurses with ‘time to care’. The majority thought that staff were delivering care to patients and that the IR paperwork supported what they were already doing.

Participant characteristics

An opportunity sample of nursing staff was identified, based on who the research team met while collecting data on the wards and who agreed to participate in the research. Thirty-three front-line nursing staff members participated in an individual, semistructured interview (see Appendix 12); Table 14 summarises these interviewees’ level of seniority and education. All of the nursing staff interviewed were aware of and had personally undertaken IR.

Findings

General contexts and outcomes

Summary

• All nursing staff mentioned accountability in some way during their interview. However, most nursing staff did not talk about IR influencing their own personal accountability for standards of care delivered, although some acknowledged that it may improve standards in hospitals that were providing poor care.

• Half of all nursing staff interviewed felt that a positive outcome of IR was that it provided evidence that nursing care had been delivered. Most viewed this as a means of protecting oneself following an incident or complaint.

• All nursing staff mentioned the consistency and comprehensiveness mechanism in some way during their interview. Many participants referred to IR as a checklist or system for checking on a wide variety of patient needs. They also felt that IR offered a useful prompt or reminder to prevent staff from forgetting to undertake particular tasks.

• Opinion was divided on whether or not IR should be applied to all patients, but no nursing staff felt that IR should be applied using a structured, systematic approach at every round. Instead, nursing staff talked about using their clinical judgement and common sense to tailor IR to each patient.

• Some nursing staff felt that IR increased the frequency of nurse–patient interactions, although these communications were usually brief, rather than lengthy discussions. Few nursing staff believed that IR could improve the quality of nurse–patient interactions.

• No nursing staff felt that they had been given specific, allocated time in which to undertake IR.

• Half of all nursing staff felt that IR encouraged or improved staff communication, generally in terms of an improved handover of information about patients between nursing staff or across shifts.

• Few nursing staff felt that IR affected nurse visibility, anticipation of needs or patient empowerment.

Participant characteristics

An opportunity sample of non-nursing health-care staff was identified, based on who the research team met while collecting data on the wards and who agreed to participate in the research. Twenty-eight other (i.e. non-nursing or managerial) health-care staff participated in an individual, semistructured interview (see Appendix 13), some of whom had direct experience of conducting IR. Table 15 shows the participant characteristics of the other health-care staff interviewed in terms of their profession/role and whether or not they had direct experience of undertaking IR.

Findings

General contexts and outcomes

Summary

• The understanding of IR in this sample of interviewees was mixed, because although some had had direct experience of doing IR, others had learned about it only through their own observations of nursing care.

• It was rare for other health-care staff to directly refer to IR documentation. Although some health-care staff realised that they ask patients similar questions, it was more usual for other health-care staff to find a nurse on duty to speak to.

• Other health-care staff recognised the dilemma between having a structure that was used in a standardised and formal way for everyone verses the need for flexibility to adapt to suit patient need.

• Other health-care professionals saw the value of having documented evidence of nursing care having been delivered.

Method

Two approaches to non-participant observation were conducted:

1. ’Shadowing’ nursing staff to explore how they interacted with patients and each other in relation to IR, and how IR contributed to the way they worked. Nursing staff were purposively sampled to attain a range of grades and levels of experience. All participants provided informed consent and researchers took narrative field notes of what they observed. These narrative field notes of nursing staff observations were then used to complete two protocols, one to record individual IR interactions and the other to assess fidelity to the original IR intervention, as set out by the Studer Group.

2. ‘Shadowing’ patients to observe individual interactions between patients and nurses. To facilitate this, the researchers undertook a Quality Patient Care Scale (Qualpacs) for five patients in each ward. Qualpacs65 is an established instrument for assessing the quality of care a patient receives from a nurse, using 68 items across the following areas of care: physical, general, psychosocial, communication and professional implications. The instrument is patient focused, with observations based on who attends a patient’s bedside to provide care and how frequently. 66 The observer(s) watched the care received by selected patients over a 2–4 hour period and rated each aspect of this care on a scale of 1 (poorest care) to 5 (best care). 66,67 To complete the Qualpacs observations, researchers (who were both RNs) had access to patients’ nursing care plans and notes to assess how the care delivered addressed a patient’s individual plan for nursing care. In sites 1 and 2, two observers scored independently and met to discuss and agree scores. In site 3, owing to staff changes, one observer conducted the Qualpacs observations.

Researchers planned to observe up to 100 individual IR interactions between the patient and nurse and interactions between nurses on each ward using these various methods. In all observations, the researcher recorded how often interactions occurred, what patients were asked during their interactions, what care was provided and, when possible, the duration of each individual interaction. External factors that affected the delivery of IR were also recorded to help establish how the intervention fitted within the whole nurse experience of the delivery of care and the whole patient experience of receiving care. Researchers made as few interruptions as possible when shadowing nursing staff and refrained from asking questions. The observation data entered into the ‘fidelity to original intervention’ protocol were analysed using descriptive statistics. The data entered into the ‘individual IR interactions’ protocol and the Qualpacs descriptions of interactions were thematically analysed using the coding framework developed to analyse the individual staff interview data, which covered the contexts, mechanisms and associated outcomes of IR and how these were linked.

Participant characteristics

A total of 188 hours of care delivery was observed by four research staff. Observations were undertaken throughout the day and evening shifts (ranging between 07.00 and 01.15) on both weekdays and weekends. Thirty-nine nursing staff were ‘shadowed’ during this time, with researchers following them for several hours at a time and recording how they interacted with patients and each other in relation to IR. Table 16 highlights the participant characteristics of those staff who were shadowed, in terms of their profession/role.

For the Qualpacs observations, researchers observed direct patient care from the perspective of 28 patients. They did this by sitting unobtrusively near each patient’s bedside and recording the time and the nature of the interactions they had with nursing staff (interactions with non-nursing were noted but not scored in the Qualpacs analysis) over 2–4 hours. A Qualpacs (see Report Supplementary Material 2) was completed for each patient to assess the quality of care they received; average care is assessed as the quality of care expected to be delivered by a newly registered nurse, and given a score of 3.

Findings

Non-participant observation of direct patient care and staff interactions with patients (Qualpacs)

Although researchers had previous experience of using Qualpacs, they found it to be a challenging tool to use in this study. Qualpacs relied on assessing whether or not the care observed addressed the patients’ needs as planned in their nursing care plans (the research team did not have access to the medical notes). However, the nursing documentation for all the observed patients was standardised nursing care plans, none of which had been personalised for the patient and no additional care plans had been written. So researchers were unclear of what nursing care should be delivered to each patient and whether or not the care observed met a patient’s individualised needs. Researchers made assessments on the appropriateness of care, which may not be accurate; this is a limitation of the study. As a result, there were concerns about the validity of the Qualpacs scores as a measure of the quality of nursing care. Therefore, these scores have not been reported. However, as part of the Qualpacs methodology, the start time of each interaction between patients and health-care staff and a description of each interaction was recorded (Table 17).

Researchers recorded the time intervals between every interaction (Table 18). Patients were seen frequently by staff: between every 12.5 and 16.8 minutes by any member of hospital staff, between every 16.5 and 22.9 minutes by any member of nursing staff and between every 28.0 and 49.8 minutes by a RN.

Summary

• Staff were observed to be very busy and to carry out a wide range of tasks. IR was usually combined with other activities and staff were frequently interrupted when undertaking IR, which meant that they were observed to document IR retrospectively. On occasion, staff delivered what looked like IR but did not complete IR documentation.

• Considerable variation in the practice of IR in relation to its consistency and comprehensiveness was observed. Across all sites, staff demonstrated a flexible approach to how IR was delivered and a scripted approach to IR was never used.

• Intentional rounding was never observed to be completed by anyone other than nursing staff (RNs and HCAs); non-nursing staff rarely looked at it.

• Nursing staff and patients were observed to talk to each other often, although the majority of interactions were not observed to be part of an intentional round.

• There was some evidence that nursing staff were anticipating patient needs, but it was difficult to say if this was due to IR.

• Intentional rounding was not observed to make any difference to nurse visibility or patient empowerment.

• On average, patients have a direct interaction with a member of hospital staff (e.g. a member of medical staff, nursing staff, AHP staff, housekeeping staff, phlebotomist) every 12.62 to 15.94 minutes.

• On average, patients have a direct interaction with a member of nursing staff (e.g. RN, HCA, student nurse) every 17.52 to 21.8 minutes, which is considerably more frequent than the recommended frequency of IR.

• On average, patients have a direct interaction with a member of registered nursing staff (e.g. staff nurse, ward manager, clinical nurse specialist) every 36.29 to 38.92 minutes, which is considerably more frequent than the recommended frequency of IR.

• Although there is similarity between the time intervals of direct interactions with all staff and all nursing staff between acute wards and care of older people wards, there is a marked difference in the time intervals of interactions with RNs. Patients in acute wards have a direct interaction with a RN, on average, every 29.03 to 30 minutes, whereas the average is every 43.30 to 49.81 minutes for patients on care of older people wards. The reasons for this are unclear; there are no obvious trends in nursing establishment and skill-mix data, as presented in Appendix 5.

Participant characteristics

A total of 34 patients and 28 carers participated in semistructured interviews (see Appendices 14 and 15). A further 19 patients and 12 carers were approached but declined to participate in an interview. Interviews were mostly conducted with one person, but in two instances one patient was interviewed alongside two carers, and in one instance two carers were interviewed together. Table 19 highlights the number and type of interviews undertaken at each site.

Interpreting data from patients and carers

Before presenting the findings from the patient and carer interviews, a few cautionary notes should be made. Interviews with patients and carers provided a range of useful observations about daily care. Some people made astute observations and had practical suggestions for how services could be improved. The interviews also provided a reality-check on how nursing practices and ward regimes were experienced by patients and those close to them. Generally, similar themes emerged across interviews, with differences possibly reflecting the diversity at each site in terms of how IR had been implemented and other factors such as ward layout. However, there were a number of factors that require caution in the interpretation of data from patients and carers. First, half of the wards selected for observation and interviews were care of the elderly wards. Many patients on those wards were frail and/or had cognitive difficulties, as indeed did some of the patients on general medical wards. For some patients, and some carers, cognitive difficulties and other personal challenges appeared to affect their ability to understand questions or to stay on the topic. Second, patients and carers often made comments of a general nature, or answered questions with simple affirmative or negative responses, without giving sufficient details to enable researchers to put a high level of confidence in their recall. Sometimes patients agreed with what they believed to be the point of the question, for example simply answering ‘yes’ to a question about nurse visibility, or whether they could communicate with them. In those cases, it was difficult to assess the patient’s level of insight or understanding.

Third, there were sometimes contradictory statements in an interview, or some ambiguity about which staff patients had seen and how often. Many patients were unsure of the professional identity or designation of staff, so they did not always understand whether or not a particular person’s presence at their bedside was part of regular rounding or for some other purpose. Nor did patients necessarily make a distinction between nurses, doctors and other health-care professionals. Fourth, patients and carers were not always clear on what had happened on their current admission or what had taken place on previous admissions (or on previous wards in this admission), or indeed what had happened to someone else. Fifth, the overwhelming majority of patients and carers did not recall an explanation of IR (by that or any other name). Although there is room for argument on how much a lack of appreciation of IR by patients or carers affects its implementation, it may well affect the recognition or perception of IR. Linked to this point is the difficulty of understanding whether or not comments from patients and carers reflected the practice of IR and any of its associated mechanisms, or lack thereof. Patients and carers were often eloquent and perceptive about the quality of care that they perceived, but it was often difficult or impossible to know whether or not, or to what extent, the care they described had taken place in an IR context.

Finally, in view of the above, it is not surprising that patients and carers had explicit views on a limited number of mechanisms, and a few contexts. Outcomes were sometimes implicit but rarely explicit. Unsurprisingly, patients and carers did not perceive what went on around them in terms of mechanisms, although they were sometimes quite tuned in to the contexts within which care was being delivered. When it had seemed reasonably safe to infer that comments were relevant to the mechanisms, contexts and outcomes reported in other parts of this report, this was done. However, in order to make the most of patient/carer information, it is also necessary and reasonable to take careful note of their broader comments on care in general, while being cautious about how this relates to the mechanisms, contexts and outcomes of IR.

Mechanism: accountability (n = 0)

This mechanism was not evident, as such, to patients and carers, although one carer noted confidence as an outcome of seeing that nurses took responsibility and knew what they were doing. Another commented on ‘red tape’ as contextual, saying:

I know they’ve got an awful lot of paperwork, sometimes you wonder if it’s too much but, you know, it’s like anything, isn’t it, maybe some of it is red tape, maybe some of it is to cover themselves, some of it is obviously because they need information and they need to pass it on to other people.

Carer

Mechanism: consistency and comprehensiveness (n = 48)

Many patients and carers made comments about consistency and comprehensiveness in their care. Some 25 comments were made about consistent monitoring, but 17 comments were made about variations in the frequency and practice of nurses coming to the bedside, for example:

. . . it’s almost like a glance, rather than a look, so it’s just ‘Oh, that’s OK, let’s go, don’t have to go in there’, that’s the sort of feeling you get.

Carer

Thirty-one people felt that regular rounding was useful for checking on specifics, with general observations and hydration mentioned most frequently. Positive outcomes of consistent and comprehensive care included confidence and reassurance, particularly for carers, and patients, while one patient felt that disturbance from night-time observations was a negative but necessary feature of regular attention.

Mechanism: nurse–patient and nurse–carer communication and relationships (n = 50)

A large number of comments were made about communication and relationships, with both patients and carers making positive comments about communication and engagement with staff, but it was rarely possible to link such comments to IR. Positive comments from patients often highlighted the relational aspects of communication:

. . . Oh yeah, you can have a laugh, yeah, you can have a good laugh with them you know, because otherwise you’re just sort of sat here and you know, growing cobwebs, but no, you can have a good laugh with them because you need it.

Patient

You know, you’re not just, to them you’re not a patient, you are a person, that’s the, I think that’s the thing, you are a person, not a patient.

Patient

No carers and only four patients felt that IR had been explained to them, whereas 18 patients and 17 carers specifically said that IR had not been explained to them. Positive outcomes of good communication were mentioned nine times, almost always in relation to feeling better and feeling reassured:

Well, it just means that I can sleep at night, really. You know, that nothing horrible is going on, you know, that they listened to her, you know, and they don’t fob her off, which is good.

Carer

Mechanism: allocated time (n = 0)

There were no comments directly relating to this mechanism, although some patients and carers reported having to wait for care, which might be construed as a negative observation in relation to this mechanism.

Mechanism: staff communication and teamworking (n = 0)

No comments were made on this mechanism.

Mechanism: visibility (n = 45)

Forty-five of the patient/carer interviews included positive comments about nurse visibility/presence, whereas eight participants made negative comments. However, this is the mechanism for which it was most difficult to be confident that patient/carer observations were evidence of a mechanism for IR, as many people seemed to be commenting on the general visibility of staff:

Ever since I’ve been here, there’s always someone in the vicinity or in here, you know.

Carer

Nonetheless, staff visibility was clearly one of the aspects of care that patients valued most, whether or not in the context of IR:

. . . there’s something to be said about just being in a bay and actually seeing faces, so I think maybe the nurses do also kind of know that they are going to be seen by maybe four or five patients when they enter the bay and kind of make it a point to go, you know, ‘Hi, how are you?’, as well, so it’s better.

Carer

Mechanism: anticipation (n = 45)

The issue of whether or not IR had an impact on anticipating needs was discussed in 45 interviews, but the majority felt that regular rounds may be useful for addressing immediate needs, rather than future needs, such as going to the toilet or aspects of comfort that might arise suddenly or unpredictably. As one patient explained:

To be really, really truthful, I think possibly regarding going to the toilet, I probably call them, they don’t, they wouldn’t necessarily come and ask if I want to go to the toilet, but they would probably say ‘are you in pain?’ They’re more likely to concentrate on the medical side there and, you know, giving out pills and things, whereas going to the toilet, it’s probably, would be more up to us to let them know.

Patient

So, call bells were still needed in such instances, and patients referred to staff telling them to use the call bell if needed. However, some patients did not like to use the call bell or reported dissatisfaction with delays in responding to it. Occasionally, patients also implied that they felt that they had a responsibility to alert staff to changes in their condition:

. . . and yes, if you don’t ask every single question every time it actually doesn’t matter, because let’s be honest, everybody has a voice, if somebody didn’t say ‘are you in severe pain and would you like some morphine?’, then you can say ‘could I have some morphine today, please?’. People are capable of asking, even in the baddest, you know, the worst state.

Patient

Mechanism: patient and carer empowerment (n = 25)

Twenty-five interviews elicited comments about patient and carer empowerment, but twice as many people felt that IR did not empower patients or carers than felt it might. Nor did the majority engage with IR charts:

I did have a look at it, but it’s got codes on and things like that, and I had a look at them and I thought ‘well it’s nothing to do with me really’; all I know is I’m getting better, I’ll be going home.

Patient

Carers only very rarely saw IR as an enabler of their involvement in the patient’s care. Because IR had rarely been explained to patients and they were often unaware that it was an aspect of their care and of its documentation, it is not surprising that this was so.

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).

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 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.

Nursing care was observed to be generally good and, at times, excellent; unsafe care or care that neglected a patient’s fundamental needs was not observed

Intentional rounding was introduced into nursing practice as a response to the extreme and shocking failures of care at the Mid Staffordshire NHS Foundation Trust. It was intended to improve nursing interaction and engagement with patients to restore confidence and trust and ensure patient safety. Senior nursing managers told us that they encouraged IR to be integrated into other activities; therefore, it is reassuring that IR was rarely observed as a discrete activity, but instead emerged as part of the process of getting to know, looking after and responding to patients within a continuous nurse–patient relationship. Drawing from the extensive observation data, we suggest that, although the Studer Group protocol of IR was rarely observed, the quality of nursing care was generally good and, at times, excellent.

Intentional rounding makes a minor overall contribution to the delivery of nursing care

Patients were observed to be seen by a RN, on average, every 37 minutes and by a member of nursing staff, on average, every 20 minutes. Therefore, nurses interacted with patients far more often than required as part of an intentional round. Furthermore, the frequency of these interactions was very similar on each of the three sites, even though on one site IR was hourly, on another every 2 hours and unspecified on another. This suggests that nursing staff work in similar ways to be available to patients and monitor what is happening with them. In this context, IR can be seen to make a small contribution, and is only part of the process of the way in which nursing staff engage with patients.

Intentional rounding is not visible to patients and carers

Patients and carers were usually not aware that nursing staff were undertaking IR. This is perhaps not surprising as patients, carers and nursing staff alike all said that IR was rarely explained to patients and carers, despite the requirement to do so in hospital policy (in the two sites that had a specific IR policy). This also supports our conclusion that nurses were more likely to absorb IR into their other activities and practice. However, nurses also rarely told patients when they would be returning to check them again, mainly because they were managing competing priorities, could not be confident that they would be available at a specific time and were careful not to raise expectations that might not be possible to meet and, therefore, could potentially result in a complaint. Thus, the opportunity offered by IR to reassure patients and carers of regular, time-specific contact was rarely realised. However, this finding needs to be understood, first, in the context of the frequent contact observed in the case study wards reported above, and, second, that patients and carers who were interviewed valued and were generally satisfied with the level of contact they had with nursing staff. Ironically, patients valued the relational elements of interactions with nursing staff, which, as the findings show, is not a prominent feature of the IR protocol. Many of the IRs observed had very little relational interaction and often involved asking closed questions or simply completing documentation without any communication at all; therefore, it is probable that the interactions in which nurses develop a relationship with patients occur when nurses are delivering other nursing care activities and not IR.

Intentional rounding is used by nursing staff as a defence/safety net

A strong theme emerging from the data was that IR provided evidence of accountability for care delivered, which was reassuring for nursing staff working in NHS organisational cultures preoccupied by the management of risk. However, at times, nurses expressed views and some anxiety that they were unable to conduct IR at the frequency required by their trust or to document IR in real time, as a result of time pressures and interruptions. This was justified in terms of nurses having been with patients anyway and already knowing what their patients needed. Anxiety to provide ‘proof that shows that we’ve been in and we’ve had the conversations with the patient’ was expressed as ‘if it’s not documented, it’s not been done’. It should be noted that bed occupancy on each case study site was > 90%, which is above the recommended rate of 85%. 81 This study has shown that nurses carry out nursing activities included in IR without completing the documentation and, conversely, complete IR documentation without carrying out the nursing care activities required. However, the observational data shows clearly that a lack of documenting IR does not necessarily mean the absence of an encounter or that patients have not been checked in some way. Furthermore, documenting IR does not necessarily mean that the IR care activities have been done.

Although senior nursing managers expressed reticence about the accuracy of IR records on the delivery of nursing care, it was clear that it provided them with reassurance that care had been delivered, with some acknowledging that IR was used as a safety net or as a defence against allegations of poor practice at an individual practitioner, ward and organisational level. Senior nursing managers expressed ambitions to develop nursing practice beyond the confines of IR, which was seen as a minimum standard and not something to aspire to, but felt restricted by a performance management approach in the NHS that perpetuated an ethos of compliance and risk aversion that inhibited innovation. 82 The emphasis on IR documentation by most nursing staff demonstrated that nurses were behaving consistently in the prevailing NHS organisational culture that values counting and transactional activity as a measure of risk mitigation rather than relationship-based care.

The intentional rounding protocol as defined by the Studer Group is not sufficient in England

The majority of trusts nationally have adapted the IR protocol, as defined by the Studer Group, in six different ways: reach, frequency, style, responsibility, content and documentation. This is often in consultation with clinical staff to improve usability in the clinical setting. These adaptations, which varied within and between acute trusts, demonstrated that the Studer Group IR format of the 4Ps is not sufficient in the English health-care context. There are notable differences in service delivery contexts between the USA and England, with the USA having hospitals that provide almost exclusively single room environments. However, in this study, the case study hospital with predominantly single rooms (site 2) also adapted the IR protocol to include more clinical components, such as food and fluid charts, wound care, incontinence checks, falls prevention and pressure ulcer risk assessments, which are all still referred to as ‘IR’.

Furthermore, hospital finance in the USA is more market driven, which is likely to have influenced the development of IR. The Studer Group’s developments coincided with Medicare stopping reimbursement for the treatment of injuries resulting from preventable inpatient falls. Health-care reimbursement is also linked to patient satisfaction surveys of nursing responsiveness, motivating providers to improve patient satisfaction with nursing care. 83

This indicates the need for caution when considering the implementation of interventions from other international health-care systems. Introducing new ways of working in complex, organisational and professional structures needs wide consultation, careful planning and piloting. This was circumvented in the case of the widespread introduction of IR in England. Announced for political expediency to contribute to managing poor public opinion in the anticipation of the publication of the Francis report,1 it is argued that IR was taken up unquestioningly by the majority of trusts and took root in a culture of fear, blame and regulation.

Intentional rounding adds to the tension inherent in the delivery of systematised care versus individual patient care

Nursing has long struggled to articulate a unified, collective position on what it uniquely contributes to patient care, experience and outcome. What is rarely disputed, however, is the centrality and importance of the relationship between the patient and nurse to the delivery of care that benefits patient recovery. Kitson et al. 84 identify an ongoing tension in nursing practice between a task-orientated, ‘mechanistic’ approach to delivering fundamental care and the need for consistency in managing the relational aspects of providing patient care. They assert that there is a need to acknowledge the:

. . . inherent systemic tension between the task and time approach to ‘getting the job done’ and the need for someone (on the patient’s behalf) to be integrating and personalizing the experience through thinking about the whole experience and linking activities into a series of meaningful encounters.

The systematised, structured approach to IR was seen to emphasise transactional care delivery rather than relational, individualised patient care. The flexibility with which IR was seen to be delivered, endorsed by senior nursing managers, was potentially a way of managing this tension by allowing nurses to individualise the care they provided to some degree while still being compliant to organisational expectations.

Intentional rounding is poorly understood by staff

Despite the widespread implementation of IR, it is noteworthy that the purpose of IR was poorly understood and valued by many front-line nursing staff, compounded, perhaps, by the lack of training and explanation provided. Our findings estimate that the annual incremental costs of IR could exceed £100,000 per hospital ward in the case of hourly IR. But there were no additional resources to support the policy directive, probably because it was thought that nurses were providing this care already, which adds a further constraint on implementation. Many nurses thought that IR was the form that documented the actions taken, rather than a vehicle for having a conversation with patients regularly to ensure that their needs were being met.

Intentional rounding does not contribute to multidisciplinary care

The Department of Health and Social Care’s85 response to the Francis report1 stressed the need for greater interprofessional collaboration:

. . . we will work together, collaborating on behalf of patients, combining and coordinating our strengths on their behalf, sharing what we know and taking collective responsibility for the quality of care that people experience.

Despite efforts to improve the communication across professional groups in the interests of patients, it is disappointing that progress is slow. Members of the multidisciplinary team and other staff were often not aware of IR and did not contribute to conducting it. Those who were saw the potential for improving patient care, but rarely accessed the information it provided. Thus, this could be seen as a missed opportunity for multidisciplinary collaboration. 86

Implications for nurses to take charge of nursing practice

The consistently strong message coming through the survey and interviews was the view of nurse leaders that IR, as an exemplar of nursing practice, should be shaped by the profession and not others:

. . . we need to, as a profession, be evolving in, and measuring ourselves and deciding going forward, you know, how do . . . we demonstrate good quality care . . . what is an outcome that we want to see, rather than a measure that we want to implement that would give us an outcome.

Director of nursing

. . . the risk of that is we won’t sort our own problems out. . . . what percentage of the workforce is graduates? Probably about 45, 50%? We’re not using the brains of those people because we haven’t created an environment where we’ve got leaders who are thinkers and doers.

Director of nursing

Some perceived that failure to do so had, in part, contributed to the political imperative to implement IR. We propose that the results of this study should inform a national nursing conversation about the future of IR in England. This would help NHS trusts and senior nursing managers decide which direction they want to take to respond to this new evidence and to consider whether or not there are alternative interventions that support the delivery of fundamental nursing care to patients.

Implications for nursing leadership: ‘If I were you, I wouldn’t start from here’

At our final study advisory group, where the recommendations from the study were discussed, a service user member recalled the joke about a tourist who asks for directions and received the reply ‘Well sir, if I were you, I wouldn’t start from here’. As explained earlier (see Chapter 1, Prime minister announcement), IR was hastily introduced at a time when government needed to be seen to be acting in response to the Francis report. 1 As borne out by these findings, IR as an intervention to address patient need is highly contestable. The implications for nurse leaders is to consider how to take the findings in a review that may recommend ‘de-implementation’ or ‘stopping practices that are not evidence-based’90 or ‘to abandon care that wastes resources or delivers no benefit to patients’. 91 We suggest that there is a need for a national discussion/debate within the nursing profession to consider whether or not IR is the best way of achieving desired outcomes, and what the desired outcomes are. It may be better to start afresh, rather than attempting to tweak a system that has been implemented. This is, arguably, an activity rarely undertaken by the profession. A director of nursing in this study said:

. . . we don’t have these professional conversations . . . we don’t have those types of forums because we’re so caught up just trying to keep it safe at the moment in most organisations . . . there’ll be more and more decisions that are made politically because we don’t have those right conversations and we’re caught on the back foot and because we don’t have a vision and a plan and a visual sense of how you do it; they can walk all over us and they implement these things because they can. That’s a cynical view.

Director of nursing

A decision to discontinue IR would be a bold undertaking and would need to be adequately resourced and supported. The NHS is under immense pressure and it is anticipated that the reassurance of the evidence that IR provides nurses would be difficult to relinquish:

. . . it is quite difficult because once things are in place, it’s really a brave person that says ‘right, stop doing that, let’s do this’.

Director of nursing

Implications for an improvement agenda: intentional rounding needs to be more purposeful and rationalised, that is ‘intentional’

An alternative to discontinuation is to lead a review to implement improvements that address shortcomings identified in this research. A relaunch of IR could consider renaming and site-specific adaptations, which often exceed the US version of IR. A broader umbrella term would reflect this (e.g. ‘comfort and safety rounds’). This study has identified lessons about implementation that should be considered if IR was relaunched:

• Review the purpose of IR and the level of flexibility that is acceptable. Consider the criteria for how a flexible approach should be implemented.

• Education should be provided to all nursing staff (and other staff if involved in IR) about the purpose of IR and how it should be delivered.

• The purpose of IR should be explained to patients and their carers.

• Consider involving other non-nursing staff in contributing to the record of when patients are seen and care activities undertaken.

• Documentation should not have set hourly intervals but instead have space for staff to write the specific time when the patient was attended to.

• Areas of duplication between different elements of documentation should be reduced.

• Audits of IR should focus on the delivery of IR, not the documentation of IR.

• Review the status of IR as a ‘comply or explain’ intervention and devise guidelines on how IR should be included in CQC inspections.

Implications of rapid policy development to complex problems

We have argued that hasty policy-making ‘on the hoof’ as a response to political crises is problematic. The development and implementation of IR as a national policy was done in a vacuum and involved importing an untested US model. A period of piloting, evaluation and refinement would support the integration of a policy of intervention into a complex system. Manski92 proposes ‘adaptive policy’ that remains flexible as the mechanisms and impacts become evident in different settings, and argues against the notion that research leads to a single true number that captures the effectiveness of policy, however seductive this may appear. This study provides evidence of the need for caution in using IR documentation as a performance indicator. Much has been written about the unintended consequences of measuring activities and setting targets, and, given the evident weakness of the documentation, it would be unwise to co-opt this as any kind of data on processes of care. 93

Intentional rounding documentation and tools

Issues surrounding IR documentation were mentioned by seven trusts. A few trusts noted that there had initially been some resistance to IR, with staff seeing it as, ‘another form to fill in’. However, over time resistance diminished and one trust stated that, when it was highlighted that staff were simply being asked ‘to document care that they were already undertaking’, there was a greater acceptance of its implementation. One trust had tried using ‘IR clocks’, but these were not a success and were withdrawn. Another trust felt that a move towards electronic recordings of patient interactions might make the process of IR easier.

Staff engagement

Some trusts stated that staff engagement was important to the success of IR and it was noted that some staff would welcome the intervention and others reject it. One trust said the process of engaging staff took time and another said that maintaining motivation for IR could be a challenge. One trust said that IR had failed when staff and leaders were not engaged in the process, believing it to be onerous and lacking in value. In these cases, the frequency of rounds had been reduced without discussion. Another trust said that, on the wards where IR worked well, the ward manager drove the intervention on a daily basis and staff embraced the principles of IR and enjoyed the process of nursing in this way. Another trust said that teaching programmes had reversed nurses’ initial negative attitudes towards IR.

Management/leadership of the process

One trust said the value of IR had to be regularly enforced by all levels of leadership on wards in order to maintain high standards, and another talked of the importance of leadership rounds. Another said they had tried to implement IR, but ‘due to the project leads moving on to new posts, the project has not progressed’.

Reason for implementing intentional rounding

Two trusts said they were already undertaking hourly rounding prior to the Francis report,1 and its implementation was, therefore, not in response to this. Two trusts said that IR had been implemented because of a change towards a larger number of single-room accommodation.

Culture of the ward

Two trusts talked of the need to embed IR into the culture of the ward and integrate it into the daily routine. Not seeing IR as a ‘separate entity’ was perceived as important to its success, although one trust acknowledged that this could be a slow process. Another noted that IR is ‘not the panacea to all concerns and needs to be used as part of a toolkit’.

The impact of other initiatives

One trust said that with ‘so many initiatives . . . ongoing it is sometimes easy to lose the sustainability’ of IR. Two trusts had recently moved nursing desks into patient bays and felt that this had a bigger impact on care and outcomes than IR.

Type of ward

As previously mentioned, some trusts did not perceive IR as suitable for particular types of ward (such as those with a high turnover/volume of patients); therefore, IR was not implemented in these areas.

Type of patient

Again, a number of trusts felt that IR was more relevant for ‘high-risk’ or ‘vulnerable’ patients, or for patients who have high physical nursing care input requirements.

Patient outcomes

Patient outcomes were the outcomes most commonly mentioned by trusts. Reduction in pressure ulcers was mentioned by 11 trusts and reduction in falls and/or injury as a result of a fall was mentioned by 11 trusts. An impact on aspects of patient experience/satisfaction was also mentioned by 11 trusts; this impact was seen as mainly positive with, for example, one trust saying that patient survey results showed that patients on the ward felt safe and that they thought that staff would notice if they became unwell, and another trust said that patients ‘generally liked quality rounds because they felt less isolated and know they will be checked regularly’. However, two trusts indicated that some patients reported negative outcomes of the implementation of IR when patients who were not part of the care rounds felt neglected or when patients felt that they were being disturbed too often. One trust said that patients had reported being disturbed too often and recognised nurses have ‘too much writing’. Patients ‘have started wanting to negotiate regular timings to be seen.’ Other, less frequently mentioned, outcomes included management of pain (one trust), reduction of patient complaints related directly to nursing care (two trusts) and that IR provides psychological safety for patients, carers and staff (one trust).

A few trusts reported these improved outcomes with some caveats, for example that IR needs to be adhered to correctly and closely monitored to have an impact, that improved outcomes are not always sustained and that how it is applied in practice is critical in terms of staff engagement and impact of patient outcomes. One trust said that, when IR was first implemented and carefully monitored, falls and unanswered call bells decreased; however, when implemented on a wider scale when close monitoring was not facilitated, its impact was thought to be limited as a result of IR not being conducted correctly. Another trust said that ‘On the wards where it works well (where the ward manager drives the process consistently), the patient and carer feedback is good.’

Carers’ outcomes

Outcomes for patients’ carers were infrequently mentioned in the survey open responses. Three trusts said that IR had a positive impact for carers. One said that, where IR works well, carer feedback is good. Two trusts indicated that it provides psychological safety for carers, for example ‘Relatives’ feedback is that they like the reassurance that their “loved one” is being seen on a regular basis’.

Staff outcomes

Ten trusts commented on staff outcomes; there was a mixed view of both positive and negative outcomes. Positive outcomes included that staff felt supported by the IR structured approach, that it provides psychological safety for staff (as well as patients and carers) and staff enjoy working with IR; for example, one trust said ‘those staff who truly embrace the principles enjoy the process of nursing in this way’. Two trusts commented that IR contributed to staff development; for example, one trust said ‘it has proved to be a useful vehicle for supporting the development needs of more junior staff’ and another said ‘Awareness amongst the RNs of their accountability for the practice of the unqualified staff is heightened’.

However, other trusts reported that staff did not find IR beneficial and, instead, thought that it took away their autonomy and was not a reflection of the care they provided; for example, one trust said ‘Staff do not like completing this as they feel it takes away their autonomy; however, they acknowledge there is a positive impact’. And another trust said ‘Staff do not appreciate ticking a chart and do not feel it is any reflection on the care they provided. They report wanting a system that is intuitive to patient’s needs and requests rather than a standardised approach’. Another trust said that nurses were reliant on IR to trigger activity rather than plan their day with their group of patients and team. One trust suggested that IR may increase the work pressure for staff. They said ‘Staff talk about not wanting to feel a failure when they cannot get to every patient every hour’. Another trust said that staff had not reported back either positively or negatively on the impact of IR on their time or job satisfaction.

Trust outcomes

Eight trusts mentioned an impact of IR on outcomes for trusts. The most frequently mentioned (four trusts) was a reduction in complaints. IR was described as ‘a very useful tool and has helped answer complaint responses, root-cause analysis evidence for falls and pressure ulcers’. Furthermore, IR was found to help ‘articulate that there is evidence that care interventions have taken place at designated times (or not as the case may be)’ when responding to complaints and determining actions for ward teams to address these issues. Other outcomes mentioned were ‘harm-free care’, as measured by the safety thermometer; most improved trust (from a sample of > 70 trusts) in terms of patient experience (PICKER survey); and that IR provides a structure for documentation and can generate large volumes of paper records for patients with extended stays.

Ward 1a

Ward 1a was a 24-bed ageing and complex medicine ward. The ward was divided into bays and side rooms, which were mainly used for infective patients requiring barrier nursing or patients reaching end of life.

Ward 1b

Ward 1b was a 24-bed acute medical ward with a specialty in diabetes and endocrinology. Ward 1b was split into three teams, each of which looked after a group of eight patients (made up of a bay of seven beds and a side room). Each team was led by a ward sister and comprised both RNs and HCAs. The layouts of wards 1a and 1b were the same; a map of this layout is provided in Figure 4.

FIGURE 4.

Layout of wards 1a and 1b.

Ward 2a

Ward 2a was a 32-bed acute trauma orthopaedics ward and dedicated hip fracture unit with 24 single rooms and two four-bed bays. The ward had the nurses’ station in the middle, opposite the main entrance, with a four-bed bay on either side and single rooms spread across a corridor on each side. Single rooms were grouped into two sets of pairs and between each pair of rooms was a standing perch, where staff could write up notes while maintaining good observation of patients.

Ward 2b

Ward 2b was a 32-bed complex medicine for older people ward with 24 single rooms and two four-bed bays. The ward provided medicine for patients with general medical problems who had complex needs. The ward was divided into four teams, consisting of RNs and HCAs; patient care was divided between the teams each shift. The layout for ward 2b was the same as for ward 2a; a map of this layout is provided in Figure 5.

FIGURE 5.

Layout of wards 2a and 2b at case study site 2.

Ward 3a

Ward 3a was a 26-bed cardiac and respiratory medicine ward. A map of the layout of ward 3a is provided in Figure 6.

FIGURE 6.

Layout of ward 3a.

Ward 3b

Ward 3b was an 18-bed, single-sex, elderly care acute medical ward, with a modified Nightingale-style layout of three bays or sections (two with six beds and one with four beds) and two side rooms. A map of the layout of ward 3b is provided in Figure 7.

FIGURE 7.

Layout of ward 3b.

Introduction

The aim of this analysis was to calculate the incremental cost to the NHS of conducting IR in the wards included in the study instead of not doing it. Three main types of cost were included in the analysis to estimate the total incremental costs:

1. direct costs – the cost of any consumable resource directly used for the implementation of IR

2. opportunity cost – the value of an alternative service given up to perform IR

3. indirect costs – cost of start-up, development and training not directly attributable to IR.

The unit of cost (total costs incurred) was reported in incremental cost per patient per day of hospitalisation. Costs and prices are reported in 2017 Great British pounds.

Method

All costs were allocated to patients hospitalised in the wards included in the analysis over different units of time. The estimate of the median number of patients per ward per day, week, month and year was calculated using bed occupancy figures. The calculations are not reported to avoid identification of the study sites.

Owing to the lack of observed data, direct costs were estimated based on the best methodological option available. As an example, the cost of printing an A4 sheet of paper was estimated by approximation, based on the unitary printing cost borne in 2017 by Kingston University (£0.20 per sheet). Storage costs were estimated based on replacement cost, the weekly cost of renting a space large enough to store a large cabinet (£6.92 per week).

Opportunity costs were estimated based on nursing time used. Median hourly wages per salary band were obtained from NHS published pay scales at national level. 95 Table 25 reports the median estimates of hourly wages of nursing staff by salary band and spine point.

Indirect costs (e.g. development of IR printed material, start-up and ward training) were estimated based on time used by nursing staff as directly observed in the field work. The nursing staff of a representative ward was obtained by the FTEs reported for two wards included in the study (site 3, wards a and b). Table 26 reports details of the staffing estimate. Indirect costs were amortised over 1 year and allocated to the median number of patient-days per ward per year.

Results and comments

The outcomes of the incremental cost analysis are reported in Table 27.

The incremental costs amounted to £8.27 per patient-day for hourly IR. Incremental costs drop to almost half (£4.47 per patient-day) if IR is conducted every 2 hours. This difference should be expected, as the opportunity cost of nursing time drives ≈90% of the total incremental costs of IR. The dominance of nursing time costs makes irrelevant a formal sensitive analysis. Total incremental costs of IR are directly correlated with the frequency of IR and the hourly wage of the nurses dedicated to it. Total incremental cost and frequency of IR seem to be linearly correlated: by reducing the frequency by 50%, the total incremental costs dropped by a similar percentage. Total incremental costs of IR are less sensitive to the hourly pay of nursing staff, because the assumption used in the base case already allocates 70% of IR to HCAs (bands 2 and 3). By allocating 100% of IR to HCAs, total incremental costs would drop to £7.19 for hourly IR and 3.96 for IR every 2 hours.

The results of this incremental cost analysis lead to a relevant conclusion: IR rounding imposed on the NHS an increase in the daily cost of hospitalisation in the range of £8.27–4.47 per patient, depending on the frequency of IR. For a ward of similar size to the ones included in the study, this would represent an annual increase of hospitalisation costs estimated to be in the range of £70,609–38,164 per year. Since NHS costs are calculated on full absorption basis,96 which includes the allocation of all overhead costs to health services produced, the annual incremental costs of IR could exceed £100,000 per hospital ward in the case of hourly IR.

This cost analysis shows that total incremental costs imposed by IR on the NHS budget would require a full economic evaluation of its value for money.