Patient and carer perspectives of intentional rounding

This chapter addresses objective 4, by exploring patients’ and carers’ experiences and perceptions of how IR influences their experiences of care.

Method

On each ward, individual qualitative interviews were conducted with up to five patients and five family carers. Researchers were guided by the nurse in charge of the ward about which patients and carers were appropriate to invite to take part. All participants gave informed consent and all interviews were audio-recorded and transcribed, unless the interviewee requested otherwise.

It was anticipated that patients and their carers might not be explicitly aware of the term ‘intentional rounding’; when this occurred, the interviewer asked about ‘hourly nursing rounds’ or about the regular contact that the patient or their carer had with nursing staff. Individual interviews were transcribed and analysed using framework analysis64 to identify themes in the data and to test and refine the causal explanations expressed as the CMO configurations identified in phase 1.

Perspectives of patients and carers

Participant characteristics

A total of 34 patients and 28 carers participated in semistructured interviews (see Appendices 14 and 15). A further 19 patients and 12 carers were approached but declined to participate in an interview. Interviews were mostly conducted with one person, but in two instances one patient was interviewed alongside two carers, and in one instance two carers were interviewed together. Table 19 highlights the number and type of interviews undertaken at each site.

Interpreting data from patients and carers

Before presenting the findings from the patient and carer interviews, a few cautionary notes should be made. Interviews with patients and carers provided a range of useful observations about daily care. Some people made astute observations and had practical suggestions for how services could be improved. The interviews also provided a reality-check on how nursing practices and ward regimes were experienced by patients and those close to them. Generally, similar themes emerged across interviews, with differences possibly reflecting the diversity at each site in terms of how IR had been implemented and other factors such as ward layout. However, there were a number of factors that require caution in the interpretation of data from patients and carers. First, half of the wards selected for observation and interviews were care of the elderly wards. Many patients on those wards were frail and/or had cognitive difficulties, as indeed did some of the patients on general medical wards. For some patients, and some carers, cognitive difficulties and other personal challenges appeared to affect their ability to understand questions or to stay on the topic. Second, patients and carers often made comments of a general nature, or answered questions with simple affirmative or negative responses, without giving sufficient details to enable researchers to put a high level of confidence in their recall. Sometimes patients agreed with what they believed to be the point of the question, for example simply answering ‘yes’ to a question about nurse visibility, or whether they could communicate with them. In those cases, it was difficult to assess the patient’s level of insight or understanding.

Third, there were sometimes contradictory statements in an interview, or some ambiguity about which staff patients had seen and how often. Many patients were unsure of the professional identity or designation of staff, so they did not always understand whether or not a particular person’s presence at their bedside was part of regular rounding or for some other purpose. Nor did patients necessarily make a distinction between nurses, doctors and other health-care professionals. Fourth, patients and carers were not always clear on what had happened on their current admission or what had taken place on previous admissions (or on previous wards in this admission), or indeed what had happened to someone else. Fifth, the overwhelming majority of patients and carers did not recall an explanation of IR (by that or any other name). Although there is room for argument on how much a lack of appreciation of IR by patients or carers affects its implementation, it may well affect the recognition or perception of IR. Linked to this point is the difficulty of understanding whether or not comments from patients and carers reflected the practice of IR and any of its associated mechanisms, or lack thereof. Patients and carers were often eloquent and perceptive about the quality of care that they perceived, but it was often difficult or impossible to know whether or not, or to what extent, the care they described had taken place in an IR context.

Finally, in view of the above, it is not surprising that patients and carers had explicit views on a limited number of mechanisms, and a few contexts. Outcomes were sometimes implicit but rarely explicit. Unsurprisingly, patients and carers did not perceive what went on around them in terms of mechanisms, although they were sometimes quite tuned in to the contexts within which care was being delivered. When it had seemed reasonably safe to infer that comments were relevant to the mechanisms, contexts and outcomes reported in other parts of this report, this was done. However, in order to make the most of patient/carer information, it is also necessary and reasonable to take careful note of their broader comments on care in general, while being cautious about how this relates to the mechanisms, contexts and outcomes of IR.

Findings

Mechanism: accountability (n = 0)

This mechanism was not evident, as such, to patients and carers, although one carer noted confidence as an outcome of seeing that nurses took responsibility and knew what they were doing. Another commented on ‘red tape’ as contextual, saying:

I know they’ve got an awful lot of paperwork, sometimes you wonder if it’s too much but, you know, it’s like anything, isn’t it, maybe some of it is red tape, maybe some of it is to cover themselves, some of it is obviously because they need information and they need to pass it on to other people.

Mechanism: consistency and comprehensiveness (n = 48)

Many patients and carers made comments about consistency and comprehensiveness in their care. Some 25 comments were made about consistent monitoring, but 17 comments were made about variations in the frequency and practice of nurses coming to the bedside, for example:

. . . it’s almost like a glance, rather than a look, so it’s just ‘Oh, that’s OK, let’s go, don’t have to go in there’, that’s the sort of feeling you get.

Thirty-one people felt that regular rounding was useful for checking on specifics, with general observations and hydration mentioned most frequently. Positive outcomes of consistent and comprehensive care included confidence and reassurance, particularly for carers, and patients, while one patient felt that disturbance from night-time observations was a negative but necessary feature of regular attention.

Mechanism: nurse–patient and nurse–carer communication and relationships (n = 50)

A large number of comments were made about communication and relationships, with both patients and carers making positive comments about communication and engagement with staff, but it was rarely possible to link such comments to IR. Positive comments from patients often highlighted the relational aspects of communication:

. . . Oh yeah, you can have a laugh, yeah, you can have a good laugh with them you know, because otherwise you’re just sort of sat here and you know, growing cobwebs, but no, you can have a good laugh with them because you need it.

You know, you’re not just, to them you’re not a patient, you are a person, that’s the, I think that’s the thing, you are a person, not a patient.

No carers and only four patients felt that IR had been explained to them, whereas 18 patients and 17 carers specifically said that IR had not been explained to them. Positive outcomes of good communication were mentioned nine times, almost always in relation to feeling better and feeling reassured:

Well, it just means that I can sleep at night, really. You know, that nothing horrible is going on, you know, that they listened to her, you know, and they don’t fob her off, which is good.

Mechanism: allocated time (n = 0)

There were no comments directly relating to this mechanism, although some patients and carers reported having to wait for care, which might be construed as a negative observation in relation to this mechanism.

Mechanism: staff communication and teamworking (n = 0)

No comments were made on this mechanism.

Mechanism: visibility (n = 45)

Forty-five of the patient/carer interviews included positive comments about nurse visibility/presence, whereas eight participants made negative comments. However, this is the mechanism for which it was most difficult to be confident that patient/carer observations were evidence of a mechanism for IR, as many people seemed to be commenting on the general visibility of staff:

Ever since I’ve been here, there’s always someone in the vicinity or in here, you know.

Nonetheless, staff visibility was clearly one of the aspects of care that patients valued most, whether or not in the context of IR:

. . . there’s something to be said about just being in a bay and actually seeing faces, so I think maybe the nurses do also kind of know that they are going to be seen by maybe four or five patients when they enter the bay and kind of make it a point to go, you know, ‘Hi, how are you?’, as well, so it’s better.

Mechanism: anticipation (n = 45)

The issue of whether or not IR had an impact on anticipating needs was discussed in 45 interviews, but the majority felt that regular rounds may be useful for addressing immediate needs, rather than future needs, such as going to the toilet or aspects of comfort that might arise suddenly or unpredictably. As one patient explained:

To be really, really truthful, I think possibly regarding going to the toilet, I probably call them, they don’t, they wouldn’t necessarily come and ask if I want to go to the toilet, but they would probably say ‘are you in pain?’ They’re more likely to concentrate on the medical side there and, you know, giving out pills and things, whereas going to the toilet, it’s probably, would be more up to us to let them know.

So, call bells were still needed in such instances, and patients referred to staff telling them to use the call bell if needed. However, some patients did not like to use the call bell or reported dissatisfaction with delays in responding to it. Occasionally, patients also implied that they felt that they had a responsibility to alert staff to changes in their condition:

. . . and yes, if you don’t ask every single question every time it actually doesn’t matter, because let’s be honest, everybody has a voice, if somebody didn’t say ‘are you in severe pain and would you like some morphine?’, then you can say ‘could I have some morphine today, please?’. People are capable of asking, even in the baddest, you know, the worst state.

Mechanism: patient and carer empowerment (n = 25)

Twenty-five interviews elicited comments about patient and carer empowerment, but twice as many people felt that IR did not empower patients or carers than felt it might. Nor did the majority engage with IR charts:

I did have a look at it, but it’s got codes on and things like that, and I had a look at them and I thought ‘well it’s nothing to do with me really’; all I know is I’m getting better, I’ll be going home.

Carers only very rarely saw IR as an enabler of their involvement in the patient’s care. Because IR had rarely been explained to patients and they were often unaware that it was an aspect of their care and of its documentation, it is not surprising that this was so.

General comments about care

Almost all patients and carers made some general comments about their care that were not necessarily directly related to IR. Broadly positive comments were made twice as often as negative comments. Positive comments tended to be generic in nature, often commending friendly and attentive staff:

. . . they all seem to be very nice, you know, I’ve never seen anybody nasty.

I found them very friendly. I got here today and it was lunchtime and they were about to help her with her lunch, but I usually try to come at lunchtime so that I can feed her and then they can feed someone else. But I found them to be very helpful, she’s always been clean. Yeah, I feel they’ve taken care of her when I’m not here, I don’t feel anxious when I leave.

Adverse comments tended to focus on poor communication or inattentive staff, or about inadequate care on other wards and poor access to other services such as primary care and community services. Commonly, individuals made both positive and negative comments, sometimes suggesting that mitigating circumstances were responsible for shortcomings:

. . . occasionally my grandmother might comment on the fact that if she has pressed the call button, it might have been a little while before somebody comes by or it might be the case that if she’s asked for something . . . they kind of go off and forget about her, which isn’t, of course, their fault, but it’s just the case that everybody’s really, really, really busy.

Overwhelmingly, patients and carers welcomed and were reassured by the visibility of nursing staff and by friendly communication, and perhaps a bit of banter. One patient said:

Yes, I mean I always sort of say, ‘when are you kicking me out?’, and they usually sort of say, ‘as soon as possible’, you know, it’s that type of rapport that makes the day go by because it’s a long day here when you can’t move and all you’ve got to do is look at the sky.

Patients clearly wanted to be able to get attention when they needed it, but were less concerned about the precise regularity or form of rounding, so long as needs were met and they felt that they were being treated with respect and good humour. Indeed, one carer, when told by the interviewer about the existence of scripted rounds, commented:

I don’t think that’s very people friendly, really.

General contexts

Patients and carers noted some of the contextual factors that influenced their care, some of which applied to IR as well as to wider aspects of their care. Patients and carers rarely linked contexts to particular mechanisms of IR, although some inferences could be drawn, for example when comments were made about the need for regular rounding varying according to a patient’s condition or stage of recovery. By far the most frequent contextual factors were staff being busy and/or wards being understaffed, which affected mechanisms including consistency and comprehensiveness and nurse–patient and nurse–carer communication. Ward layout was also significant (e.g. whether or not there were single rooms, the proximity of a patient to the nurses’ station, whether or not staff were based in bays), in so far as it affected staff visibility.

Summary

• Interviews with patients and carers provide insight into what patients and carers value, although it is less clear how much IR is the best vehicle for delivering these attributes of nursing care.
• There is no convincing evidence that IR is widely understood or perceived by patients, and its potential for empowering patients is limited as a stand-alone approach to engaging and empowering patients and those close to them.
• In so far as IR may help to bring nurses regularly to patients’ bedsides to attend to their current needs, it may be welcomed by patients and carers, although it is unlikely to be the only means of achieving regular contact, nor a reliable way of anticipating future needs.