Introduction

This mixed-methods realist evaluation of intentional rounding (IR) in acute hospital wards in England, conducted in four phases, was designed to address the research question: what is it about IR in hospital wards that works, for whom and in what circumstances? This chapter describes the background to IR in England and the structure of the report.

Background

State-funded systems of health care in advanced economies are facing unprecedented challenges arising from ageing populations and increasing demands for care in the context of stretched resources. The revelations of the systemic and appalling failures of compassion and care at the Mid Staffordshire NHS Foundation Trust that took place between 2005 and 2009 were a profound shock to the public, government, health-care system and professions, and led to Sir Robert Francis’ landmark inquiry, report1 and recommendations to improve accountability and governance for the paramount purpose of protecting the interests of patients. The Francis report1 raised fundamental questions about the nature of compassionate organisational cultures and nursing care in the NHS and called for more research.

In response, the National Institute for Health Research Health Services and Delivery Research programme commissioned a stream of new research intended to generate evidence to meet the gaps in knowledge of service delivery, and to discover what worked well for whom and at what cost. The call, After Francis: Research to Strengthen Organisational Capacity to Deliver Compassionate Care in the NHS [see the commissioning brief on the project web page; URL: www.journalslibrary.nihr.ac.uk/programmes/hsdr/130787/#/ (accessed 4 July 2019)], invited robust evaluations of interventions to improve the leadership, organisational culture and quality of front-line care across a broad range of staff. One of the concerns of the Francis report1 was the neglect of some patients by dysfunctional nursing that failed to respond to fundamental needs, such as pain, hydration, hygiene and comfort, and failed to ensure patient safety. One of the 290 wide-sweeping recommendations made by Francis in his final report (Volume 3, p. 1610) was that:

Regular interaction and engagement between nurses and patients and those close to them should be systematised through regular ward rounds.

Regular patient rounds, often called back rounds or comfort rounds, have always been a plank of nursing care and have recently received renewed interest in the USA and the UK with what has become known as ‘intentional rounding’ (IR), a structured intervention that systematises regular nursing ward rounds. It was this model of regular rounding that attracted attention from policy-makers, triggered by public-interest concerns following the publication of the Francis report.1

The origins and meanings of intentional rounding

The specific intervention recognised as IR was developed in 2007 in the USA by the Studer Group,2 a private, for-profit health-care consultancy company (Pensacola, FL, USA), and the Alliance for Health Care Research. The term ‘intentional rounding’, originally coined by the Owensboro Medical Health System Inc. (Owensboro, KY, USA), is not universally used and IR has also been called ‘hourly rounding’,2 ‘proactive patient rounds’,3 ‘comfort rounds’4 or ‘rounds with intent to care’.5 IR is a timed, planned intervention that sets out to address fundamental elements of nursing care, typically by means of a regular bedside ward round. The aim is to proactively identify and meet patients’ fundamental care needs and psychological safety. The typical format of IR, as developed by the Studer Group, is based on the 4Ps (Box 1), although there are lesser-used variants based on 3Ps (pain, position and personal needs),9,10 5Ps (potty, position, pain, possessions and patient focus)11 and 6Ps (pain, positioning, proximity, personal care, pumps and promise).12

During each round, the following standardised protocol is used by a nurse for each patient.

• An opening phrase is used by the nurse to introduce his or herself and to put the patient at ease.
• Scheduled tasks are then performed.
• A discussion follows of the four key elements of the round, often called the ‘4Ps’:
  • positioning – making sure the patient is comfortable and assessing the risk of pressure sores
  • personal needs – assessing a patient’s personal needs, including whether or not they need assistance with getting to the toilet
  • pain – asking patients to rate their level of pain on a scale of 0–10
  • placement – ensuring that any items a patient needs are within easy reach.
• An assessment of the care environment, such as checking the temperature of the room or any fall hazards.
• Ending the interaction with a closing phrase such as ‘Is there anything else I can do for you before I go?’.
• The patient is informed of when the nurse will return.
• The nurse documents the round.

If patients are unable to respond during the round, the nurse may follow this process with family members.7

The policy context for the introduction of intentional rounding in England

Even before Sir Robert Francis’ recommendations, and in anticipation of his report,1 emerging concerns about what had happened at the Mid Staffordshire NHS Foundation Trust increased the level of concern about patient care and patient safety among the public, health-care professionals and politicians. Interest in IR began when it was identified by The King’s Fund Point of Care programme as a possible way of improving the patient experience of care. Around this time, some senior nurse managers in the UK had visited the USA and had been exposed to IR, as expounded by the Studer Group.13

Prime minister announcement

In January 2012, while visiting Salford Royal Hospital, in the Salford Royal NHS Foundation Trust, the then prime minister David Cameron announced a raft of changes, including measures designed to bolster leadership, improve care and allow patients to rate their care.14 He stated that nurses should make hourly rounds to ensure that each patient was comfortable. In the same speech in 2012, he set up a new national body called the Nursing and Care Quality Forum (NCQF) to promote ‘best practice’ among staff.

As the study was nearing its end, we were able to talk to an official who was close to implementation of the policy about the circumstances of the introduction of IR. The policy development was rapid and took place over the Christmas/new year break to be included, together with the formation of the NCQF, in an announcement by the then prime minister David Cameron on 6 January 2012 as part of the plans to manage the expected messages in the Francis report.1 The ideas were generated at speed and were not given the usual time for the measured, consultative and thoughtful processes expected of policy development. Although not a statutory requirement (and, therefore, not mandatory), it was supported by the chief nursing officer (CNO) at the time and, therefore expected to happen. Not surprisingly, there were no guidelines to support its implementation and IR was not defined other than as an intervention to be delivered by registered nurses (RNs) in order to see their patients hourly using the 4Ps as discussed in the US evidence (see Box 1). It was expected that RNs would use their professional judgement about how to deliver IR, what to ask the patients and how to interpret and act on the subsequent interaction. Interestingly, it was envisaged that IR would not be explicitly documented on a specific IR form, although documentation about care delivered and patient condition was expected to be written in a patient’s notes, which could be done retrospectively at the end of a shift as long as the evidence was recorded. Furthermore, there were no resources to support the development and implementation of IR, as it was thought that RNs would be regularly checking their patients anyway. There was no expectation that progress with implementation of IR would be reported back to the Department of Health and Social Care. The NCQF was tasked with supporting IR implementation as part of its ‘having time to care’ workstream.

Role of the Nursing and Care Quality Forum

When the NCQF was convened, it inherited supporting the implementation of IR as part of its role. Some NHS trusts were early adopters, piloting and implementing aspects of IR in 2011 before the majority of other trusts,15 so some of the key aspects of structured rounds were already under way in a few places. The NCQF was well informed by the experience of IR in early-adopter trusts and endorsed the implementation of IR as part of their workstream on making time to care,5 in which they planned to:

. . . accelerate the implementation of person centred approaches such as ‘rounding with intention to care’ – where every individual receiving care knows they will have at least hourly contact with staff . . .

The forum of nursing experts were concerned that IR could easily become a tick-box exercise; however, it was thought that it would support nurses in prioritising talking to their patients. Therefore, the content of IR was considered less important than the interaction that it would enable and so the 4Ps structure was not expected to be used rigidly. The NCQF assumed that there would be a form to document IR. However, there were no guidelines for trusts about how to implement IR or recommended documentation. Furthermore, there was no evidence of a strategy for introducing IR across the country or for overseeing its development and impact. To address this, the NCQF supported the development of seven ‘demonstrator sites’ for IR, chosen to reflect a variety of health-care and social care providers in a range of geographical locations to support implementation of IR.

The NCQF commissioned a small study4 to learn from these sites, the findings of which noted the potential benefits and limitations of IR, variations in practice and included recommendations of how to conduct IR. This was released in August 20134 as widespread national implementation of IR was already under way and a new CNO was appointed at NHS England, who launched a new vision for nurses called Compassion in Practice.16 At this point, the role of the NCQF became unclear and it is not known how widely this report was circulated. It was available on an NHS website (www.6cs.england.nhs.uk) until 2016, but is no longer publicly available. A freedom of information request was submitted to the Department of Health and Social Care in January 2018 for the report and minutes of NCQF meetings, but no documents were available.

Structure of the report

This report is structured as follows:

• Chapter 2 reports the study aims and objectives, and the methodological approach used to address these.
• Chapter 3 describes the first phase of the study, the realist synthesis of the evidence for IR. The aim of this phase was to generate hypotheses on what the mechanisms of IR may be, what particular groups may benefit most or least and the contextual factors that might be important to its success or failure.
• Chapter 4 describes the second phase of the study, the national survey of non-specialist NHS acute trusts in England. This survey explored how IR was being implemented and supported across England and the way in which organisational context (or features of services and health-care organisations) influenced its implementation.
• Chapter 5 gives an overview of the three case study sites and their staff data, describing how IR has been implemented, developed and supported at each site. This chapter also investigates trends in patient outcomes and provides an analysis of the costs and benefits of IR.
• Chapter 6 explores nursing staff and other clinical, management and administrative staff experiences of IR, how they believed it affected the way they delivered care and the barriers and facilitators they experienced. Through observations of nursing staff undertaking IR and of the care that patients received, Chapter 6 also highlights how IR has been implemented on the ground.
• Chapter 7 explores patients’ and carers’ experiences and perceptions of how IR influences their experiences of care.
• Chapter 8 synthesises the data from each phase of the study to identify what aspects of IR work, for whom, in what circumstances and why.
• Chapter 9 sets out the key messages from the study, reviews the approach and methods used and discusses the implications of the findings for policy, practice and research.