Analysis

Senior nurses need to discuss whether the practice of intentional rounding continues

A new study suggests that intentional rounding is just a tick-box exercise, wastes nurses’ time and has little effect on patient care

A new King's College London study suggests that intentional rounding is just a tick-box exercise, wastes nurses’ time and has little effect on patient care

  • Intentional rounding seen as just a tick-box exercise
  • It does little to improve patient care or promote the nurse-patient relationship
  • Rounding is poorly understood by staff and fails to encourage multidisciplinary care
Picture shows a female medic chatting to an older woman who is sitting up in a hospital bed. The article says the nursing profession needs to debate whether intentional rounding is the best way to deliver care to patients.
Picture: iStock

Senior nurses should contribute to a national conversation about whether the widespread practice of intentional rounding should be discontinued in light of the latest evidence, researchers say.

A study by King’s College London says the practice, involving routine ward rounds, is just a tick-box exercise that does little to improve patient care.

Intentional rounding originated in the US and entails checks on patients at regular intervals. These checks involve patient positioning, their personal needs, pain level and control and placement of items they need, together known as the ‘four Ps’.

‘It tends to prompt nurses to focus on completion of the rounding documentation rather than on the relational aspects of care’

Ruth Harris, lead author of the King's College London study

The system was introduced across acute hospitals in England in 2012, after the care scandal at Stafford Hospital and following an announcement by then-prime minister David Cameron.

17

senior nursing staff were interviewed by researchers

Although intentional rounding ‘may satisfy an organisational culture preoccupied by risk management’ it now does little to promote the nurse-patient relationship, the study says.

The cost of hourly rounds could exceed £100,000 per hospital ward per year, it says.

Evidence for the effectiveness of intentional rounding as used in England is weak, according to the study, funded by the National Institute for Health Research.

Picture of Ruth Harris, professor in the Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care at King’s College London. She is lead author of a study looking at whether intentional rounding is the best way to deliver care to patients.
Ruth Harris

Lead author Ruth Harris, professor in the Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care at King’s College London, says: ‘Checking patients regularly is important but intentional rounding tends to prompt nurses to focus on completion of the rounding documentation rather than on the relational aspects of care.

Patients preferred more spontaneous interactions with nurses

‘Few front-line nursing staff or senior nursing staff felt intentional rounding improved either the quality or the frequency of their interactions with patients and their family.’

Patients were found to prefer more spontaneous interactions with nursing staff that occur when nurses undertake other care activities.

Nursing managers told researchers they encouraged integration of intentional rounding into other activities, so it is not carried out as originally designed in the US.

A key finding of the study was that intentional rounding made only a minor overall contribution to the delivery of nursing care even though patients were observed on average every 37 minutes, far more often than required.

Rounding is poorly understood by staff and fails to encourage multidisciplinary care, the study found.

Intentional rounding leaves a paper trail some find useful

Senior nursing staff involved in the study said one of the benefits of intentional rounding is the documented evidence it provides.

This evidence is thought to be useful to ward-based nursing staff as it demonstrates what care is delivered and where it is delegated to healthcare assistants. It provides them with what one participant called ‘psychological safety’, making sure they do the right things, intentionally, for patients.

The highly structured and standardised evidence from rounding is also useful to senior nurses as it shows a minimum standard of care is being delivered to all patients, particularly in unstable environments when there are shortages of regular staff and temporary staff are being used.

Such evidence helps deal with incident reporting, answering complaints and handling referrals to a coroner.

The report suggests that a discussion is needed in the nursing profession about whether intentional rounding is the best intervention to support the delivery of fundamental nursing care to patients.

Yet with 97% of NHS acute trusts in England that responded to the survey using the approach in some form, senior nurses may ask how easy it will be to engage the profession in reconsidering its use.

‘Individualised care is simply not possible without a solid investment in the nursing workforce’

Bronagh Scott, RCN director of policy and practice

Researchers say implications for nursing managers include that they need to:

  • Consider halting the rounds, stopping practices that are not evidence-based, or abandoning care that wastes resources or delivers no benefit to patients.
  • Hold a national discussion in the nursing profession to consider whether intentional rounding is the best way to achieve desired outcomes, and what those desired outcomes are.
  • Consider whether it would be better to start afresh rather than try to tweak the system.

RCN director of policy and practice Bronagh Scott says it may not be possible to discuss the best way to deliver care until the nursing workforce crisis is resolved.

240

intentional rounds were observed within 188 hours of care delivery observation

Ms Scott says: ‘The findings in this study highlight the need to have focused discussions on how nurses can be supported to ensure they are able to provide the care patients need.

Ensure that safe and effective care is delivered

‘We know that nurses are currently struggling to deal with the ever-increasing number of patients and it is not always possible to fulfil the needs of even the most basic of ward rounds.

‘Nurses are continually working to ensure that safe and effective care is delivered, but such individualised care is simply not possible without a solid investment in the nursing workforce to not only recruit more nurses but also retain the ones we already have.’

Professor Harris says she would be keen to work nationally with directors of nursing and help people to think about how they might use the findings of the research.

‘I hope this study prompts nursing leaders to discuss together how they envisage the delivery of fundamental care and what “good” looks like.

‘As a research team, we do this work because we want to improve the way care is delivered.’

Ending intentional rounding could leave a void

The study by King’s College London acknowledges that to discontinue intentional rounding would be ‘a bold undertaking’.

‘The NHS is under immense pressure and it is anticipated that the reassurance of the evidence intentional rounding provides nurses would be difficult to relinquish,’ the authors say.

‘I hope this study prompts nursing leaders to discuss together how they envisage the delivery of fundamental care’

Ruth Harris, lead author of the King's College London study

In interviews with 17 senior nursing staff as part of the study, one director of nursing 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 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.’

Another director of nursing said: ‘It is difficult because once things are in place, it’s a brave person that says: “Right, stop doing that. Let’s do this”.’

Study lead Ruth Harris says ending intentional rounding would leave a void and the best approach is for nurse leaders to start a national conversation about the best way forward.

‘Change needs to be carefully managed. If people are taking decisions together they will feel more supported.’


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