Professional perspectives of intentional rounding and observations of its delivery

This chapter addresses objectives 2, 3 and 6, exploring 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 to and facilitators of IR that they experienced. This chapter also highlights how IR has been implemented on the ground, exploring the contribution of IR to the delivery of patient care as a whole; this is possible because of the observations that were carried out of nursing staff undertaking IR and of the care that patients received.

Method

On each ward, individual qualitative interviews were conducted with the ward manager (n = 1), ward nursing staff and HCAs (n = 5), and other stakeholders, such as doctors and therapy staff (n = 5). Health-care staff were purposively sampled to attain a range of professions and grades. Generally, most staff who were approached agreed to participate in the research and only three members of staff across all the sites declined to participate in an interview.

Interview schedules were informed by the findings of phase 1 and specifically designed to elicit detailed reflections on how the different mechanisms and contexts of IR influenced the interviewee and others around them. 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 senior nurses and ward managers

Participant characteristics

Seventeen senior nurses and ward managers participated in individual, semistructured interviews (see Appendix 11). Table 13 highlights their participant characteristics, in terms of their role. It should be noted that none of the senior nurses interviewed personally delivered IR and so often talked in interviews about how they thought IR was delivered or how they expected it should work.

Findings

Mechanism: accountability (n = 17)

All senior nurse participants mentioned accountability during the interview. Eight participants were clear that IR was the responsibility of the RN and, although IR was frequently carried out by HCAs, this was under the supervision of the RN. However, in two of the case study sites, when IR was first implemented, it was found that RNs did not complete it, because they thought that it was a task for HCAs, a view that senior staff felt needed to be addressed. In one trust, the documentation was revised to specify that RNs were required to complete IR every 4 hours.

Intentional rounding documentation

Accountability was seen to be demonstrated primarily by documentation of IR:

. . . from an exec[utive] nurse’s perspective, gives me some assurance that if you’ve ticked box then you’ve done it, and if not ticked box, you haven’t.

This need to focus on documentation was commonly explained by the widely accepted mantra of ‘if it’s not documented, it’s not done’, although some participants expressed the view that the act of documenting did not always make someone feel accountable. There were varied views about the format of IR documentation. Some senior staff thought that it brought together lots of different forms, including IR, in an easy format that everyone could follow. There was an understanding of the need to streamline documentation to reduce the burden of paperwork; however, there were also concerns that the IR form could reduce the scope of nursing care provided to patients:

. . . so we’ve got kind of one kind of uniform approach, and it’s all in one booklet. But then there’s certain things that aren’t in the booklet, so then there’s risk of, if it’s not in the booklet we don’t have to do it, does that make sense?

In all sites, documentation had been designed and subsequently adapted, involving groups of nurses usually adding components not typically associated with IR (e.g. pressure sore risk assessment, food and fluid charts) to increase the clinical utility of the intervention. Several senior nurses shared unease about whether or not too much had been included, so that the form became unwieldy and more confusing to complete, as different elements needed to be completed at different time intervals. Furthermore, there was a lot of duplication with other documents and assessment, resulting in information being recorded in two or more places at times.

Benefits of intentional rounding documentation

Senior nursing staff gave a very clear view that one of the benefits of IR was the documented evidence that it provided. This evidence was thought to be useful to ward-based nursing staff as it demonstrated care delivered, including where care delivery was delegated to HCAs, and provided them with what one participant called ‘psychological safety’, making sure that they were doing the right things, intentionally, for their patients. This highly structured and standardised evidence was very useful to senior nursing staff, as it gave them assurance of a minimum standard of care delivered to all patients, particularly in unstable environments when there were shortages of staff and increased numbers of temporary staff. This evidence was found to be useful in dealing with untoward incident reporting, answering complaints and cases referred to the coroner:

I have been sat in meetings where we’ve had to talk to families before coronial processes and it’s been a relief to the family, and to me as a Director of Nursing, to be able to take those charts and say ‘But this is the care that was provided to your loved one, this is the way in which we diligently cared for them, this is the way in which they interacted with the nurses on an hourly basis or a 2-hourly basis during the night’. When, sometimes, those families walk away, they’ve got some peace because we’ve got an ability to say that we did and we provided care that was to an appropriate standard when they’ve sometimes been worried we haven’t.

One participant also thought that IR could counteract a lack of skill in the nursing workforce:

. . . it’s a prop to good nurse education, so if we structure this in such a way, the IR is a prop to any gaps we might have in the knowledge and skills of our nurses.

Limitations of intentional rounding documentation

Although IR documentation was considered a useful source of information by some participants in order to respond to complaints, the majority of participants voiced concern about how accurately IR documentation reflected care delivered to the patient:

. . . from what I see on an audit, it literally is a tick, tick, tick, tick, tick, tick, tick, tick, tick. Now, for me, that doesn’t necessarily mean it was done . . .

As a result, few relied on IR alone to respond to a complaint, but instead they looked at the entire patient record. Senior staff were aware that nurses were frequently interrupted or had other priorities in caring for a group of patients that sometimes hampered timely documentation, even though IR had been done. Senior nurses, particularly in sites 2 and 3, also expressed concern that the principle of regularly checking patients inherent in IR was being lost in the focus on completion of documentation and whether or not IR was completed in a cursory way. They were unsure of what nurses did as a result of checking the patients’ needs, as this follow-up information was rarely documented:

. . . the task had become the documentation, not the actual conversation or the care.

Auditing intentional rounding

There was variation in the approach to auditing IR. Site 1 had a very structured approach as part of a well-defined, trust-wide quality assurance programme, but the senior nurses at sites 2 and 3 were unclear about how IR was audited. One participant at site 3 spoke about a large trust-wide audit conducted on the quality of staff interaction with patients, which included observation of care episodes. This prompted a realisation that IR had not been mentioned at all in the findings of this audit.

The influence of policy on intentional rounding

Six participants talked directly about the political origins of IR with the publication of the Francis report1 and the government’s response to this being very influential. All those who talked about the report described the findings as shocking, and four participants thought that the introduction of IR was either strongly recommended or mandatory as a result. One participant did not perceive it as an NHS ‘must do’, but saw it as an important response to restore public confidence and trust. In one trust, preparations for IR had already started prior to the report’s publication. Several participants talked about the ongoing influence of the Francis report1 on nursing and IR, and participants from all sites talked about their aspirations to develop nurses and nursing. In two sites, participants talked about how they wanted to get to the point where IR was not needed and the approach to regular, individualised contact with patients was the cultural norm for nursing staff. At the third site, this was not talked about. One participant talked about the need for nursing to evolve and become accountable for outcomes of care rather than processes of care (i.e. IR):

. . . I think the horror that was the findings of the Francis report was horrific and everyone knows that, it’s the bit where even team members will say ‘well if you don’t do this, it’ll be like Francis’ . . . I guess, for me, Francis is old now and we need to, as a profession, be evolving in, and measuring ourselves and deciding going forward, you know, how do you we demonstrate good-quality care, what is, what is an outcome that we want to see, rather than a measure that we want to implement that would give us an outcome.

However, several participants talked of IR as a safety net or safety valve that reduces the pressure on the trust and the directors of nursing in a financially challenged health system with increasing shortages of staff, and how it would take a brave person to stop doing it. Although it was no longer thought to be required or audited by the CQC, there was the perception that if something went wrong, there would be the expectation that IR should have been in place.

Mechanism: consistency and comprehensiveness (n = 16)

Sixteen senior nurse participants discussed the consistency and comprehensiveness of IR in some way. Thirteen described it as a ‘checklist’, an ‘aide memoire’ or a ‘framework’, which supported staff to deliver care and prompted them to think about safety aspects of patient care. It was thought to be particularly helpful for junior and temporary staff or those unfamiliar to the ward to know what they should be doing. Furthermore, it was thought to support standardised care and be an important way of checking if care was delivered and ensuring that it was documented, which was important for governance. An important perceived benefit of the IR checklist was alerting nurses to safety risks (e.g. falls risk assessment, pressure risk assessment, pressure-relieving equipment, food and fluid intake). However, many of the prompts that were considered useful were local adaptations and additions to the original US model of IR.

Although the ‘checklist’ function was considered useful, there was also concern that it would be a prescriptive, task-orientated way of asking set questions. Instead, it was thought that IR should be delivered as part of a nurse–patient conversation to identify and meet individual patient needs. None of the participants thought that IR should be delivered in a standardised, rigid way at every round, as this would compromise holistic care. They felt that IR needed to be adapted so that questions were appropriate to the care being provided and tailored to each individual patient’s needs. For instance, it was not thought necessary to always ask all of the questions, but that nurses should be able to use their clinical judgement (or common sense, at times) to determine which questions were appropriate. One participant also emphasised the word ‘intentional’:

And I think it’s all about the word ‘intentional’, we intended to ask you this and we’ve found that out and so we intend to ask you whether you’re comfortable, we intend to find that out, so it’s our intention to do that as opposed to it’s our intention just to tick a box and we’ll just make sure that’s done on every ward for everybody.

Should intentional rounding be delivered to all patients?

Eight participants considered that IR should be delivered to all patients. This was thought to be particularly important for site 2, where there was a large number of single rooms. In site 1 the importance of ‘eyeballing’ every patient was emphasised, and IR was seen as facilitating this by one participant:

Sometimes, or you’ll be assessing them at a level that actually is probably a bit of overkill, do you know what I mean? But you will know that everybody got it.

Senior staff in site 3 were more amenable to the idea that not all patients needed IR. One participant thought that some patient groups, typically younger, self-caring patients and some services (e.g. short stay or day surgery) did not need IR, although they were cautious of having some patients on the ward receiving IR while others on the same ward did not. Another participant in site 3 thought that conducting IR with young, self-caring patients took time away from more vulnerable patients whose needs were for fundamental care.

Flexibility of the frequency of IR was also discussed and there were different views at the three sites. Most participants from site 1 expected IR to be delivered every hour, although one member of senior staff had a different view and said that the frequency of IR was decided at ward level, in partnership with matrons and also with individual patients, on the premise that ‘one size doesn’t fit all’. Senior staff at site 2 thought that it was unrealistic to do IR at a fixed time every 1 or 2 hours, and so were clear that IR should be recorded at the actual time that patients were seen by nursing staff. Three participants explained that few nurses told patients when they would return to do the next IR because some patients have high expectations and would expect the nurses to be back at the exact time and would be unhappy if this did not happen.

Fewer senior staff discussed the comprehensiveness of IR, although those who did acknowledged that IR was adapted to include other aspects of care beyond the 4Ps (e.g. skin bundle, food and fluid charts, body map, invasive devices, elimination, hearing aids and dentures) in order to make it a more holistic framework. However, the tension of adding more elements to what was essentially a quick check was highlighted. Furthermore, there was concern that the focus on IR had reduced the scope of nursing practice to a narrow focus on the fundamentals, as well as the prevention of adverse events, leading to degradation of individualised care management:

. . . I mean, I don’t want it to be important because it shows that we are at a state in our evolution that that’s the minimum standard, in a sense. I would rather have nurses who are able to articulate, ‘Mr Smith, I need to be doing this, this and this because I spotted that’s what’s going to make the difference for him while he’s in hospital.’ . . . otherwise, we have people sitting in hospital for ages because all we’re doing is the fundamentals.

Mechanism: staff communication (n = 12)

Twelve participants discussed staff communication and teamworking. IR was thought to facilitate some communication between nurses and HCAs, although this tended to focus on whether or not patients had been checked (i.e. IR documentation was completed), rather than on sharing information about the patient or facilitating the way staff worked together. One participant could see how IR documentation would help the nurse in charge keep up to date with care delivery for patients, but did not see how it would help nurses working together.

Intentional rounding was seen by six participants as helpful in supporting RNs to supervise the work of unqualified staff, both in terms of knowing what they had done and, particularly for newly qualified nurses, in delegating work to very experienced HCAs:

I think, you know, when you’re delegating care, I think it works well, if you’re working with a HCA workforce, because they’ve got evidence that they’ve delivered the care they were expected to deliver, and that can be reviewed.

Although IR was seen as an intervention that could be undertaken by members of the multidisciplinary team, it was acknowledged that only nursing staff delivered IR and, therefore, IR had little impact on communication within the wider team.

Mechanism: nurse–patient communication (n = 12)

Three participants thought that IR increased the frequency of communication between nursing staff and patients, although none thought that it would improve the quality of that communication. Few participants thought that IR facilitated communication with carers; those that did focused on carers being reassured by IR documentation, indicating that patients had been seen and had received food and drinks, rather than IR facilitating conversations. Four participants thought that IR had no influence on nurses’ communication with patients and their carers, reducing nursing interaction to a list of tasks or closed questions to complete rather than the opportunity to talk with the patient:

. . . the contact becomes transactional rather than enriching, so you’re not having a conversation with that patient.

Four participants said that they did not think IR was explained to patients.

Mechanism: allocated time (n = 11)

Eleven participants talked about the allocated time mechanism, but did not see IR as providing nurses with ‘time to care’. They were aware of time constraints that nurses experienced in delivering care, particularly when wards were short-staffed, and how that perceived lack of time influenced the way IR was conducted:

I won’t ask the questions or I won’t look at the, because they’re going to ask me and I haven’t got time to answer those questions. They might ask me, I might have to go and find someone else and I haven’t got time to do it, you know, I’ve heard that, staff say that.

Four participants described IR as encouraging the conversation rather than following a script:

. . . they’re just questions that you should ask, along with other things as well, so then you just complete that you’ve done it, rather than stand there and be like, ‘do you want the toilet?’ and tick, you know?

Senior staff talked about their expectation that IR would be incorporated into other clinical or care activities (e.g. helping a patient to wash or doing a dressing). The majority thought that staff were already delivering this care to patients and that the IR paperwork supported what they were already doing:

I’ve been sort of saying, you’re doing it as part of your care at the same time, you know, particularly when you’re also washing somebody, you’re doing one of your intentional roundings then.

I think staff are doing it anyway, staff are in the rooms and they’re delivering that care, it’s just a case of signing that paper, ‘cause they’re doing it . . .

Mechanism: visibility (n = 9)

Seven participants thought that IR increased the visibility of nurses:

. . . if we didn’t have intentional rounding . . . what would I use to understand whether nurses were sat around a nursing station or they were actually in a bay working with our patients and their families? IR for me is the hook that keeps nurses going to the bedside, I guess.

This was thought to be particularly important in environments with a large proportion of single rooms, irrespective of whether patients were fully dependent on nurses for their physical needs or self-caring. Even in a Nightingale ward structure, where nurses were already visible to patients, IR was still considered important to facilitate direct contact, as patients were sometimes reluctant to disturb busy nurses to ask for help. However, in wards with four- to six-bedded bays, IR was not thought to increase visibility, as nurses spent most of their time in the bay (which had a computer and phone extension in it) already, and they had no reason to leave.

Mechanism: anticipation (n = 8)

Five senior nurses thought that IR may enable staff to be proactive and anticipate patients’ needs ‘as long as they’re not just going through the motions’. However, this was thought to be restricted if patients were not aware that a nurse would be returning at a specific time, if nurses were delayed because they were with another patient or if something unexpected happened on the ward. Furthermore, one participant was unconvinced that patients waiting for a nurse to return to ask for something was a good thing:

. . . I don’t want somebody to wait for an hour for the toilet because they think someone’s coming back, I want them to press their buzzer when they want it.

Mechanism: patient empowerment (n = 3)

Of the three participants that mentioned patient empowerment, one thought that IR could empower patients if it was conducted in the right way and two said that patients and carers were aware of the IR documentation and sometimes read the forms. There was no evidence that senior nursing staff thought or expected IR to empower patients.

General contexts and outcomes

General contexts

In addition to the contexts linked with specific mechanisms already discussed, interviewees discussed some more general contexts that influenced IR as a whole, for instance ward culture and leadership, and staff education and training. Senior nurses thought that ward culture and leadership had a key influence on the nursing care delivered and on how IR was delivered, that is, not as a tick-box exercise, although IR was not thought to contribute to this ward culture. Senior nurses considered staff development had a more important influence on quality of nursing care than IR and some talked about their longer-term plans to do this. Although a couple of senior nurses thought that training had been provided when IR was first introduced, they were not able to provide details of this. Another senior nurse recalled seminars with nurses to discuss how they wanted to implement IR. However, the majority thought that formal training had not been provided, and that ward managers had explained how to complete the IR documentation to their teams, described by one senior nurse as ‘there was no roll-out so it was the blind leading the blind a bit to start with’.

All senior nurses thought, but were not sure, that subsequent ‘on-the-job’ training was delivered locally, arranged by ward managers as part of staff induction. However, this training focused on how to complete the documentation rather than the purpose of IR and what the anticipated outcomes would be. As one ward manager said:

It’s actually good to think about IR, because it’s not something that I’ve ever sat down and really thought about and scrutinised, because I think, as a band 5, it was just something that we had to do, you just did it because that’s what you’re told to do. So it’s never, it’s not something that I’ve ever sat and thought about as to why we do it and what the benefits are and, but it’s good to.

Senior staff were aware that nurses were concerned initially about the additional paperwork required by IR, that they did not see the point of it and that they thought they should be spending their time doing something more important. However, with time IR was thought to have become embedded, not questioned, ‘done without a second thought’ and, according to one ward manager, ‘I don’t think it makes any difference any more.’ Senior nurses talked about their ambition to develop the quality of nursing care provision so that IR would not be needed through staff development, nursing leadership development and being very clear about what good nursing care looks like.

General outcomes

Although there was acknowledgement that determining the causal effect of IR on specific patient outcomes would be very difficult, senior staff did think that IR could have an impact on falls and pressure ulcers. Several also thought that IR had an impact on nutrition, hydration and pain reduction. However, these perspectives focused mainly on the patient outcomes that IR could potentially influence rather than having evidence that it did influence these outcomes. IR was not thought to influence ward atmosphere or call bell use, as found in the US evaluation studies.8,22,26,37,39,40,47

Summary

• All senior trust and ward managers mentioned accountability in some way during the interview. Accountability was seen to be demonstrated primarily by documentation of IR. Senior staff felt that one of the benefits of IR was the documented evidence it provided, although they acknowledged that this evidence was not always sufficient/reliable.
• Most senior staff described IR as a checklist, aide memoire or a framework that supports nursing staff to deliver care. However, there were concerns that it could be used in a prescriptive, task-orientated way, when it should be delivered in a conversational way, tailored to individual patient needs. None of the senior staff interviewed thought that IR should be delivered in a standardised, rigid way at every round.
• Intentional rounding was thought to facilitate some communication between nursing staff, although this tended to focus on whether or not patients had been checked.
• Few senior staff believed that IR increased the frequency or quality of staff communications with patients.
• Senior staff did not see IR as providing nurses with ‘time to care’. The majority thought that staff were delivering care to patients and that the IR paperwork supported what they were already doing.

Perspectives of nursing staff

Participant characteristics

An opportunity sample of nursing staff was identified, based on who the research team met while collecting data on the wards and who agreed to participate in the research. Thirty-three front-line nursing staff members participated in an individual, semistructured interview (see Appendix 12); Table 14 summarises these interviewees’ level of seniority and education. All of the nursing staff interviewed were aware of and had personally undertaken IR.

Findings

Mechanism: accountability (n = 33)

All nursing staff mentioned accountability in some way during the interview. Four participants mentioned the political origins of IR, believing this was the reason why it was implemented in the UK:

. . . I’m aware this came out as a pre-emptive thing, didn’t it? In light of the Francis report, a pre-emptive strike by David Cameron to show that we’re actually doing something after the horse had bolted, before it broke in the press.

Others thought it had been implemented as a ‘standard-setter’ for nursing care across hospital settings, in order to ensure that patients were ‘safe’ and ‘not neglected’. However, most participants did not talk about IR as influencing their own personal accountability for the standards of care delivered. Only six said that IR made themselves or other nursing staff feel more accountable for the standard of care they were providing, whereas three believed that they would provide the same standard of care with or without IR. Some acknowledged that IR may improve standards in hospitals that were providing poor care, but did not see how it could benefit their hospitals, as they rated their institutions highly.

Audits of intentional rounding

Some participants were aware that IR documentation was being audited in their trust. Two senior staff nurses were able to identify positive outcomes associated with this, such as being able to identify and improve poor care and celebrate and reward good care. However, others (including a ward sister) were not clear whether or not IR was audited, and, if so, who audited it and what information they reviewed. Some staff also queried the usefulness of auditing IR documentation without assessing the quality of the round delivered:

. . . it’s just a tick and you can’t assume that someone’s done a good job because of a tick.

Intentional rounding documentation

Although IR documentation varied between sites (see Appendices 6–9) broadly, opinion on the format of IR documentation was divided. Some (but not all) HCAs and newly qualified staff liked the format, appreciating that it was fairly concise and had a ‘tick-box’ style that was quick and easy to complete. Others did not like the tick-box format, stating that the documentation missed important information about patients and did not demonstrate the variety of tasks that nursing staff had undertaken. Some also said that they would prefer more open space on the documentation to add more detailed text.

Benefits of the intentional rounding documentation

Intentional rounding provides evidence that care has been delivered

Sixteen staff felt that a positive outcome of IR was that it provided ‘evidence’ or ‘proof’ that nursing care had been delivered. The need to evidence the care one delivers seems to have been entrenched into participants’ way of thinking, with many repeating a particular phrase, or words to this affect: ‘. . . if you haven’t written it down, you haven’t done it’. That is not to say that nurses changed their actions because of IR: they said they were working as they always had done, but the IR documentation now gave them written proof of this:

Most appeared to be accepting of this need to evidence care, acknowledging that this was the current nature of the NHS, although some expressed dismay that nursing care had moved in this direction. Two nurses saw the IR documentation as a means of positively highlighting how much time they do spend with their patients or as a way to ‘emphasise the good work that we do’, but the majority viewed it as a means of protecting or ‘covering’ oneself following an incident or complaint. The need for written evidence in the light of complaints suggested that nursing staff felt that their testimony alone would be insufficient in these circumstances. A number of examples of specific aspects of care that should be evidenced were provided, including the need to prove that nursing staff had been inspecting patients’ skin and changing their positions regularly, offering them food and drink and asking about their pain. For others, because nurses were required to initial each round, the IR documentation offered a means of proving which nurses had been delivering attentive patient care and identifying those who had not.

Intentional rounding documentation provides staff with an overview of the patient over the day

Ten participants said that IR documentation provided staff with a useful picture of each patient over the course of the day, identifying how much food and fluid they had consumed and how often they had passed urine or opened their bowels. (Staff mainly referred to the food and fluid balance records when discussing this, which is not part of the Studer Group IR protocol, but is an additional item that many of the case study sites had added into their IR documentation.) Staff found this to be useful because it enabled them to identify and respond to potential problems.

Intentional rounding documentation allows carers to see what has happened to patients in their absence

Five participants felt that a benefit of the IR documentation was that carers could read through it and find out what had happened with patients outside visiting hours. (Again, however, this tended to be associated with the information stored on the food and fluid chart, which is not part of the Studer Group IR protocol.) This was felt to be particularly important for patients who had dementia or other conditions that meant that they could not feed back this information to carers themselves. They thought that being able to access this information would be reassuring to family members (hereafter referred to as ‘carers’), enabling them to feel confident that the patient was receiving good care in their absence and would also mean that carers did not have to keep asking nursing staff for this information.

Problems with the intentional rounding documentation

Intentional rounding documentation is not always completed at the time of the round

Only three participants said that they always completed the IR documentation at the time of interaction. Contextual factors that facilitated the completion of IR documentation included locating it at the bedside, being reminded by management to complete IR documentation in a timely manner and ensuring that everyone had sufficient and suitable training in IR so that they knew how and when to complete it. For some, personal beliefs about the importance of nursing documentation also influenced their likelihood to prioritise its completion.

Rounds are carried out but not always documented/documented later in the shift

One-third of participants said that they or their colleagues often completed IR documentation later in their shift, after the round had taken place. These staff were clear that they had completed the round itself, but they just had not had time to document it. They therefore felt that this was an acceptable and inevitable part of the IR process, so long as the documentation was up-to-date before the end of their shift (even if this meant that they had to stay back late to complete it). Nevertheless, for some, this lack of compliance with documentation procedures led to anxiety, as they knew that this was not how the IR documentation was supposed to be completed and they worried about the potential consequences. Other concerns arose when participants were providing more frequent care to patients than the IR procedures implied (i.e. more frequently than once or twice hourly). In these cases, nurses were not writing down every time they assisted a patient; therefore, they worried that the IR documentation was not an accurate reflection of the care a patient had actually received.

For almost all of these participants, a lack of time, created either because of staff shortages or through conflicting tasks and priorities, was the main reason that they either forgot or chose not to complete their IR documentation on interaction and instead completed it later in their shift. In such busy working environments, nursing staff felt that they needed to use their professional judgement in order to decide which tasks to prioritise, and IR was often felt to be a lower priority.

Intentional rounding documentation is completed prospectively or without undertaking the round

Six participants said that they or their colleagues had either completed the IR documentation prospectively or completed it without undertaking the round. Prospective completion of the documentation involved either writing all of the times of interaction with patients onto the form in advance, at the start of the day and then filling the rest in later or writing the incorrect time of interaction onto the form, in order to fit within the allocated hourly slot. Others admitted that the IR documentation was sometimes completed without the round even being undertaken:

Again, a lack of time was reportedly the main reason why nursing staff chose to complete the IR documentation prospectively or completed it without undertaking the round, as, when time was scarce, they were more likely to perceive IR as a tick-box exercise. This temptation to document rounds prospectively, or without completing the round, was exacerbated by senior management pressure to ensure that documentation was always up to date. At one site, a number of staff mentioned that management had instructed them to be honest on their IR documentation and record it for the exact time at which the round had taken place. Staff at this site appreciated this and felt that inaccuracies on the IR documentation were decreasing following this guidance. They also felt that it was important for their trust to see an accurate picture of how often they were able to interact with patients, so that they were aware of the reality of their busy workloads.

Intentional rounding documentation has negative consequences for nursing staff

Six participants said that the IR documentation could lead to negative consequences for nursing staff, making them feel scrutinised or worried that they would face disciplinary action if they did not complete it. This was particularly notable when wards were short staffed or busy workloads had prevented nurses from undertaking IR or completing the IR documentation.

Intentional rounding documentation restricts the time that nursing staff spend with patients

Five participants struggled with balancing their desire to spend time with patients and their requirement to complete documentation. Others noted the difference between ‘a good nurse’ and ‘a good documenter’ and felt frustrated when colleagues appeared to prioritise their documentation over their patients. One nurse concluded that implementing IR documentation alone was not sufficient to ensure compassionate patient care:

. . . there’s no documentation that’s going to go along and say ‘hey, you should care more about your patients and check out if they’ve got water’; you’ve either got that passion and you’re already going to do that . . . and you’ve got that caring, compassionate nature that nurses have or you don’t.

Mechanism: consistency and comprehensiveness (n = 33)

Intentional rounding as a checklist or ‘checking’ mechanism

All nursing staff mentioned the consistency and comprehensiveness mechanism in some way during their interview. Eighteen participants referred to IR as either a ‘checklist’ or a system for ‘checking’ on a wide variety of patient needs. Some participants felt that this checklist was more beneficial for new/inexperienced members of staff and for agency/bank staff. Others felt that there was a greater need to regularly ‘check’ on patients in single rooms, as nurses could not see how they were doing without physically entering their rooms. It was also noted that regular checks worked successfully only if there were sufficient staff on duty. Generally, the perceived outcomes of such checking were to ensure that the patients were ‘comfortable’ or ‘OK’, but a small number of participants felt that regular checking could help prevent pressure sores, reduce the number of falls and ensure that patients were eating and drinking sufficiently. Others also felt that these checks could be satisfying for nursing staff, enabling them to leave a patient knowing that they were comfortable and had everything they needed.

Some participants said that the tasks undertaken in IR were ‘things that we should be doing anyway’ but 17 participants felt that IR offered a useful reminder or prompt to prevent staff from forgetting these tasks. Again, some felt that these reminders were more useful for bank/agency and new/recently qualified staff and less necessary for permanent members of staff or those with more experience. In busy working environments, where staff were juggling many different tasks, some also said that they found the IR documentation useful to remind themselves of what they had previously done with a patient (e.g. what side they had last been turned on to), although again this refers to additional checks and detail not usually associated with IR.

The role of flexibility

Is intentional rounding suitable for all patients?

Opinion was mixed on whether or not IR should be applied to all patients, but the belief that IR should be applied to all patients was more frequently aired by staff from case study site 1. These participants said that applying IR to all patients resulted in less confusion for staff and ensured that all patients received comprehensive care without anyone being missed. However, these staff had also experienced problems with this approach and sometimes saw it as additional, unnecessary work. The notion that IR was not suitable for all patients was more commonly raised by staff from case study site 3, who felt that IR was more beneficial for some patients (e.g. higher-risk, elderly, unwell, bed-bound patients and those with dementia, cognitive impairment or pressure ulcers) than others (e.g. younger, more mobile, independent patients or those who were more ‘well’). Some nursing staff said that it was not possible to ask all patients the IR questions because some lacked the capacity to answer. Therefore, nursing staff were required to use their observational skills and professional judgement to answer the questions for them or ask their carers’ advice.

Should intentional rounding be a structured or flexible process?

No one said that IR was or should be applied using a structured, systematic approach at every round. Instead, staff talked about using their clinical judgement and their common sense to tailor IR to each individual patient. Such flexibility was regularly applied, in terms of how the questions were posed, what was asked and how often they were asked.

How are the questions posed?

No one felt that it would be appropriate for nursing staff to simply read out the questions to patients from the IR documentation; participants instead preferred to incorporate them as part of a friendly conversation. They felt that doing so was more genuine and was more likely to help build a rapport with patients, whereas asking them ‘parrot fashion’ was more likely to cause irritation.

What is asked?

Some staff said that they chose not to ask every question at every round because they did not think it was necessary or because they felt that it would become ‘tedious’ for everyone involved. Others questioned whether or not it was realistic to expect nurses to be able to complete IR as intended, saying that they simply did not have the time to ask each patient every question because of their busy workloads, lack of staff and other demands on their time:

I think if you . . . did it asking each question how you’re supposed to do it, you would never do anything else.

One participant felt that the question ‘is there anything else I can do for you?’ was the most useful question on the IR form, and helped identify those issues that were important to patients but which might otherwise be missed (e.g. did the patient need something from the shop? or did they want to read a newspaper?, etc.). Some people said that they asked this question more indirectly or more casually, with statements such as ‘do you need anything?’ or ‘can I help you?’, but others said they chose not to ask patients this question at all, simply because they did not have the capacity to respond to their answer:

. . . sometimes that’s not a question you want to ask, ‘is there anything else I can do for you?’, because you don’t want to know the answer [laughs].

How often are intentional rounding questions asked?

Many participants felt that there should be flexibility in how often IR was conducted with patients and that some patients needed it more frequently than others, depending on their health needs and other personal circumstances. For some, this flexibility was simply a practical solution to the fact that each day was different and you could never guarantee being able to check on each patient at the same interval each day. At case study sites 2 and 3, nursing staff had a degree of flexibility around how often they could undertake IR and many said that they did vary the regularity of their rounds depending on individual need. However, some participants from these sites did acknowledge that using this flexible approach could be confusing for nursing staff, as everyone did IR slightly differently and they were not always sure how frequently they were supposed to round each patient. At case study site 1, staff did not have any flexibility around the regularity of IR as they were all aware that it was supposed to be hourly, although some staff still tried to carve out an element of flexibility within these boundaries.

Comprehensiveness of intentional rounding

Fewer staff discussed the comprehensiveness of IR and whether or not it was able to help identify all patient needs (n = 9). Most felt that the breadth of areas included in IR was very good and that everything included in a round was an important component of positive patient care.

Mechanism: nurse–patient communication and relationships (n = 30)

Two ways in which IR could potentially influence nurse–patient communication were identified. These were as follows.

Intentional rounding could increase the frequency of nurse–patient communication

Eleven participants said that IR increased the frequency of nurse communication with patients. Busy working environments and a general lack of nursing time was the key context for this, as some felt that, in the light of the competing demands on their time, IR enabled them to ensure that they returned to their patients regularly. Others said that without IR they would spend less time talking with their patients and more time responding to their other tasks. However, the communications that arose from IR were generally seen as brief, with nurses describing just ‘popping in’ to check that patients were OK rather than having lengthy discussions with them. Nevertheless, some staff felt that brief but more frequent communication was appreciated by patients and their carers, making them feel ‘cared for’ and ‘valued’ and giving them confidence that they would not be ‘forgotten’. One nurse referred to this as offering ‘good customer service’ to patients and their carers. Others believed that IR made patients feel more comfortable with nursing staff and more confident to approach them with any problems they may have or any issues they would like to discuss.

However, not all outcomes of more frequent communication were positive, as some said that nursing staff and patients (particularly those who had been on the ward for longer periods of time) found the increased frequency of communication to be a ‘nuisance’. A further unanticipated negative outcome was that IR could raise patients’ and carers’ expectations of how much time nursing staff should be spending with patients, an expectation that, in reality, nursing staff were not able to meet.

Intentional rounding could improve the quality of nurse–patient communication

Only three participants believed that IR improved the quality of nurse–patient interactions. These participants felt that the process of IR helped them to open up lines of deeper communication with patients (particularly those who were less vocal or had communication difficulties), enabling them to focus on each person’s individual needs.

Impact of intentional rounding on nurse–patient relationships

Few participants talked of the impact IR could have on nurse–patient relationships and only four participants said that IR could be beneficial for improving these relationships. Some said that the process of IR made patients feel more cared for and considered by nursing staff, which enabled positive relationships to develop. For others, the increased regularity of communication with patients due to IR helped nursing staff get to know their patients better, enabling them to detect subtle, significant changes that could affect safety.

Some overall contexts that influenced nurse–patient communication and relationships were identified by nursing staff. For example, a lack of time generally made participants feel that nurse–patient communication and relationships suffered. The personal characteristics of staff were also felt to be important, with some staff being identified as more approachable and chatty than others. It was acknowledged that some staff were better at starting conversations with patients; therefore, IR may be more useful for those that struggle to communicate (or are less experienced at communicating) with patients than for those who do this naturally. Equally, some patients were felt to be chattier than others and IR could be useful for encouraging quieter patients to make their voices heard.

Mechanism: allocated time (n = 29)

All but four participants discussed the allocated time mechanism, but they focused, not on the presence of this mechanism, but the absence. No one felt that they had been given specific, allocated time in which to undertake IR. In fact, a small number of participants (including both qualified and non-qualified staff) perceived IR to be ‘additional work’, which took up more of their time. Others believed that they would be doing the tasks included in IR anyway, even if it had not been introduced:

. . . I just feel like it’s a term that’s been coined for something that we’re already doing, they’re just putting a name on it.

But most participants said that IR did not take up too much of their time because they simply incorporated it alongside other aspects of their workload. For example, RNs talked about fitting IR in alongside their medication rounds and HCAs talked of incorporating it into the daily patient washes and bed linen changes. Generally, these participants said that they had chosen to incorporate IR alongside their other tasks because there was not the time or number of staff required to do it any other way. At case study site 2, staff were told that they should be doing IR every time they entered a patient’s room; therefore, they usually combined IR alongside whatever other task they had entered the room to undertake.

Only one participant felt that IR enabled them to prioritise patients’ basic care needs. However, one experienced nurse disagreed with the idea that RNs should be prioritising basic care when, in reality, they often needed to be focused on more clinical aspects of care and could delegate basic care to unqualified staff. Nine participants discussed the idea that IR might affect the organisational or time management skills of nursing staff and two (both band 5 nurses) felt that IR could have a beneficial impact on this. Seven said that certain tasks/patients have to be prioritised over others and that choosing not to undertake IR was often a demonstration of good time management/prioritisation skills.

Mechanism: staff communication and teamworking (n = 24)

Twenty-four participants discussed this mechanism; 16 felt that IR encouraged or improved staff communication, usually in terms of an improved handover of information about patients between nursing staff or across shifts. Others felt that IR enabled nursing staff to better share their tasks and responsibilities among each other and pick up on any tasks that their colleagues may have missed. Six participants also felt that IR was useful for RNs as a day-to-day supervisory tool for more junior or unqualified staff. These participants said that the IR documentation was checked by senior members of staff to ensure that those under their supervision were working as expected and completing their allocated tasks.

Although everyone acknowledged that IR was, first and foremost, a nursing document, used mainly by nursing staff, a few participants did feel that their non-nursing colleagues (mainly doctors and dietitians) did refer to the IR documentation for information about patients (however, this was generally the food and fluid parts of the form, which, again, are not part of the original US protocol). Some felt that there was a missed opportunity for good interprofessional teamworking and that it would be beneficial if other health-care workers also completed the IR form when they were with the patient. This seemed particularly relevant to therapy staff, who were reported to spend longer periods of time with patients than nurses could often manage. It was felt that therapy staff could undertake some of the tasks on the IR form (e.g. offer a drink, ask about the toilet) as part of their therapy session and document this so that it offered a more realistic picture of the number of people who had visited the patient each day.

A relationship between IR and teamworking was identified by some participants (i.e. not only was IR perceived to improve staff communication and teamworking, but strong staff communication and teamworking were perceived to be important for effective IR). Good teamworking, which assisted IR, involved reminding colleagues when they had forgotten to undertake IR, offering assistance to others when they were too busy to undertake rounds or taking the initiative to help colleagues with particular aspects of the IR load. The only other influencing context of the mechanism was individual staff personalities and characteristics, as some team members were naturally more proactive and better team players than others.

Mechanism: visibility (n = 21)

Twenty-one participants discussed this mechanism, although only five believed that IR actively increased nurse visibility. These participants talked of their busy working environments, which involved many tasks to be completed away from patients’ bedsides (e.g. taking telephone calls, working in the clinic, documenting on the computer). They felt that IR offered a clear reason for nursing staff to ‘keep going back’ to patients, thereby increasing their visibility. This was believed to be ‘comforting’ to both patients and nurses, making patients less anxious about being left alone and reassuring nurses that their patients were OK. However, one HCA found that increasing her visibility meant that she was being asked to do additional, non-urgent tasks by patients.

Not everyone agreed that IR increased nurse visibility and four participants (who all worked on wards with bay layouts) said that they rarely left their bay anyway, and were, therefore, visible to patients most of the time. Indeed, 15 participants talked of the important context of ward layout and its impact on nurse visibility, with most stating that IR may be a more useful means of increasing nurse visibility in single room wards or side rooms, rather than bay-based settings (as patients in single/side rooms did not see nursing staff as often as those in bays). However, not everyone agreed with this and one participant felt that IR did not even increase nurse visibility in single/side room settings.

Mechanism: anticipation (n = 20)

Twenty participants discussed this mechanism and five felt that IR enabled staff to better anticipate and proactively address patient needs. This was believed to be beneficial for toileting, avoiding falls and overall experience of care, as well as enabling nursing staff to identify any issues before they escalated. One participant believed that, by enabling nursing staff to anticipate patient needs, IR resulted in fewer patient call bells; however, two disagreed, stating that IR had no impact on call bell use. This may be because call bell use was perceived to be complex and dependent on the personal characteristics of the patients or the variety of needs and requests they may have. Eight participants felt that IR did not influence how proactive they were or affect their ability to anticipate patient needs. In particular, some staff felt that it was not possible to anticipate patients’ toileting requirements or whether or not they would like a hot drink, as these needs could change rapidly. Instead, these staff informed patients to use their call bell should such needs arise. Others felt that anticipating patients’ needs was already part of their nursing skill or personal characteristics and something they would be doing with or without IR.

The key context of the mechanism was associated with patients’ and carers’ understanding and awareness of IR. When asked if they told patients and their carers about the process of IR and what it entailed, all but three said that they did not tell them unless a patient or carer specifically asked. For some, this also included not telling them when they would be back to see them next. Generally, nursing staff said that they did not tell patients and their carers about IR because they did not think that they would care about the working processes nurses were undertaking or that they would not understand them. However, in most cases, the anticipation mechanism could not be triggered for patients and carers as they were unaware that IR was taking place and, as such, could not anticipate when a nurse would return. The layout of the ward was the only other influencing context in the anticipation mechanism, as having a nurse based in a bay was felt to be more beneficial for nursing staff to observe patients closely and proactively identify any requirements they might have.

Mechanism: patient empowerment (n = 8)

Only eight participants discussed the patient-empowerment mechanism. On the basis of participants’ responses, patient empowerment appeared not to be an independent mechanism of IR, but a possible outcome of the increased frequency of communication that IR promoted. Four participants said that IR enabled nursing staff to go to a patient’s bedside more regularly and, as a consequence of this, patients became more familiar and confident with the nursing staff and more likely to ask them for what they needed. However, four participants disagreed with this and felt that IR made no difference to patient empowerment. One staff nurse said that IR could not empower patients because they did not know that it was happening, whereas others said that the patients on their ward were already confident enough to ask for what they needed, regardless of IR. No other contexts or outcomes associated with the mechanism were identified.

General contexts and outcomes

General contexts

In addition to the contexts linked with specific mechanisms already discussed (e.g. staff shortages, lack of time, ward layout), all interviewees also highlighted some of the more general contexts that influenced the intervention of IR as a whole. This included the amount of training and education nursing staff received around IR. Although some participants remembered attending training or lectures about IR, many said that no formal training had been provided, perhaps because the intervention was viewed as ‘self-explanatory’ (senior staff nurse, band 6) or something that, ‘anyone can use’ (senior staff nurse, band 6). Instead, it was more common for staff to receive informal training from their colleagues, with more experienced nursing staff explaining the IR paperwork to new team members and demonstrating how they undertook IR. However, this sometimes posed problems as the training they delivered depended on the trainer’s own understanding of the intervention, which meant that they could sometimes pass on incorrect guidance and information:

. . . I suppose there’s no hard and set rule of how to do it, so they’ll talk them through how they do it.

There was also a sense that many staff did not know why they were delivering IR and had not received any training around its purpose or why particular components of care had been included. Participants said they delivered IR ‘because I have to’ (staff nurse, band 5) and had never really formed much of an opinion or reaction to it. Others said that they undertook IR because that was just ‘how we work’ (staff nurse, band 5) and that it was a ‘process that’s automatic’ (staff nurse, band 5) and so embedded in their daily routine that it was not something they ever gave much thought to:

. . . I don’t think about doing it, yeah, more like it’s just a bit of a routine, it’s ingrained.

. . . I just do it second nature.

Some participants, therefore, felt that it was important for nursing staff to develop a greater understanding of ‘why it’s so important’ (staff nurse, band 5) so that they all delivered IR as intended and did not view it as extra work that was a hindrance or nuisance. This links to another important influencing context: the level of engagement that staff felt around the implementation or process of IR. Few staff said that they were involved in the implementation of IR or influenced it in any way, but it was felt that improving staff engagement in IR would improve nursing staff understanding of its benefits:

. . . I think just probably ensuring people understanding fully what the tool is used for and making sure that they’re supported just to sort of use it properly and then allowing them to see the benefits of use.

Individual staff characteristics, such as having good communication skills and empathy, as well as the amount of experience nurses had in working with patients, were also felt to be important contexts in the success of IR.

General outcomes

Generally, staff did not associate IR with any specific outcomes, although some nursing staff felt that it could be a helpful tool for reducing pressure sores and falls, which could possibly lead to a quicker discharge from hospital. Others said that IR helped them feel satisfied that they were delivering good patient care.

Summary

• All nursing staff mentioned accountability in some way during their interview. However, most nursing staff did not talk about IR influencing their own personal accountability for standards of care delivered, although some acknowledged that it may improve standards in hospitals that were providing poor care.
• Half of all nursing staff interviewed felt that a positive outcome of IR was that it provided evidence that nursing care had been delivered. Most viewed this as a means of protecting oneself following an incident or complaint.
• All nursing staff mentioned the consistency and comprehensiveness mechanism in some way during their interview. Many participants referred to IR as a checklist or system for checking on a wide variety of patient needs. They also felt that IR offered a useful prompt or reminder to prevent staff from forgetting to undertake particular tasks.
• Opinion was divided on whether or not IR should be applied to all patients, but no nursing staff felt that IR should be applied using a structured, systematic approach at every round. Instead, nursing staff talked about using their clinical judgement and common sense to tailor IR to each patient.
• Some nursing staff felt that IR increased the frequency of nurse–patient interactions, although these communications were usually brief, rather than lengthy discussions. Few nursing staff believed that IR could improve the quality of nurse–patient interactions.
• No nursing staff felt that they had been given specific, allocated time in which to undertake IR.
• Half of all nursing staff felt that IR encouraged or improved staff communication, generally in terms of an improved handover of information about patients between nursing staff or across shifts.
• Few nursing staff felt that IR affected nurse visibility, anticipation of needs or patient empowerment.

Perspective of other health-care professionals

Participant characteristics

An opportunity sample of non-nursing health-care staff was identified, based on who the research team met while collecting data on the wards and who agreed to participate in the research. Twenty-eight other (i.e. non-nursing or managerial) health-care staff participated in an individual, semistructured interview (see Appendix 13), some of whom had direct experience of conducting IR. Table 15 shows the participant characteristics of the other health-care staff interviewed in terms of their profession/role and whether or not they had direct experience of undertaking IR.

Findings

Mechanism: comprehensiveness and consistency (n = 20)

Intentional rounding is/should be applied to all patients

Opinion was split on whether or not IR should be applied to all patients. Even interviewees who said that they thought that it should be applied to everyone gave examples of it being more beneficial for certain patients or in certain settings. The key arguments in favour of applying IR to all patients in a ‘standardised and formalised’ way, is that no one and nothing ‘gets missed’.

Intentional rounding benefits some patients more than others

Participants highlighted those patients who they felt were most in need of IR, which included those who were not independent or were at risk of pressure damage, falls or malnutrition; elderly patients, especially those with dementia; patients who wandered or were in need of enhanced care; patients who needed turning; stroke patients; and those with difficulties communicating verbally. It was felt that IR checks could be done less frequently for those patients who were relatively well or those who were waiting to go home. Participants who suggested changing the frequency of IR said that it should be done through individual risk assessments, as a patient’s condition could change unexpectedly. They felt that using IR flexibly allowed nurses to use their clinical judgement to determine the frequency of IR needed for each patient. If IR was used for all patients, regardless of risk, interviewees argued that it may be viewed as time-consuming, frustrating and monotonous, rather than useful for patient safety.

Intentional rounding as a memory aid/checklist

On the whole, having a checklist to act as a ‘visual reminder’ was seen as beneficial for everyone, especially when working in environments where there was likely to be constant distractions. Interviewees felt that IR checks were helpful as a memory aid to avoid things being missed and/or overlooked, although not everyone agreed that this was necessary:

. . . I think everybody probably needs documentation and structure to the thinking, to think ‘OK continence, pain, food and fluid’.

I don’t think a lot of these things would be addressed without this document, because it’s just, it’s a visual reminder, isn’t it, to address.

Rigid, scripted versus conversational style of intentional rounding

Opinion was divided on whether IR should be done in a rigid or flexible way (i.e. in terms of the specific questions asked, how frequently, and if and how it should be adapted). For example, as people became used to doing IR, they developed their own style and form of wording, rather than using a formal script:

. . . but I literally used to do everything by the book and said every single question and made sure I said ‘is there anything else that I can do?, even though most of the time people said, ‘no, no, I’m fine’.

Others recognised that not all IR questions would be relevant to all patients and there was a need to use a conversational style and open questions when doing IR to encourage a dialogue:

That’s a difficult one because there’s a part of you that thinks it should be done rigidly, because it’s our job to make sure that we cover all bases, but then at the same time it’s that, that relationship between nurse and patient that you don’t want it to seem like the patient can’t tell you their concern and their worries.

Mechanism: accountability (n = 19)

Although it was understood that the responsibility and accountability for IR lay with the RNs, it was not always obvious how this worked in practice. Some interviewees noticed that IR was often completed by HCAs and checked by RNs and ward managers. In one site, the IR form was changed so RNs were required to sign it every 4 hours to say that they had checked their patients themselves and to check that the day’s intentional rounds were up to date. All student nurses interviewed said that they had completed IR checks and documentation ‘to help out’.

Importance of intentional rounding documentation

Evidence of care

There was a consensus among the ‘other health-care’ professionals that IR documentation was valued because it provided evidence of nursing care having been delivered, should that be required at a later date for responding to patient complaints and coroners’ inquests:

. . . some patients you think ‘oh they’ll be fine’, but once they go home they might complain and that’s when you want to look at IRs as well.

The majority of interviewees mentioned that nursing staff needed to provide evidence that care had been delivered in order to protect themselves in case ‘something terrible happens’:

. . . obviously to cover your back I suppose, and to make sure that you’ve got proof that they’ve been rolled if they develop a further pressure sore, or if they get moisture damage because they’ve been left incontinent, so that you’ve got documentation to show, I guess.

Record keeping of ongoing monitoring and food/fluid intake

Where IR documentation was enhanced with site-specific adaptations, this was regarded as helpful of keeping track of care provided (e.g. last skin check, positioning changes, food and fluid balance).

Accuracy and completeness of documentation

Retrospective completion

A few interviewees who completed IR themselves and/or checked IR documentation reported that they had noticed gaps and realised that nurses completed it retrospectively, particularly when the ward was short-staffed:

. . . I certainly can say that I’ve filled a form in and I’ve not completed it when the times have been there. But we have just been so short-staffed . . . when the ward’s up to staff, it’s not a problem, they do get it done.

A student nurse explained that they would not sign IR documentation if they had not done the round, but would put a line through the box to show that they had not done it. One consultant said that they had confidence in the accuracy and completeness of the IR documentation on the case study ward:

. . . I know on [the ward] it’s very well filled in and it’s complete. I’ve worked on a couple of other wards in the trust and it’s not always so complete, so I wouldn’t be asking on (the ward) about the quality of information because I’d know it would be correct.

Issues relating to a ‘tick-box’ approach/mentality

Some interviewees spoke of the dangers of IR becoming a tick-box exercise and the balance between making it feasible to do, yet sufficiently detailed to be meaningful:

. . . it is a bit of a tick-box exercise and, but, in a way, that’s the same with most documentation is you can only go on what’s been documented; I mean, technically people can write whatever they want so . . . [laughter] . . . there has to be an element of trust that what’s being written down is what’s actually being done.

Tick-box completion – can be misleading if don’t know story behind the ticks.

One medical consultant spoke about the dangers of not detecting changes over a longer time period because the focus was on task completion.

Mechanism: allocated time (n = 16)

A total of 16 ‘other health-care staff’ referred to this mechanism; none thought that IR provided allocated time to care and two interviewees thought that IR would involve extra work or was ‘sometimes a hindrance’:

. . . obviously it will take them, it must take time to do the IR and make sure it’s regularly up to date . . . the actual process and documentation of itself, it might be adding to the workload if the ward’s understaffed.

Mechanism: staff communication/teamworking (n = 15)

Knowledge and understanding about the purpose of intentional rounding

All other health-care staff interviewees were able to give some explanation of what IR was, although a few interviewees admitted that they had been prompted to ask their nursing colleagues what it was having seen our research posters. Eleven interviewees were able to speak knowledgably because of their direct experience of doing IR (as a student nurse, or through previously working as a HCA). The types of IR descriptions and explanation they gave were as follows:

It’s to make sure that the patient’s OK, the call bell’s in reach if they need anything, any pain management because some people might not ask for it, positional changes, pressure relief, that’s a big one as well, people might not be able to move, it just prompts to keep on top of changes.

Well, it’s mainly falls and pressure areas and if you see anybody walking about in the bay, you know, should they be up? So it gives me the idea of looking on there, should they be walking about?

Others learned about it through their own observations and reflections of nursing care:

I think it’s just where the nursing staff just do regular checks to check their patients are all right, so literally just popping their heads into the room and asking them if they’re OK and if they need anything, and then continuing on to the next person.

Views on uses of intentional rounding

Intentional rounding documentation directly used by non-nursing staff

It was rare for other health-care staff to directly refer to IR documentation. In one case study site, several interviewees said that they had referred to IR documentation, but they were referring to ‘enhanced, site-specific IR add-ons’. Other health-care staff recognised that they asked patients the same IR questions, but said that they preferred to do this rather than look at IR documentation. Alternatively, they said that they would speak directly to a nurse on duty to get the information they required:

No. If we needed more information, we tend to just ask the nurses or ask the patient, quite often, or ask them if they’ve been up to the toilet and in any pain and things like that, rather than looking at the sheet.

Improved quality and frequency of nurse–patient relationships

A consultant felt that IR allowed patients to say if they needed anything when asked directly and two student nurses felt that IR helped them build rapport with their patients through regular, one-to-one interaction, but they also recognised that using IR to build rapport was unusual:

I’m quite happy with doing it and it allows me to actually build rapport with the patient, whilst I’m speaking to them, I can do the documentation; but, in practical terms, once you’re a nurse and you’re looking after patients all on your own, then it happens to be the case that it’s not such a rapport-building activity, because I don’t see any nurses interacting and filling them out really, I don’t see that happening.

Perceived benefits of intentional rounding for carers

Participants perceived the main advantage for carers to be that when IR documentation was visible (e.g. placed outside a patient’s room or at the end of the bed) it had the potential to reassure them that patients were being seen and regularly monitored. However, these benefits were dependent on how IR was done and, particularly, how visible the IR checks and interaction were to others:

I’ve seen nurses and HCAs filling them out . . . I’ve seen occasionally where they’ll ask questions, but most of the time when I see it they’re just looking at the patient in their bed space.

. . . it tends to be quite yes and no rather than an open, more open conversation.

Unfortunately, taking this approach created problems because when it was not obvious that IR checks had been done while carers were visiting, and/or the IR documentation was not up to date, this led to worries and complaints to other health-care staff, for instance:

. . . yesterday a patient’s friend looked at the chart and was quite worried because, according to the chart, the patient hadn’t had anything to eat or drink for quite a few hours, so then that made the relative worried . . . they mentioned it to the staff on the ward and they mentioned it to me and I think they were told by the staff that the chart may have been incomplete, so they, the patient probably did have something to eat or drink but it was just, it looked like it may not have been filled on the chart.

Mechanism: anticipation (n = 4)

A few interviewees were familiar with the theory that IR led to a more efficient use of nursing resources by pre-empting problems, (e.g. preventing incontinence or dehydration). Some interviewees also thought that IR might lead to nurses referring high-risk patients on for further interventions:

. . . nurse can get dietitian involved if they see patient not eating or drinking enough.

Mechanism: patient empowerment (n = 4)

There was virtually no support that this mechanism played a role in IR, although two interviewees said that they had been asked by patients about IR or had seen patients completing a food–fluid chart (an IR add-on at one site).

General contexts and outcomes

General contexts

Other health-care staff spoke about the general contexts that they felt influenced IR. Most usually, they mentioned the success of IR being influenced by wider infrastructure of organisation, for example being short staffed, winter pressures, patients who require closer attention:

. . . at the moment we’re short [staffed] again because they’ve potentially tried to deprive us of nurses, but because we’ve had to work more beds due to winter pressures, the nurses have been pushed across the organisation and the numbers are swollen. So I expect they’re struggling at the moment doing IR.

There was a lack of awareness in multidisciplinary teams of IR generally, and, for those who had experience of doing IR, a lack of guidance, leading to confusion on how it should be done:

I think it would be really useful to understand how nurses are meant to be doing their rounds . . . sometimes we don’t know how other professions operate and it’s really important.

General outcomes

Given this lack of general awareness of IR, other health-care staff guessed what the intended outcomes of IR might be. These included improvements in patient safety and care (i.e. reductions in dehydration, falls, toileting accidents, incontinence, and monitoring pain, skin integrity, mood and well-being) and a better patient experience because it shows patients that you’re really thinking about them. They thought that IR would be good for less cognitively able patients who would not necessarily press the call bell and actively seek help.

One doctor reflected that:

I don’t know. I would say that, over the course of the last 10 years or so, I think the nurses have got better in this particular environment, in this particular ward at things like the MDT [multidisciplinary team]. So, for example, when I ask ‘is she eating?’, ‘is she confused?’, ‘is she continent?’, I do get better answers these days. I’m not sure that’s down to, necessarily, IR; I couldn’t say.

Summary

• The understanding of IR in this sample of interviewees was mixed, because although some had had direct experience of doing IR, others had learned about it only through their own observations of nursing care.
• It was rare for other health-care staff to directly refer to IR documentation. Although some health-care staff realised that they ask patients similar questions, it was more usual for other health-care staff to find a nurse on duty to speak to.
• Other health-care staff recognised the dilemma between having a structure that was used in a standardised and formal way for everyone verses the need for flexibility to adapt to suit patient need.
• Other health-care professionals saw the value of having documented evidence of nursing care having been delivered.

Observations of intentional rounding (nurse shadowing and non-participant observation of direct patient care)

This section addresses objectives 2 and 6, utilising non-participant observation to highlight how IR had been implemented on the ground, exploring its contribution to the delivery of patient care as a whole and how it fitted alongside other approaches to improving quality and safety.

Method

Two approaches to non-participant observation were conducted:

1. ’Shadowing’ nursing staff to explore how they interacted with patients and each other in relation to IR, and how IR contributed to the way they worked. Nursing staff were purposively sampled to attain a range of grades and levels of experience. All participants provided informed consent and researchers took narrative field notes of what they observed. These narrative field notes of nursing staff observations were then used to complete two protocols, one to record individual IR interactions and the other to assess fidelity to the original IR intervention, as set out by the Studer Group.
2. ‘Shadowing’ patients to observe individual interactions between patients and nurses. To facilitate this, the researchers undertook a Quality Patient Care Scale (Qualpacs) for five patients in each ward. Qualpacs65 is an established instrument for assessing the quality of care a patient receives from a nurse, using 68 items across the following areas of care: physical, general, psychosocial, communication and professional implications. The instrument is patient focused, with observations based on who attends a patient’s bedside to provide care and how frequently.66 The observer(s) watched the care received by selected patients over a 2–4 hour period and rated each aspect of this care on a scale of 1 (poorest care) to 5 (best care).66,67 To complete the Qualpacs observations, researchers (who were both RNs) had access to patients’ nursing care plans and notes to assess how the care delivered addressed a patient’s individual plan for nursing care. In sites 1 and 2, two observers scored independently and met to discuss and agree scores. In site 3, owing to staff changes, one observer conducted the Qualpacs observations.

Researchers planned to observe up to 100 individual IR interactions between the patient and nurse and interactions between nurses on each ward using these various methods. In all observations, the researcher recorded how often interactions occurred, what patients were asked during their interactions, what care was provided and, when possible, the duration of each individual interaction. External factors that affected the delivery of IR were also recorded to help establish how the intervention fitted within the whole nurse experience of the delivery of care and the whole patient experience of receiving care. Researchers made as few interruptions as possible when shadowing nursing staff and refrained from asking questions. The observation data entered into the ‘fidelity to original intervention’ protocol were analysed using descriptive statistics. The data entered into the ‘individual IR interactions’ protocol and the Qualpacs descriptions of interactions were thematically analysed using the coding framework developed to analyse the individual staff interview data, which covered the contexts, mechanisms and associated outcomes of IR and how these were linked.

Participant characteristics

A total of 188 hours of care delivery was observed by four research staff. Observations were undertaken throughout the day and evening shifts (ranging between 07.00 and 01.15) on both weekdays and weekends. Thirty-nine nursing staff were ‘shadowed’ during this time, with researchers following them for several hours at a time and recording how they interacted with patients and each other in relation to IR. Table 16 highlights the participant characteristics of those staff who were shadowed, in terms of their profession/role.

For the Qualpacs observations, researchers observed direct patient care from the perspective of 28 patients. They did this by sitting unobtrusively near each patient’s bedside and recording the time and the nature of the interactions they had with nursing staff (interactions with non-nursing were noted but not scored in the Qualpacs analysis) over 2–4 hours. A Qualpacs (see Report Supplementary Material 2) was completed for each patient to assess the quality of care they received; average care is assessed as the quality of care expected to be delivered by a newly registered nurse, and given a score of 3.

Findings

Mechanism: allocated time

Range of tasks

Staff were very busy and were seen to carry out a wide range of tasks including technical clinical care (e.g. medication administration, i.v. medication, dressings, cannula insertion), assessments (e.g. manual handling, nutrition, pressure areas), personal care (e.g. helping patients to wash/shower, clean teeth, go to the toilet; feeding patients) and administration (e.g. ward rounds, taking telephone calls, updating senior staff on bed availability/transfers, handovers). Some tasks were scheduled at routine times (e.g. drug rounds, washing patients) whereas others were performed as needed.

Staff were undertaking many tasks in addition to intentional rounding

Intentional rounding was sometimes a stand-alone activity, but staff often multitasked and combined IR with other activities:

• RNs sometimes completed IR as they did drug rounds, focusing on aspects that may require adjustments to medication, such as pain or whether or not patients had opened their bowels.
• Inspecting pressure areas when helping patients wash or moving and turning them.
• Checking pain level and food and fluid intake when doing observations (e.g. blood pressure, measuring blood sugar).
• Distributing meals and taking note (mentally and written) of what patients were given.
• Removing cannulas, and recording this on the medical devices adaption on the IR form.
• Making and answering telephone calls.
• Responding to patient and carer queries.

Staff were frequently interrupted by patients, carers and other health-care staff, and sometimes nurses interrupted themselves (e.g. to check a call bell, answer the telephone or to find someone to help them with a patient). Particularly in site 1, where IR was hourly, staff were observed retrospectively documenting rounds or catching up. This suggests that nurses did not have sufficient time to do IR as they were having to prioritise other activities. In addition, some patients needed additional care beyond the expected allocation of time. Sometimes staff spent a lot of time with certain patients to meet their needs for clinical care and/or reassurance.

Mechanism: visibility

Intentional rounding was not observed to make a difference on the extent to which nurses were seen as having a presence or being visible to patients and ward layout had a bigger influence. In wards with bays or a Nightingale layout, patients were seen to speak to nurses/ask for things because they could see them. Nurses were also seen to act responsively and intervene/help patients because they could see help was needed. In wards with a large number of single rooms, nurses were less visible to patients and other staff. IR was not observed to increase the frequency of direct interaction between patients and nurses as nurses were with patients or were visible to them for a variety of purposes far more often than the IR was completed.

Mechanism: consistency and comprehensiveness

Considerable variation in the practice of IR, in relation to its consistency, comprehensiveness and the documentation of rounds, was observed. However, it remains challenging to distinguish between the types of variation and the reasons for differences in practice, and, in particular, whether variations were attributable to deliberate patient-centred flexibility or to different interpretations of what was expected. It is also apparent that some variations seemed to be influenced by different degrees of staff buy-in or to contextual factors such as staff shortage or lack of time. Relevant observations are grouped under a series of headings, as follows.

Intentional rounding embedded into routine practice

In some cases, there was little or no evidence of a standardised or scripted round, as nurses engaged informally with patients as they assisted with tasks such as repositioning without any evidence of a linear or structured way of asking questions of the patient. The nurse would then complete the IR form while engaging with the patient. Staff were sometimes observed delivering comprehensive care to patients. For example, for one particular patient, care delivered, which included detailed assessments and completion of IR, took 45 minutes.

Intentional rounding as a system for ‘checking’ on patients

Staff were observed to check on patients during their rounds, asking them both general questions and more specific questions. Although this checking seemed mainly positive, there was one instance in which a HCA seemed so focused on checking specific aspects of the IR documentation that she did not react to other concerns raised by a patient. There was also evidence that staff used IR as a mental checklist for all the different tasks that they needed to undertake with every patient. Although this may ensure that nothing was missed, occasionally this checklist made some staff appear particularly task orientated in their approach.

Flexibility and variation in the style and content of rounds

Across all case study sites, staff demonstrated a flexible approach to how IR was delivered and a scripted approach to IR was never used. For more details of how staff used flexibility and variation in the style and content of their rounds, see Chapter 8, Fidelity to the original intervention.

Flexibility around frequency of rounds

At case study site 1, less flexibility was observed around how often IR was undertaken, as it was usually conducted hourly. In case study site 2, staff were instructed to undertake IR every time they went into a patient’s room rather than at specific timed intervals. This might explain why we observed differences in the regularity with which IR documentation was completed for different patients at case study site 2 and why there was some confusion in case study site 2 as to how often IR was supposed to be conducted. Some staff recorded the actual time of rounds whereas others recorded the time the round was supposed to take place, notwithstanding that every patient could not be seen at the same time. Some staff at this site also appeared to worry that they were not undertaking IR as often as they should.

Consistency/inconsistency of documentation

The IR documentation was comprehensive with all the elements of IR (as described by the Studer Group) included in the form. All documentation had site-specific IR additions; thus, they were more comprehensive than IR. However, this structured, comprehensive approach was not observed to be consistently delivered.

Different pattern of rounding at night

Regular checks continued during night shifts. On the whole, IR documentation was observed to be completed sensitively and proportionately during the night. No patients were observed to be woken up to do IR, although staff regularly walked around the ward areas observing patients. In the Nightingale ward in site 3, one HCA sat at the far end of the ward to keep an eye on patients. An assistant practitioner said that IR was difficult at night as they needed to watch patients who were at a high risk of falls so they do a very quick walk around the ward to check everyone else and may not be able to document IR at the time.

Temporary staff

Few temporary staff were seen working on the ward areas, and permanent staff sometimes covered unfilled shifts. One bank nurse was seen completing IR without talking to the patient, so there was no indication that IR was helping her provide care on this occasion. However, it was not clear whether or not she knew the IR policy.

Mechanism: staff communication/teamworking

Good teamworking as important for successful intentional rounding

There was some evidence of teamworking among staff when delivering IR. For example, at case study site 2, staff were allocated a certain number of patient rooms each day and focused their time on the patients in these rooms. However, when other staff were busy, a HCA was observed to attend a patient to whom she was not allocated, assisting him to use the bedpan and then completing his IR documentation. There was also evidence of teamwork when staff shared out the different components of IR between themselves. However, occasionally this made IR difficult to observe (and perhaps more complex to undertake), as it was sometimes difficult to distinguish who was completing what parts of the documentation, for whom and why. This also sometimes led to errors being made, such as IR documentation not being completed for some patients, or a duplication of effort by nursing staff.

Lack of evidence of beneficial impact on team communication/teamwork

In other instances, IR was not observed to be particularly beneficial for team communication/teamworking. Nursing staff working together were seen catching up/updating each other at regular intervals during shifts but IR was rarely seen to be mentioned. This tended to be focused on progress with patient care tasks rather than IR, although updating each other on a patient’s condition was sometimes observed. All sites had a form of bedside handover, but IR was rarely discussed at this handover between shifts. When IR was discussed in relation to managing work, it often appeared to be seen as a task (e.g. how to allocate rounds between staff). In one instance, a staff nurse and HCA were talking about what they needed to do next and the HCA stated that he had ‘done all the ticks’.

Sharing aspects of intentional rounding

Some aspects of the IR form were completed by different members of staff (e.g. the RN would ask about pain during the drug round, and the HCA would complete the pressure area parts of the form after helping a patient wash and complete the food and fluid parts of the form after meals). How this was agreed was not observed, although there was some indication that this evolved over a period of working together. In most wards, unqualified staff were observed to complete a large proportion of the IR forms. On one ward, which was more acute and had a higher skill mix, IR was seen as predominantly a RN task. On this ward, one HCA told the observer that she would fill in the IR chart/skin bundle chart if she had time and knew the patient.

Lack of evidence of intentional rounding as a supervisory or management tool

There was little evidence of IR and its documentation being used as a supervisory/management tool for RNs to check on the work that unqualified staff had done, although during informal conversations with staff, some RNs said that they did use it in this way.

Intentional rounding and other members of the health-care team

Intentional rounding documentation was occasionally observed to be looked at by other members of the multidisciplinary team (e.g. consultants). However, on one occasion, it was the additional food and fluid part of the form that was referred to and not the IR intervention as defined by the Studer Group. IR was never observed to be completed by anyone other than the nursing team.

Mechanism: nurse–patient communication and relationships

Nurse–patient communication during rounds

Nursing staff and patients were observed to talk to each other often. The majority of interactions were not observed to be part of an intentional round, although it is possible that any information discussed/observed by nurses may contribute in some way to completing IR documentation. Some interactions, although not all, were very short, sometimes just passing comments as nurses were working in the bays. Patients were often seen to start conversations/make requests when nurses were in the vicinity, but opportunities for ad hoc conversation were fewer for patients in single rooms. Longer conversations between nurses and patients were infrequent, but were observed (not as part of IR). However, communication was also observed during IRs. Regardless of ward layout, nursing staff in all settings were seen to communicate with patients during IR.

Sometimes the focus was on the content of the round and communication was very short, with nurses asking if the patient was OK or had any pain. Longer conversations tended to occur when patients were having a wash or other procedure (e.g. dressings, putting up i.v. lines, feeding). During these times, some staff were observed having general social conversations or chats with patients about their carers, pets or plans for the weekend; during other times, staff were observed to be less chatty or focused on patients’ health needs/conditions. In some instances, no specific IR questions were asked and the interaction was more akin to a general conversation, but pertinent aspects of IR were assessed. Nursing care frequently focused on addressing physical needs (e.g. helping patients to wash or to go to the toilet, giving medications, feeding and undertaking observations). Nursing staff were rarely seen to address psychological care needs (e.g. talk about patients’ concerns and anxieties, providing information about treatment plans and conduct detailed assessment of a patient’s nursing needs). On one occasion, a patient was observed to be very distressed about a cancelled operation. During an interaction with a student nurse, the opportunity to talk to the patient about this was missed and the completion of IR, which apparently took precedence, seemed unhelpful at this time.

Doing intentional rounding without including patients

On a number of occasions, nursing staff were observed to complete the IR documentation when patients were asleep or when patients were not at their bedside:

Interaction 1: [Nurse] does not disturb the sleeping patient, but picks up their IR form and fills it in. Interaction 2: [Nurse] goes to the next patient, who is also asleep and fills in their IR form. Interaction 3: This bed is empty and the patient is not in the room. [Nurse] picks the IR form up and completes it.

Some staff were even observed to complete the IR documentation without communicating with patients who were awake and next to them. Furthermore, on one occasion, a HCA was observed to complete IR documentation after asking another member of staff the question, rather than the patient themselves:

[HCA] is outside bed [X] and next to the domestic. She asks the domestic ‘did she drink her cup of tea?’ and the domestic says yes. [HCA] completes the fluid balance for this patient.

Not all patients want to communicate with staff during rounds

Some patients did not appear to want to communicate with nursing staff as they undertook their rounds, perhaps because they were making a telephone call or watching television. Occasionally, patients were unpleasant to nursing staff, making communication difficult. One patient was observed to be sexually inappropriate in their conversation, to which the nurse skilfully and kindly redirected the conversation. In a ward caring for older people, some of the more confused patients were also aggressive when nurses were delivering fundamental care.

Nurse–carer communication

Staff were less frequently observed to interact with carers during IR, mainly because carers were often not present. However, when they were present, carers were observed asking staff questions and staff tried to answer any queries they had. On one ward with a large number of single rooms, the ward manager stated that staff were sometimes reluctant to go into patient rooms when carers were there and that she had had to tell them that they must.

Mechanism: anticipation

Evidence of anticipating patient needs

There was some evidence that nursing staff were anticipating patient needs, but it was difficult to say if this was due to IR. There were occasions when patients were observed to press their call bell shortly after an intentional round had been conducted (e.g. to go to the toilet). However, in one instance when this was observed it is not known if IR would have anticipated this need as the HCA did not ask the patient if he needed to go to the toilet. There was some evidence that nursing staff were anticipating patients’ needs for water, as some would top up patients’ glasses without being asked. On one occasion, a RN was observed to anticipate a patient’s future need for pain relief, although this was likely to be because she was doing the drug round, rather than IR. Call bells were often observed to be placed where patients could reach them, especially at site 2, which had a high proportion of single rooms. One member of staff was concerned that a patient did not know how to use the call bell, despite it being explained.

On site 2, there were no apparent guidelines about how often IR should be done. Staff were told to complete IR every time they went into a patient’s room/bed area, so this did not change practice and staff saw patients when they had something else to do for them. Staff were sometimes heard telling patients that they would see them later, but a time for this was never specified, which limited the anticipation mechanism. Nurses often told patients to let them know or to press the buzzer if they needed anything. Observations demonstrated little other evidence of the anticipation mechanism in action. As previously stated, staff never told patients a specific time that they would return. Instead, staff were regularly observed to tell their patients to call them or to use the call bell if they needed anything. In one example, when there had been no use of call bells on a particular morning, the HCA and nurse agreed that this was because there was always a clinical staff member in the bay.

Mechanism: accountability

Accuracy of documentation

The potential for IR to contribute for accountability in relation to care was observed to be somewhat constrained by the ways in which IR was documented. The completion of IR documentation was observed, but it was rare that all the components of IR were done, although most of the time they were documented as being done. Sometimes staff would put a dash for an item that was not asked/assessed at the time of documentation. Sometimes staff completed the documentation without asking any of the questions. Sometimes documentation was incomplete or filled in for only some of the times for which rounding was supposed to have taken place.

Completion of aspects of intentional rounding, but without documentation

On occasion, staff delivered what looked like components of IR but did not complete the IR documentation. This was more common in case study site 3, where clear examples of IR were very difficult to observe. Staff were often seen to incorporate aspects of IR into their general interactions with patients (e.g. ensuring that patients were comfortable, asking them about their eating and drinking, ensuring that they could reach everything they needed), but not documenting this as IR, so care was sometimes delivered to patients and nursing staff talked to patients and checked if they needed anything, but IR was not documented.

Sometimes nurses attended to patients’ needs, such as providing water, or moving possessions within reach, but this was not recorded. It is not clear in such instances if the interaction was seen as part of an intentional round or, possibly, seen as part of some other interaction such as a medicine round, or simply as an unstructured interaction with patients to meet their needs as they arose. Staff were aware of the issue of not completing documentation. During an observation session, the observer asked the RN about the issue with documentation and was told that time was a big issue; staff do not have the time to document rounds and there are constant interruptions and other demands. The staff member realised that this was not ideal but ‘patients come first’.

There were a number of instances observed when IR documentation was complete and up-to-date. However, some errors in the IR documentation were identified, for example in relation to the risk of falls.

Retrospective and prospective completion of intentional rounding documentation

On one ward in site 3, a RN told the observer that she rarely had time to complete IR during the shift so she usually completed it retrospectively at the end of the shift. Staff were observed both retrospectively and prospectively completing IR documentation. Examples included:

The HCA asked the patient about their food: ‘I weren’t on this morning and no one’s filled it in’ (the IR chart) she says to the patient. She asked for details about what the patient ate for breakfast and lunch and fills in the chart.

[Nurse] moved on to the next patient’s room and picked up the notes from outside the room. She flicked through and started filling in the IR form outside the room. She told the observer she likes to look at and complete the IR form just before she goes in; otherwise, she says ‘you get a barrage of questions’ and it disturbs her completion of it.

At case study site 2, where IR documentation tended to be kept outside the patients’ private room, some staff were observed to complete the IR documentation just before they entered the room to undertake the round. Frequently, nursing staff were observed to complete several time slots in one go. This occurred more often with hourly IR and where times were specified on the form (i.e. 08.00, 09.00, 10.00, 11.00) rather than have a space to write the actual time.

Completing intentional rounding documentation without asking the questions

Staff were additionally observed to complete sections of the IR documentation without asking the questions, or asking a general ‘everything alright?’ and then completing all of the boxes from there. For example, an observer noted that all of their boxes had been completed on the front page of the IR chart, even though the patient was asked only about her food and drink. In another instance, the HCA asked the patient if everything was all right and then completed the form to indicate ‘8am. Drink ‘Y’, Toilet ‘N’, Pain ‘Y’, Anything else ‘N’.

In other instances, staff were observed to complete charts at the end of their shift, sometimes ticking to indicate that checks had been done, but sometimes marking ‘not seen’ if that was the case. One observer, in conversation with a staff nurse in a site where patients were looked after in side rooms, noted that the nurse explained that when she began her shift she would complete the IR forms for the eight patients she was looking after first but would insert ‘N’ or ‘/’ if it had not been checked (e.g. something like a pressure sore, which will probably be checked by HCAs during the washes and can be completed then). The reason for doing all the IR forms immediately was because it looked ‘nicer’ having the chart filled in first thing in the morning and she did not want it to appear that a patient has been neglected if left until 9/10 a.m. when the medication round was completed and washes began.

Complaints handling and evidence of care

On one occasion, the influence of IR in handling a complaint was observed. A matron came in and started to ask a nurse about a patient complaint. The family had complained that care had not been delivered and the matron had looked at the IR chart and found it to be empty. The nurse was visibly concerned and could not remember the patient. She told the observer it may have been the day when the ward was very short staffed and she had 16 patients to look after. On another occasion, the observer spoke to a band 6 RN about the use of IR as evidence and the nurse said that IR was important as evidence to demonstrate care had been delivered. She placed this in the context of carers complaining a lot and making assumptions that people were not doing their job properly, not just nurses but doctors as well. IR enabled staff to demonstrate that they have done their jobs.

Lack of auditing of intentional rounding documentation

No evidence of auditing IR was seen by the observers.

Mechanism: patient empowerment

Observers noted that patient empowerment would be difficult to observe. Although patients and carers were observed asking questions or asking for specific things (e.g. drinks, or to go to the toilet) there was little evidence of patients asking for more than the usual care that nurses were providing anyway. Overall, there was little evidence of patients being empowered by IR, although on one occasion, a nurse was asking a patient about their pain during IR and this seemed to assist the patient in asking about his other needs. Both patients and their carers were observed to ask nursing staff questions and queries throughout the day, calling them over as and when required, rather than waiting until rounds took place.

Non-participant observation of direct patient care and staff interactions with patients (Qualpacs)

Although researchers had previous experience of using Qualpacs, they found it to be a challenging tool to use in this study. Qualpacs relied on assessing whether or not the care observed addressed the patients’ needs as planned in their nursing care plans (the research team did not have access to the medical notes). However, the nursing documentation for all the observed patients was standardised nursing care plans, none of which had been personalised for the patient and no additional care plans had been written. So researchers were unclear of what nursing care should be delivered to each patient and whether or not the care observed met a patient’s individualised needs. Researchers made assessments on the appropriateness of care, which may not be accurate; this is a limitation of the study. As a result, there were concerns about the validity of the Qualpacs scores as a measure of the quality of nursing care. Therefore, these scores have not been reported. However, as part of the Qualpacs methodology, the start time of each interaction between patients and health-care staff and a description of each interaction was recorded (Table 17).

Researchers recorded the time intervals between every interaction (Table 18). Patients were seen frequently by staff: between every 12.5 and 16.8 minutes by any member of hospital staff, between every 16.5 and 22.9 minutes by any member of nursing staff and between every 28.0 and 49.8 minutes by a RN.

Summary

• Staff were observed to be very busy and to carry out a wide range of tasks. IR was usually combined with other activities and staff were frequently interrupted when undertaking IR, which meant that they were observed to document IR retrospectively. On occasion, staff delivered what looked like IR but did not complete IR documentation.
• Considerable variation in the practice of IR in relation to its consistency and comprehensiveness was observed. Across all sites, staff demonstrated a flexible approach to how IR was delivered and a scripted approach to IR was never used.
• Intentional rounding was never observed to be completed by anyone other than nursing staff (RNs and HCAs); non-nursing staff rarely looked at it.
• Nursing staff and patients were observed to talk to each other often, although the majority of interactions were not observed to be part of an intentional round.
• There was some evidence that nursing staff were anticipating patient needs, but it was difficult to say if this was due to IR.
• Intentional rounding was not observed to make any difference to nurse visibility or patient empowerment.
• On average, patients have a direct interaction with a member of hospital staff (e.g. a member of medical staff, nursing staff, AHP staff, housekeeping staff, phlebotomist) every 12.62 to 15.94 minutes.
• On average, patients have a direct interaction with a member of nursing staff (e.g. RN, HCA, student nurse) every 17.52 to 21.8 minutes, which is considerably more frequent than the recommended frequency of IR.
• On average, patients have a direct interaction with a member of registered nursing staff (e.g. staff nurse, ward manager, clinical nurse specialist) every 36.29 to 38.92 minutes, which is considerably more frequent than the recommended frequency of IR.
• Although there is similarity between the time intervals of direct interactions with all staff and all nursing staff between acute wards and care of older people wards, there is a marked difference in the time intervals of interactions with RNs. Patients in acute wards have a direct interaction with a RN, on average, every 29.03 to 30 minutes, whereas the average is every 43.30 to 49.81 minutes for patients on care of older people wards. The reasons for this are unclear; there are no obvious trends in nursing establishment and skill-mix data, as presented in Appendix 5.