Intentional Rounding: Implimentation, Use and Effectiveness

Intentional Rounding is a structured approach where nurses conduct checks on patients at set times to assess and manage their fundamental care needs (Forde-Johnston, 2014). As stated by Forde-Johnston (2014) in her ‘Intentional Rounding: a review of literature’ article, concerns about poor standards of basic nursing care have refocused attention on the need to ensure fundamental aspects of care delivered reliably. This literature review was conducted to “inform nurses planning to use this approach in their practice and to direct future research within this area”. The aim is to explore the implementation and use of intentional rounding and its effectiveness in improving patient care (Forde-Johnston, 2014), as well as focusing on evidence on the lack of effectiveness.

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A number of high-profile reports have drawn attention to examples of poor standards of what is often called “basic nursing care” – attending to patients’ needs for support with feeding, positioning, personal hygiene and skin integrity (Parliamentary and Health Services Ombudsman, 2011; Department of Health, 2010). However, there is an increasing body of evidence suggesting more nursing time per patient results in improved patient outcome (Cheung et al, 2008; Aiken et al, 2002; Kovner et al, 2002). Health professionals on wards say there is never enough time to do everything, and that they are too busy to have time to care. This is often due to poor staffing levels, leaving an extra hefty load of work on the staff managing the ward(s). Poor staffing levels means not all patients receive the care that they are entitled to and the care that they deserve. However, ways are being sought to make the ward a calmer, less chaotic environment for health professionals and patients alike, and to release time to care. Interventions such as the Intentional Rounding have been designed specifically with this in mind (NHS Institute for Innovation and Improvement, 2011).

Intentional Rounding is stated to be an “efficient process” where nurses are required to overlook their patients at set intervals, typically hourly. During these checks, scheduled tasks are usually carried out (Nursingtimes.net, 2019). Rounding helps frontline teams to organise ward workload to ensure all patients receive attention on a regular basis (Nursingtimes.net, 2019). As stated by Nursingtimes.net (2019), the consistency of care brings with it the confidence of staff and patients alike. Rounding requires health professionals to adopt certain behaviours. The round often begins with nurses introducing themselves, to build a brief relationship between them and the patient(s). This is then usually followed by completing scheduled tasks, such as medication, taking patients to the toilet, and completing vital observations. Upon completing all scheduled tasks, the round includes double-asking patients if they are comfortable with all the care they have received, and if they require anything more. This does not only reassure the patient, but it also “addresses the frequently reported issue that patients do not like to ask for support because they can see how busy staff are” (Nursingtimes.net, 2019); therefore, by nurses asking the patients themselves, they are reassuring the patient that they are being cared for in the manner that they are entitled to. Finally, a round comes to an end when everything is documented (written or electronically). This is done to confirm anything that has been done, and is there as backup information if it is ever needed.

The efficacy of Intentional Rounding has been widely debated and questioned; therefore studies have been carried out to ascertain staff and patient views on its effectiveness (Nursingtimes.net, 2015). Many studies exist, however majority of them are carried out in the US with only a ‘few UK studies and, where they do, samples are small, with researchers failing to use comparative or controlled research methods’ (Dix et al, 2012; Bartley, 2011; Lucas et al, 2010). There are mixed views on the effectiveness of Intentional Rounding. How well this intervention works highly depends on who is carrying it out and how they are carrying it out. Intentional rounding can be effective dependant on certain circumstances. On wards where there is less staff, intentional rounding can be proven to be very ineffective due to the increased workload. In these situations, nurses and healthcare assistants will find it extremely difficult to keep up with hourly checks on patients. As stated in the Nursingtimes.net (2015) ‘Staff and patient views on intentional rounding’ article, majority of the staff claimed that intentional rounding did not improve patient experience. This is because staff were too busy to check on patients every hour, and they found it more helpful to see to patients when necessary. Therefore, when a patient buzzed or called for help, it was more beneficial for the staff. Also, it was found that many patients were not aware of the Intentional Rounding process when they were asked about it. When they were informed about the process, most questioned its use or effectiveness. As discussed by Hutchings (2012), patients do not ‘appear to value the intervention as a method of providing care or improving experience’. Patients reported seeing their nurse “enough” (Nursingtimes.net, 2015). As discussed by Mitchell et al (2014), intentional rounding is proving to be more ineffective than desired.

Rounding as an approach is flexible and can be adapted to certain circumstances. For example, although the original studies focused on hourly rounding by nurses, some hospitals have adapted this to involve nurses and healthcare assistants doing alternate rounds, so patients are still seen hourly but alternately by nurses and other staff (Nursingtimes.net, 2019). Rounding can be used in many ways. However, it is vital that it is conducted with the intention of achieving an outcome for patients – it must have a clear aim, so it is possible to judge its effects objectively. The idea of intentional rounding is/was to improve patient care by making them more comfortable and attending to their needs on a regular basis. However, both patients and staff have agreed that this process is quite unnecessary as patients are seen to when required, and both staff and patients prefer it that way.

Furthermore, to improve the use, effectiveness and outcomes of intentional rounding, the Plan, Do, Study, Act cycle would be an effective way to implement change. The model for improvement provides a framework for developing, testing and implementing changes leading to improvement. It is based in scientific method and moderates the impulse to take immediate action with the wisdom of careful study (improvement.nhs.uk, 2019). Using a Plan, Do, Study, Act (PDSA) cycle is very beneficial as it allows change from a small scale, building on any learning curves before wholesaling implementation. This makes the process much safer for both patients and staff (improvement.nhs.uk, 2019). Although the PDSA cycle allows you to test as many times before making any big decisions, it is always crucial to know what changes you wish to make and how you wish to achieve them.

The framework includes three key questions to answer before testing an improvement concept and a process for testing change ideas: 1) What are we trying to accomplish? 2) How will we know if the change is an improvement? What measures of success will we use? 3) What changes can we make that will result in improvement? (improvement.nhs.uk, 2019). In addition to the framework, the PDSA cycle has four stages: Plan – the change to be tested or implemented, Do – carry out the test or change, Study – based on the measurable outcomes agreed before starting out, collect data before and after the change and reflect on the impact of the change and what was learned, Act – plan the next change cycle or full implementation (improvement.nhs.uk, 2019).

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Using this framework and cycle can help improve the outcome of intentional rounding as it gives many the opportunity to join in and make collective decisions/changes. This will not only inform patients of intentional rounding and how it is used, but will inform staff on how it can be used effectively, achieving the outcomes that are desired. Thus far, intentional rounding has been proven to be ineffective again and again. Using the PDSA cycle, it will give the chance to make active changes until it is ready to be implemented in wards, effectively. Small tests of change are extremely useful in exploring staff concerns about whether it is effective, or whether it adds to workloads, for example (nursingtimes.net, 2019).

In conclusion, and agreement with Mitchell et al (2014), intentional rounding is failing to achieve the desired outcomes in patient experiences and improvements. There is major disagreement and dispute among nurses regarding the improvement intentional rounding makes to effective patient care considering the amount of time involved, required documentation and the poor evidence base. Intentional rounding has already been tested in many settings, and in many settings,  it is still used as part of daily care giving. Intentional rounding can be improved majorly and used to its full advantage. However, this can only be done if intentional rounding is tested and carefully implemented as major work is needed to ensure that the evidence base is developed and the initiative is continued.

REFERENCES:

• Improvement.nhs.uk. (2019). [online] Available at: https://improvement.nhs.uk/documents/2142/plan-do-study-act.pdf [Accessed 28 Jul. 2019].
• Cody, R. and Williams-Reed, J. (2018). Intentional nurse manager rounding and patient satisfaction. Nursing Management (Springhouse), 49(4), pp.16-19.
• Forde-Johnston, C. (2014). Intentional rounding: a review of the literature. Nursing Standard, 28(32), pp.37-42.
• Intentional rounding. (2014). OR Nurse, 8(4), p.6.
• Introducing Intentional Rounding: a pilot project. (2013). 6th ed. [ebook] Dewing J, Lynes O Meara B. Available at: https://www.academia.edu/20778673/Introducing_intentional_rounding_a_pilot_project [Accessed 28 Jul. 2019].