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If you would like to contribute to the Art & science section, email gwen.clarkeiffircnpublishing.co.uk
The synthesis of art and science is lived by the nurse in the nursing act JOSEPHINE G PATERSON
Introducing intentional rounding: a pilot project Dewing J, Lynes O'Meara B (2013) Introducing intentional rounding: a pilot project Nursing Standard. 28,6,37-44. Date of submission: March 2 2013; date of acceptance: June 18 2013.
Abstract Aim To report on the introduction of intentional rounding in an NHS trust. Method A two-stage pilot project with participatory methods underpinned by core practice development principles was undertaken to introduce intentional rounding. Findings Patients and staff found intentional rounding to be a positive experience, although nurses and midwives felt they were inadequately prepared to implement the practice. Leaders and managers who engaged in learning opportunities before the pilot study tended to achieve more successful and sustained practice change. Conclusion There is disagreement among nurses about the contribution of intentional rounding to patient care, particularly in light of the weak evidence base, time involved and associated documentation. Therefore, further research is needed in this area.
Authors Jan Dewing Professor of person-centred research and practice development. East Sussex Healthcare NHS Trust and Canterbury Christchurch University, Canterbury. Brenda Lynes O'Meara Assistant director of nursing. East Sussex Healthcare NHS Trust, Eastbourne. Correspondence to:
[email protected]
Keywords Intentional rounding, patient safety, practice development
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
© NURSING STANDARD / RCN PUBLISHING
PEOPLE ENTER HOSPITALS expecting to be helped not harmed, but unintended harmful events such as falls, hospital-acquired infections and hospital-acquired pressure ulcers are common and are a burden on NHS resources (Sherrod et al 2012). The consequences of harm in the hospital setting can significantly affect a patient's recovery, quality of life and even life expectancy (The Mid Staffordshire NHS Eoundation Trust Inquiry 2010, Care Quality Commission 2011, Parliamentary and Health Service Ombudsman 2011). The Department of Health (DH) supports the implementation of the NHS Safety Thermometer, a tool for measuring, monitoring and analysing patient harm (NHS 2012). The NHS Safety Thermometer gives nurses and midwives a template with which to check that fundamental levels of care are being met, and to identify where there are problems and take action. While the safety of patients is a priority, patient experience is also important. Service user experience is broadly defined as 'how well people understand and feel about the service they receive while they are using it' (Bate and Robert 2007). This is different to assessing patient attitudes or satisfaction, which was the traditional way in which patient care was evaluated (Bate and Robert 2007). The NHS Commissioning Board (2012a, 2012b) requires that measurement should focus on the experience of the person as well as the outcomes of care. In the UK, intentional or purposeful rounding is viewed as contributing to harm-free care (Box 1) (Harm Eree Care 2013). It has been suggested that intentional rounding increases patient satisfaction with nursing and midwifery care, although it does not feature as an action in the new vision for nursing and midwifery in the October 9 :: vol 28 no 6 :: 2013 37
Aij'd'^jscience service development NHS (NHS Commissioning Board 2012a). The government in England has directed the nursing and midwifery workforce to implement intentional rounding in practice. It has been promoted by the prime minister, David Cameron, and publicised by the chief nursing officer for England and NHS organisations. Political promotion and wide implementation of intentional rounding has taken place despite a questionable evidence base for the practice (Snelling 2013). The Royal College of Midwives (2012) suggested that intentional rounding has been introduced without clear discussion of whether it is relevant to midwifery and whether it is the most appropriate initiative to improve care. This article presents an overview of intentional rounding and reports the findings of a two-stage pilot study for intentional or essential care rounding in nursing and midwifery at East Sussex Healthcare NHS Trust in England.
Literature review A literature review using the British Nursing Index was carried out to explore information on intentional rounding. The search terms used were intentional rounding, hourly round and comfort rounds. Eourteen articles were selected for review from the UK, United States, Canada and Australia. Inclusion criteria were that the articles should cover intentional rounds only, be written in English, and be peer-reviewed. Exclusion criteria included articles written about other types of rounds, those where the main focus was not intentional rounds, and were not peer reviewed. Nursing rounds are defined by Meade etal (2006) as a systematic, proactive practitioner-driven evidence-based intervention to anticipate and
Structurelofjntentional'rounds • Nursing and midwifery staff typically begin by introducing themselves to the patient receiving care and explain what intentional rounding involves. • The patient is told to expect to see a healthcare professional for nursing care every hour or every two hours. • The healthcare professional assesses and addresses the patient's personal needs, such as continence, comfort and positioning, and pain, as well as the safety of the room or immediate environment. * Before leaving the bed area, the healthcare professional asks about any unaddressed needs. • Once these needs are met, the patient is told when a healthcare professional will return. 38 October 9 :: vol 28 no 6 :: 2013
address needs in hospitalised patients. Certain aspects of the practice are common to all settings (Box 1). Rounding creates the opportunity for a scripted intentional interaction each hour, allowing nurses, midwives and caregivers to spend more time with patients addressing fundamental care needs (Castledine 2002, Meade etal 2006, Fitzsimons et al 2011). By increasing the quality of nursing care, patient satisfaction improves and the image and reputation of the organisation are enhanced among patients and their families. The concept of rounding in nursing and midwifery is not new. Castledine (2002) called for the introduction of patient comfort rounds to be carried out every two hours. He reinforced the benefits of the traditional 'back care rounds' that disappeared with the advent of holistic and individualised care, and identified six key areas to be included in the rounds (Castledine 2002, Castledine et al 2005). These are similar to the six core areas identified by Dix eííz/(2012): y Pain. • Hydration and nutrition. • Continence. \ Anxiety. • Falls. • Pressure ulcer prevention. Dean (2012) highlighted that rounding focuses on the fundamentals of care such as assisting people to use the toilet with dignity, effective pain relief and adequate nutrition. Effective hourly rounding can promote patient safety, foster team communication, improve the ability of healthcare professionals to provide efficient patient care, and improve job satisfaction and staff retention (Meade etal 2006, CuUey 2008, Generals and Tipton 2008, Tea etal 2008, Weisgram and Raymond 2008, Gardner et al 2009, Deitrick et al 2012). Evaluation of the effectiveness of hourly rounding has been measured by tracking the use of call lights, the number of patient falls, and levels of patient and staffsatisfaction (Meade ei a/2006, Culley 2008, Tea etal2008, Gardner eia/2009, Murray etal 2010). Direct comparisons of most evaluation measures are not possible because different tools are used in each of the studies. For example, Meade et al (2006) studied patients' use of call lights related to the frequency of nursing rounds. In this study, rounds were performed at one or two-hourly intervals, and the effect of rounding on the frequency and reasons for use of the call light, patient safety as measured by the rate of patient falls, and patient satisfaction were assessed and compared to a control group © NURSING STANDARD / RCN PUBLISHING
over a six-week period. A significant reduction in call light use and patient falls, and increased patient satisfaction were found. In a service development project using intentional rounding, Dix et al (2012) reported a significant reduction in the frequency of call bell use from an average of eight times each hour before intentional rounding was introduced to once an hour following the intervention. They also found that the time taken to respond to the calls reduced from three minutes before intentional rounding to less than one minute after the intervention had been implemented. Whether any other initiatives in the practice setting may have influenced the outcomes is not stated. This differs from findings by Murray etal (2010), who reported that the likelihood of patients activating a call light decreased significantly for most needs when rounding was used as a nursing intervention, but increased for non-specific reasons, for example asking caregivers to check something. There has been little systematic examination of the nursing and midwifery experience of intentional rounding. Dix et al (2012) found that staff had mixed views and experiences in relation to the introduction of intentional rounding - some approved of them while others were opposed to them. In a study by Deitrick et al (2012), nurses viewed hourly rounding as involving more work rather than a proactive intervention. Staff also experienced difficulties in accomplishing hourly rounding because of competing priorities and tasks. Only one study included areas using both hourly and two-hourly rounds, with researchers finding that two-hourly rounding resulted in positive changes in patient satisfaction and a reduction in falls, while hourly rounding had higher patient satisfaction rates (Meade et al 2006). Some nurses did not feel a sense of ownership of the hourly rounding process and perceived rounding as a top-down process imposed on them (Meade eia/2006). Milner etal (2008) explored rounding in psychiatric wards and found that nurses felt they were unclear about the purpose of rounding and that it was poorly explained to them. In a descriptive pilot study exploring nurses' perceptions of rounding, Neville et al (2012) found that nurses felt hourly rounding was beneficial to patients and their families, but significantly less beneficial to nurses' professional practice. Challenges to successful rounding were found to be documentation, patient ratios and skill mix. Ethnographic research by Deitrick et al (2012) reported that there appeared to be a lack © NURSING STANDARD / RCN PUBLISHING
of understanding about the benefits of hourly rounding among staff, as well as lack of clarity about how to implement hourly rounding into the patient care workflow. Recommendations were made in relation to a redesign of rounding. These included more extensive assessment of those implementing the practice, training unit-level champions to lead the implementation effort, inclusion of unit-level staff at all phases, establishment of a more robust communication and education plan, use of a project management and/or quality improvement process, and identification of meaningful outcome indicators. Lucas (2011) found that rounding helped to enhance the patient experience, although in wards where there had been inconsistent nursing care, that lack of consistency continued. The most positive findings were that rounding improved team communication and nurses' sense of their relationship with patients. The most negative finding related to duplication of documentation. Lucas (2011) recommended that nurses should follow a 'script' because asking patients if they want anything may not lead to patients verbalising their needs. In addition, regular audits were recommended as a way of positively reinforcing compliance and to provide an opportunity to discuss issues with team members. However, audits introduce additional monitoring and paperwork. The branding of rounding as prevention of harm may create a negative or defensive image of this activity and make practitioners less likely to feel it is necessary in their care setting (Lucas 2011). Eitzsimons etal (2011) rebranded the principles of intentional rounding as a way of rneeting essential care needs. This may present a more positive image for nurses and midwives. However, Eitzsimons etal's (2011) script focuses primarily on the physical and environmental needs of patients. The literature review suggests that intentional rounding is used to reduce the number of harmful events, and can enhance the patient experience. However, it seems that all patients are included in rounding regardless of their risk of experiencing harmful events. In an era of individualised nursing care based on clinical and risk assessment, nurses and midwives may therefore question the logic underpinning this practice. Intentional rounding seems to be primarily focused on the physical and environmental needs of patients, excluding their emotional and psychological needs. In addition, evidence of the effectiveness of hourly compared to two-hourly rounding is sparse. October 9 :: vol 28 no 6 :: 2013 39
service development Aim Because of a lack of time and workforce resources to set up a local formal research study, the authors used practice development resources already established in East Sussex Healthcare NHS Trust and the practice development principles of inclusion and participation to guide the pilot project, and to enhance the probability of successful implementation (Garbett and McCormack 2002, McCormack etal2007). Therefore, the introduction of intentional rounding was carried out with existing resources as a service improvement initiative. A two-stage pilot of intentional rounding was undertaken at two general hospitals in the trust in 2012. Stage one involved six wards: three adult inpatient wards, an adult outpatient area, children's ward and a maternity ward. Stage two involved all adult and children's inpatient and outpatient services. The pilot project had several aims: • To pilot the rounding method to ensure it was fit for purpose regardless of context and workplace culture. • To be compliant with local practice and encourage local improvement in care delivery. • To prepare clinical leaders to take responsibility for and embed the intervention in their services. • To use findings from the pilot study to model practice development methods and processes. • To make a positive contribution to cultural transformation in the organisation.
Method Senior nursing and midwifery leaders and matrons rebranded intentional rounding as essential care rounds for adult services and top-to-toe care rounds for children's services. These terms were used because intentional rounding did not really tell patients or their families what the rounds were about and because the workforce did not like the term. While it is not helpful generally to introduce several terms for the same or similar practice, it was determined that this was required to demonstrate that staff were being listened to and to encourage commitment to and ownership of the practice. This was also necessary because of the weak evidence base for intentional rounding, and to contribute to a more inclusive and participative culture that the authors sought to develop through local and national nursing and midwifery strategies. No formal ethical approval was required for the pilot project because it was deemed a service improvement initiative; however, NHS trust 4 0 October 9 :: vol 28 no 6 :: 2013
project governance principles were followed. Formal reporting was undertaken with the clinical management executive and the nursing midwifery advisory group chaired by the director of nursing. Phase one
The assistant directors and heads of nursing were offered a tutorial on essential care rounds and top-to-toe care rounds. A small working group developed necessary resources, including information leaflets for patients, women and children; staff information leaflets; pocket guides; posters; presentation and literature for use by teams for work-based learning and staff discussion; and record sheets and feedback sheets to collect evidence. Initial testing of these resources involved critique by clinical leaders in the six test sites and some team members. Following revisions, draft resources were ready for use in the pilot project, including a script to be used during rounding. Phase one ran for four weeks during March and April 2012. Learning opportunities were offered to matrons, and ward or department clinical leaders and managers with the expectation that they would be able to share knowledge and ideas with team members. Evaluation at the end of phase one showed that rounding was useful. The essential care rounds reinforced current practice and provided documented evidence of regular individualised care. Three versions of documentation were required for adult inpatients, adult outpatients and children's inpatient services. Feedback from patients and carers was positive. They liked the regular rounds, and they made particular reference to the increased visibility of nurses and midwives on the wards and in outpatient areas. They noted that they felt able , to articulate to staff when they felt less frequent rounds were more appropriate, and this generally meant moving from an hourly round to a twohourly round. In particular, family members noted the importance of these rounds in relation to the patient's diet and fluid intake. Staff recognised they needed to embed the rounds into their daily routine, as opposed to viewing them as an additional activity. It was realised that because the script was essentially focused on physiological care, it tended to emphasise a task approach. The script was adapted to include two new measures: asking the patient how he or she was feeling and whether he or she had any information needs. It was anticipated that this would increase individualised care provision and would mean that nursing and midwifery team members © NURSING STANDARD / RCN PUBLISHING
would speak directly to patients. From phase one, a third amended document for outpatient areas was produced that the teams working in these areas were involved in devising. Further workshops were provided for clinical staff of all disciplines to discuss the continued implementation of care rounds, and visits to clinical areas were arranged to discuss the implementation of this initiative. The project team was also in a better position to agree exclusion criteria, meaning that areas where one-to-one or high-visibility care was already in place, such as the emergency department, intensive care unit, high dependency unit, delivery suite and special care baby unit, did not need to perform rounding. Phase two Phase two of the pilot project ran for eight weeks in May and June 2012. Seminars for heads of nursing and matrons were revised and offered to continue raising awareness and provide discussion opportunities. A standardised PowerPoint presentation was developed for heads of nursing and matrons to use with all staff. Staff were asked to introduce the essential care rounds gradually throughout their area over a six to eight-week period. For example, one bay at a time was suggested as manageable by ward staff. Emphasis was on rounding as a process of cultural change as opposed to a tick box exercise. For evaluation a short focused observation schedule and a six-item questionnaire were used. Questionnaires were sent to all clinical managers and matrons, with a follow-up reminder after two weeks. Staff were asked to complete and return the evaluation form within the eight-week period and to continue with the implementation, with any refinements as a result of the evaluation made as the implementation of the care rounds progressed. Staff were encouraged to contact the pilot leads with any queries or to speak with staff from the initial pilot sites with any questions or concerns, or ideas relating to implementation of the intervention. Staff were also encouraged to take ownership of and talk about how the process could work most effectively in the organisation.
Findings Thirty teams returned completed questionnaires, representing a response rate of 40%, and their contents were thematically analysed. In many of the returned questionnaires, more than one team member had contributed. Three themes emerged in response to the question on what © NURSING STANDARD / RCN PUBLISHING
worked well when rounds were introduced. These were: increased visibility and time spent in direct patient contact, patient experience and staff experience. Increased visibih'ty and patient contact time There was increased visibility of nursing and midwifery staff, while the time spent in direct patient contact also increased: 'It's about having time to talk to patients and spend more time with them' (Participant 1). 'It does make you have one-to-one time with patients, and that is actually really good for us and them' (Participant 2). 'Increased communication with our patients' (Participant 3).
Patient experience Patients viewed rounds as being positive experiences, for example: 'Patients loved it' (Participant 4). 'Patients welcomed being kept informed - we have had fewer complaints about unavoidable delayed wait times as patients are advised every hour of the situation, so they can go and get refreshments [outpatient areas]' (Participant 5).
Staff experience Staff experience of care rounds was also positive: 'Staff [are] more aware of the patient's needs' (Participant 6). 'Staff are very positive about the rounds' (Participant 7). However, some staff gave no positive evaluation commentary and used this question as an opportunity to report back what they did not like: 'We have always done it-just never had any documentation to fit' (Participant 8). '7i'5 not very useful to our area as our patients are "regulars'" (Participant 9). 'It stresses staff out having to stop what they are doing to carry out essential care rounds' (Participant 10). October 9 :: vol 28 no 6 :: 2013 41
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service development When staff were asked about concerns they experienced when introducing the care rounds, most felt they were being micromanaged and told to give care they believed they were already giving: 'Let the HCAs and nurses get on with their hands-on work rather than carrying out essential care rounds which suit central government. This is an insult to nurses' common sense - we do this in our daily work anyway' (Participant 11).
'Some patients reported they were bored with the repetitive questions, some patients found it amusing; they often asked the questions before we did' (Participant 19). ' Why do you keep asking me the same questions?' (Participant 20). 7 would like to be left alone' (Participant 21). 'Oh no, not back again' (Participant 22).
Two other themes emerged from the questionnaires. The first was that patients were dissatisfied with rounding. They did not appreciate being interrupted when they had visitors: 'Some patients found it strange being spoken with hourly' (Participant 12). 'Some patients were annoyed at being asked the same questions over and over again' (Participant 13). '... interrupting patients for rounds when visitors were there' (Participant 14). The second theme was that staff experienced prioritisation challenges. They found it difficult to find time to complete the essential care rounds, for example: 'Not being able to go to everybody every hour as wards were busy and emergencies had to take priority' (Participant 15). 'Not having enough time to do the rounds properly' (Participant 16). 'Form filling took the nurses away from giving the actual care' (Participant 17). 'Too repetitive' (Participant 18). The effect of care rounds on patients was explored. Patient reports or commentary were requested, rather than obtaining nurses or midwives' inferences about how patients felt. Generally, it appeared that patients felt more involved in their nursing care as they were spoken with more frequently, although some patients appeared irritated by the way they were asked questions by staff, especially in the earlier part of the pilot. This issue resolved as staff adjusted to regular direct contact with patients and became more spontaneous with the script. Comments from patients (reported through practitioners) included: 4 2 October 9 :: vol 28 no 6 :: 2013
Throughout the pilot project, a trend where some teams wanted to exclude their service from the essential care rounds and top-to-toe care rounds was found. The most frequently asked questions were whether the care rounds had to apply to their setting followed by queries about whether the script had to be followed and the frequency of the rounds. In relation to frequency, there was a suggestion to reduce the frequency of rounding, with twice daily being preferred as opposed to every two hours. Most patients were satisfied with a two-hourly round rather than an hourly round. However, it is not known which patients were excluded from the evaluation. It may be that patients who were acutely unwell or at increased risk of harm were not asked about, or were unable to share their experiences easily and may have preferred or needed hourly rounds. Rounding in rehabilitation settings may be particularly challenging, with staff in these areas reporting that some patients were doing less for themselves and waiting for staff to assist them on their rounds. 'Essential care rounds are tricky in a rehab unit as it encourages patients to depend on the staff when they are here to regain their independence' (Participant 23). Staff were asked how well prepared they felt for the pilot study on a scale of one to ten. The average (median) score was four out of ten, despite the range of learning and preparation opportunities that were available. However, there was variable engagement with the preparation opportunities, and not all leaders or managers took up the training offered or enabled their team members to do so. This may illustrate the complexities involved in introducing even a small-scale practice change. It could also demonstrate that, in general, staff do not feel well prepared for leading improvements and innovations in their workplace. The pilot project had some limitations. Further evidence could have been obtained if © NURSING STANDARD / RCN PUBLISHING
the evaluation of evidence was better organised. Specifically, evidence could have been collected directly from patients rather than asking staff to report the patient experience. At the time of the pilot project, other organisational changes were taking place, the main one being a move to an 11.5 hour shift pattern. This may have meant that staff were less open to adopting other changes in the practice. The fact that rounding was a government initiative helped some leaders to promote the concept in their clinical areas, while others resented the intervention for the same reason.
Post-pilot experience Six months after the pilot project was completed, some teams were embedding care rounds into their daily practice, and others had either reduced the frequency or content of the rounds, or had abandoned them altogether. Some staff devised variations of the care rounds that they believed were more suited to their areas. Examples included only carrying out care rounds for patients in single rooms, only doing rounds in an afternoon or until 8pm in the evening and changing the agreed documentation or script. It is difficult to find an evidence base to support these variations, other than staff preference or convenience. Once the pilot project had been formally reported, agreed by senior nursing and midwifery leaders and become a required activity, it was difficult to excuse teams seeking to 'opt out'. Opting out frequently occurs with any new idea being implemented, and teams will usually attempt to adapt new practices to their needs, but this can lead to new practices becoming diluted or distorted.
Discussion Castledine (2002) suggested that comfort rounds complement holistic individualised care, where regular contact and close communication, between the healthcare professional and the patient are integral. The NHS Commissioning Board (2012a) sets out actions for working with people to provide a positive experience of care, stating that is not enough simply to provide high-quality technical care. When patients reflect on their experiences of care, they also think about the environment in which they received care and whether they were treated with compassion and respect. In the pilot project, some teams focused more on the delivery of the script or the tasks (the technical aspects) in the care rounds than on © NURSING STANDARD / RCN PUBLISHING
the overall ethos of providing compassionate care. This is similar to findings by Tea et al (2008), who showed that the most important variable in patient satisfaction with rounding is staff responsiveness. Therefore, it is not what the nurses and midwives do while carrying out a round that is important, but how they do it, thus stressing the caring and communication aspects of practice (Tutton and Seers 2004, NHS Commissioning Board 2012a). By engaging staff in the pilot project, it was possible to comply with and encourage local innovation. The longer-term commitment of clinical leaders and managers to own and embed practice changes in their services is variable and needs further work. Having introduced the practice of intentional rounding, the challenge is now how to sustain and adapt it. It is necessary to place intentional rounding in a wider social and political context because of the current politically driven changes in the NHS, for example the emphasis on quality of care and patient-led inspections of hospitals (Topping 2012). When policymakers attempt to find a quick solution and this is combined with an expectation of universal adoption, these initiatives tend to fade after time (Harrison 2012, Snelling 2013). Further, Snelling (2013) concluded that the evidence base for the wide-scale introduction of intentional rounding is questionable. Barker (2012) argued that patient care could better be assured through improved communication between healthcare professionals and patients than a government directive to inspect wards, a view also held by some nurses and midwives. There is no single method to enhance patient experience, so creating unrealistic expectations and targets is unhelpful. The success of a method depends on practitioners who understand the science underpinning it and are responsive to it, and the art of how to integrate it into practice (Tea et al 2008); something a national directive on intentional rounding does not appear to do. Giving less competent practitioners more methods and tools does not accelerate the rate of change and may eventually even reduce it. The authors recommend that: • Nurse leaders should support national policy-led practice changes with evidence valued by nurses and midwives. • Nurse leaders should identify and intervene with teams who try to opt out of intentional rounding because it affects their established ways of working. • Nurse leaders should identify and intervene with teams that find ways to subvert October 9 :: vol 28 no 6 :: 2013 43
Alé B^science service development agreed methods and documentation for intentional rounding. > Research is needed to examine if intentional rounding is effective and in what circumstances.
Conclusion There is disagreement among nurses about the contribution intentional rounding makes to effective patient care when considering the
amount of time involved, required documentation and the poor evidence base. Intentional rounding should focus on the core aspects of nursing such as compassion (how the person is feeling) and communication as well as technical competencies. In the majority of services, intentional rounding is now part of daily care giving. However, further work is needed to ensure that this initiative continues to be implemented and that the evidence base is developed NS
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