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Intentional rounding: Assessing the evidence

Intentional rounding, or checking on patients at regular intervals, has become commonplace, but does it improve care?

Intentional rounding, or checking on patients at regular intervals, has become commonplace, but does it improve care?

intentional rounding
Critics say the evidence for intentional rounding is poor.
Picture: iStock

Every nurse knows that on a busy shift there are patients who risk losing out on care and attention. There is the quiet old lady in the corner who never asks for anything, the patient who is sleeping a lot and it is easier not to disturb, and the demanding patient who everyone scuttles past.

Intentional rounding – where nurses or healthcare assistants (HCAs) purposely tend to each patient every one or two hours – is meant to prevent this ‘overlooking’ of patients. For many nurses it has become part of the everyday care offered to patients. It received a boost in 2012 when then prime minister David Cameron endorsed it during a visit to Salford Royal NHS Foundation Trust.

Salford has used intentional rounding since 2010 and says the approach is here to stay. ‘Nurses are visible to our patients, which creates a better patient experience,’ says lead nurse for corporate services Fiona Morris. She says the 2011 opening of a new building at the trust that houses many patients in side rooms added impetus to the need for visibility.

Communication

But intentional rounding remains controversial. Ruth Harris, who is leading a major study into how it is being used in the UK, says the evidence base so far, mainly from the US, suggests it increases the frequency of communication between patients and nurses, but ‘there is less evidence it improves communication’.

Professor Harris, from King’s College London, says her ongoing research in England may tease out the nuances of how intentional rounding is working and which patients benefit.

Existing studies show benefits including lower call bell use, which could indicate patients’ needs are being met before they become urgent, better pain control, as well as a reduction in falls and pressure sore incidence. Patients may feel reassured by the system, and report better experience and higher satisfaction levels. In Salford, there has been a considerable reduction in the use of nurse call buzzers.

Measuring

However, many of the studies into intentional rounding are observational and descriptive. There is little evidence on the impact on staff time and whether the time spent on rounding could produce similar or even better outcomes if used in a different way.

Professor Harris says she is exploring what is it about intentional rounding that may lead to improved outcomes. She says the dynamic nature of care in hospital, with changes being introduced continually, makes it harder to link changes in outcomes to a specific intervention. And she cautions against making a correlation between an intervention being introduced and causation of outcome changes.

‘Is there something about completing and then signing the intentional rounding documentation that makes staff feel personally accountable for the standard of care?’ she asks.  ‘Is there something about the regularity and physical presence of nurses in the room which gives patients confidence?’

Intervention isn’t rounding

University of Worcester principal lecturer in adult nursing Paul Snelling has concerns that the practice has been implemented hastily, based on poor evidence, may not translate across healthcare systems, and has been driven by political expediency after the Mid Staffordshire NHS Foundation Trust scandal. ‘If rounding means everyone gets visited at a certain time using a certain protocol, I think that is silly,’ he says.

‘But if people are assessed for their needs and asked if they need the toilet or food, for example, that’s good, but it is not rounding.’ He describes this as an assessed nursing intervention, which is what nurses ought to be doing, using their professional judgement.

‘If the reasons for doing it are led by patient care and equity of care, then it is great for patients. If the reasons are to comply with a checklist, then less so.’

Jocelyn Cornwell, Point of Care Foundation

Dr Snelling is not alone in his reservations. The chief executive of the healthcare charity Point of Care Foundation, Jocelyn Cornwell, also has qualms about intentional rounding. However, she acknowledges that the approach appears to have been useful in the US, especially with patients who don’t speak up for themselves or don’t have a relative with them.

‘We know there are patients who are not popular on wards, and if we are going to protect patients from being left out, from not having food or drink within reach, then it is very important that they are seen regularly,’ she says.

Not a magic bullet

‘We know there are patients who are not popular on wards, and if we are going to protect patients from being left out, from not having food or drink within reach, then it is very important that they are seen regularly,’ she says.

Intentional rounding may help improve ‘equity of care’ and ensure that those who need care get it, Dr Cornwell says. ‘If the reasons for doing it are led by patient care and equity of care, then it is great for patients,’ she says. ‘If the reasons are to comply with a checklist, then less so.’

She warns that intentional rounding should not be seen ‘as a magic bullet to solve a lot of things. It is everything that goes on around it that matters – the conversations, the thinking, the philosophy.’

It is also important that any rounding system is ‘pulled’ rather than ‘pushed’, with backing from nurses who feel it will improve care, rather than being imposed from above, she says.

Support from nurses can be tentative at first. In Salford there was ‘initial anxiety’, and comments from staff led to the development of an intentional rounding policy and a ‘crib sheet’ to help nurses and HCAs complete the forms. 

‘It has ensured that some of our most vulnerable patients get the attention they need. Staff see it as a positive that helps them focus during the day on the priorities.’

Debbie Talbot, Birmingham City Hospital

Birmingham City Hospital introduced rounding several years ago. Associate chief nurse Debbie Talbot says that with hindsight there should have been more focus on supporting staff and using change management techniques. However, there has been some tweaking since then and nurses now seem happy with the approach. Crucially, the nurse’s professional judgement is still respected and built into the process.

‘It has definitely ensured that some of our most vulnerable patients get the attention they need,’ she says. ‘Staff see it as a positive that helps them focus during the day on the priorities.’ 

Electronic recording

In Salford, support workers do many rounds, with a nurse doing them at least every four hours, and in Birmingham, care rounds, as they are called at the hospital, are either once every hour or once every two hours, depending on the needs of the patient. Patients won’t be woken during the night for routine rounds unless they have been risk assessed as needing it, such as someone with a high risk of pressure sores who might need repositioning day and night.

The Midlands trust is moving to electronic recording next year, which will be an opportunity to revisit how care rounding is recorded. Ms Talbot says the handwritten method allows for easy visibility, including for relatives, but recording electronically will allow better collation of data and automatic reminders if care rounds aren’t carried out.

As part of her research, Professor Harris surveyed all acute trusts in England in 2015. Of the 70% who responded a ‘large majority’ had adopted intentional rounding in some way. Whatever the arguments over whether it is the best way to improve the care received by patients, intentional rounding seems here to stay.

What is intentional rounding?

Intentional rounding, also known as care or comfort rounds, is the process of checking on patients’ needs at regular intervals. This normally involves checking the ‘four Ps’ of positioning of the patient, personal needs, pain level and control, and placement of items they may need.

In its most formalised manifestation, nurses are expected to:

  • Introduce themselves with an opening phrase, designed to put the patient at their ease.
  • Perform scheduled tasks.
  • Ask about the four Ps.
  • Assess the care environment.
  • Use key words when closing and tell the patient when they will be checked again.
  • Document the round.

The Francis Inquiry into failings of care at Mid Staffordshire Foundation Trust recommended regular interaction and engagement between nurses and patients.


Alison Moore is a freelance health writer

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