In Chapter 8, the findings of the realist evaluation were presented and it was shown how the complex processes inherent in IR contributed to the delivery of nursing care to patients in acute hospitals in England. This research offers unique perspectives on the effectiveness of IR, in particular what works, for whom and in what circumstances. Its strengths are the careful analysis and unpacking of views of IR through multiple and multidisciplinary lenses at both national and granular levels of three case studies. The extensive observation of nursing practice, as well as the results of the national survey, analysis of case study interviews and quality outcomes, provide a significant contribution to the knowledge and understanding of the practice of nursing, as it is played out through IR. The aim of this chapter is to set out the key messages from the study, review the approach and methods used and discuss the implications of findings for policy, practice and research.
Key messages
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
Strengths and limitations
A key strength of the study was the use of mixed methods and their integration, guided by the realist evaluation approach. The realist synthesis comprehensively reviewed all available international literature and provided an initial programme theory for the impact of IR that was largely missing in the existing literature. Using this initial programme theory to underpin the main study ensured that the study directly built on what was already known, thereby advancing knowledge.
The high response rate for the national survey of English acute trusts (70%) gives confidence that the findings provide an accurate account of the implementation of IR, and is unique in that it gives a comprehensive and reliable overview.
The study captured the experiences and perceptions of multiple stakeholders and has provided a comprehensive view of IR, seen through the lens of those leading, implementing, delivering and receiving it. Researchers spent 2–3 weeks on each case study ward to ensure that the evaluation was focused on the delivery of IR on the ground. This benefited the study hugely. During interviews with senior nurse managers, researchers were frequently directed to interview other senior nurses; they therefore interviewed more managers than intended. This gave additional richness to the data on nursing leaders and executive perspectives of IR, often a hard-to-reach group.87
A limitation of the study was that, because IR was often delivered alongside other care activities and in a flexible way, it was sometimes difficult to identify when IR was occurring. During the observation, it was important that the researchers did not interrupt nurses, so asking questions was kept to a minimum. However, interviewing nursing staff immediately after shadowing them would have enabled researchers to follow up on nurses’ reasoning for the care delivered and how IR contributed to this. Furthermore, nurses kept a lot of information about patients in their heads and often worked with patients for several days at a time, which influenced the interactions they had with patients. It was not possible for researchers to observe how this knowledge affected the delivery of IR. It was discussed in Chapter 8 how IR is often difficult for researchers to observe, as it was rarely delivered as a discrete activity, but was instead undertaken alongside other nursing activities, an approach encouraged by senior nursing managers and leaders. Furthermore, the lack of findings about the influence of IR on patient outcomes included in the safety thermometer data limits inferences on how mechanisms link to clinical outcomes for patients.
Case study sites were selected using the responses to the national survey to provide breadth of context within which IR was implemented. However, being able to achieve the depth of data required for detailed examination of how IR worked limited the number of case study sites that could feasibly be included. Therefore, there may be some important contextual factors that we were unable to select for and this may limit the generalisability of findings. Furthermore, trust nursing managers selected the wards to be included in the research, which may have introduced bias.
There were also some disparities between sources of data from the different methods used (e.g. what staff talked about in the interviews and what researchers observed).88
Implications for policy and practice
The evidence from this study, to our knowledge the first national evaluation of IR worldwide, demonstrates that the effectiveness of IR is very weak. However, there is also clear evidence for a lack of clarity in the purpose and expectations of IR, lack of education and preparation of staff nationally and locally and a lack of resources to support the introduction and sustainability of IR. It is probable that the way in which the policy was developed, disseminated, implemented and supported influenced the effectiveness of the delivery of IR. It is clear that guidelines for good policy-making89 were not adhered to in this case. In the following sections, we set out the implications for the management of health-care services and for nursing through the voices of senior managers, the stakeholder advisory group and others.
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.
. . . 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.
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.
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’.
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
Recommendations for further research
The implications for policy and practice discussed above are wide-ranging and, as we have suggested, contingent on discussion by senior nursing managers and leaders on how to respond to this evaluation of IR. However, what is clear is the need to identify what patients and their carers would value and expect from nursing interventions that support fundamental care delivery, whether a revised form of IR or an alternative intervention. Furthermore, it would be valuable to explore the extent to which patients and their carers want or need to understand nursing processes in order to have a good experience and/or outcome of care.94
This study has identified that further research is needed in the following areas:
- Identify and evaluate the effectiveness of approaches to strengthening the relational aspects of nurse–patient relationships, taking into account the complexity of the care provision (i.e. what works, for whom and in what circumstances).
- As the number of unregistered nursing roles increases, identify and evaluate the methods of RN supervision of patient care.
- Implement and evaluate a community of nursing practice and change supported by an effective learning/buddy network.
Conclusions
This is the first theory-informed, large-scale, mixed-methods evaluation of IR, to our knowledge. It makes a significant contribution to our understanding of the delivery of nursing care in the NHS. The evidence shows the effectiveness of IR, as adapted in England, is very weak and suggests that there is a need for a national discussion about whether or not IR is the optimum intervention to support the delivery of fundamental nursing care to patients. This is a long-standing priority for nursing and this study of IR demonstrates the challenge of how national nursing initiatives permeate to the frontline of care provision. Furthermore, it demonstrates the lack of organisational resilience insofar as IR is not stable when the acute wards are under pressure.
If we want dignity and respect, we need to focus on nurses and the care they deliver . . .
Although patients were observed as having contact with a RN every 37 minutes on average, and were generally positive about their experience with nursing care, we have demonstrated that IR, in isolation, is not sufficient. To uphold dignity and respect, more is needed than a tick-box approach. Nurses themselves recognised this and were ambivalent at best about the value of IR. This is a watershed moment that requires us to think again, putting the focus on the patient and the nursing care that they want, and that nurses want to give.