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OPINION

'Careful consultation with nurses is vital when introducing rounds'

Intentional rounding can reduce the demands made on nurses, says Beverley Fitzsimons

The recent call from the Royal College of Nursing and the Royal College of Physicians that nurses should be present on every hospital ward round has raised as many questions as answers.

Few would disagree that multidisciplinary ward rounds are the cornerstone of good care, facilitating interprofessional communication, building trust with patients and families, and aiding coordinated planning for the patient. Are ward rounds really being “neglected”, as the RCN and RCP report?

The comments on nursingtimes.net (tinyurl.com/8pmod6j) are pretty unambiguous. The intensity of work and time pressures on nurses leave insufficient time to carry out multidisciplinary ward rounds systematically and well. The way work is organised is not centred on the needs of patients. Having many doctors coming and going on the wards at different times to see different patients makes organising a ward round even more challenging.

We know that patients have more acute needs now than before and they are more likely to be moved around the hospital (especially older people). We know nurses and healthcare assistants, especially on wards caring predominantly for older people, are stretched, and levels of staffing and ratios of qualified to unqualified staff are highly variable. In some places, it might seem impossible for a senior nurse to find sufficient time to do a ward round.

“Changing ward routines to make care more systematic can reduce the pressures on nurses”

Some commentators have said that, with seemingly ever-increasing demands on nurses, the response tends to be to work harder or work around problems, rather than change how care is organised.

Sometimes, changing ward routines to make care more systematic can reduce the pressures on nurses. The RCP has suggested that one doctor is assigned to each patient, and this doctor coordinates specialist input for their patients.

Another example is our work with teams that have introduced intentional rounding (also sometimes called “care rounds” or “comfort rounds”) on acute wards. This practice is separate from but complementary to the multidisciplinary ward round. Intentional rounds ensure that patients’ essential care needs (positioning, pain, nutrition, hydration, and personal needs - including time to build relationships with nurses) are addressed in a planned, systematic way. Their introduction has raised similar concerns that this is additional work that nurses simply cannot cope with.

Where intentional rounding has been implemented well, nurses have reported fewer ad hoc demands on their time, for example answering call bells, as patients are confident they will be attended to regularly. Nurses have reported feeling more confident about the reliability of care. Studies in the US have shown improvements in patient safety, with fewer falls.

Giving high-quality care and positive patient experiences depend on reliable care processes and well-supported, satisfied staff. Careful consultation with nurses has been key to the successful implementation of intentional rounding: really listening to their concerns and attempting to address them, adjusting new ways of working to fit local circumstances, and monitoring the impact of new initiatives on workloads. Considering the impact on staff yields dividends, and is a principle that should also be applied to changes in arrangements for multidisciplinary ward rounds.

Of course, reorganisation of work cannot solve the problem of too few nurses and healthcare assistants. But, with sufficient staff, it can help deliver positive patient and staff experiences, by contributing to more reliable systems of care on the ward.

Beverley Fitzsimons is the programme manager for the Point of Care Programme at the King’s Fund

Readers' comments (6)

  • Key phrase at the end 'reorganisation of work cannot solve the problem of too few nurses'. I wonder whether the results showing the improvements of intentional rounding have been read with a bias and are more to do with there being enough staff.

    What does one do, plan the care around your patients for the day, or do intentional rounding, what happens when you start in bay 1 but the bell is ringing in bay 2? Then you are out of sync.

    High quality patient care requires dedicated hard working nurses, who are sufficient in number, that with great effort as always, they can exercise their knowledge and skills as autonomous practitioners.

    I understand David Cameron, our great leader is a fan of intentional rounding, that tells me all I need to know.

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  • " Programme manager for the Point of Care Programme at the King’s Fund"
    I am impressed !

    Did this woman ever work on a ward never mind a busy ward ?

    Maybe Beverley Fitzsimons would carry more authority if she wrote about the work she has undertaken on a ward in the past month.

    Writing articles is a soft option if not underpinned by solid evidence of having undertaken. personally, the challenging task of managing the care of 25+ patients for 168 hours /week, 52 weeks of the year !

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  • I have been a nurse for over 30 years and during that time seen and experienced firsthand just how complex bedside care has become. Patients needs are much greater and nurses are placed under incredible strain trying to deliver the care they want for patients. It with this in mind that I have been working on implementing intentional rounding, primarily as a means of supporting ward nurses to ensure fundamental aspects of patients care are relaibly and consistently addressed for ALL patients. When wards are busy which they clearly are most of the time, often attention is placed on the sickest most needy patients and other patients can receive less consistent care. By regularly checking on patients on a regular basis you can see if they are deteriorating, check pain, encourage fluids and ensure their needs are met and provide a safer more positive experience of care. Hospitals that get implementation of rounding right like Salford see better outcomes, the data speaks for itself, less pressure ulcers , less falls, happier patients,hence the prime ministers genuine interest in spreading the process. We can be cynical but the startling stories and press reports that reflect poor example of beside care are also a reality and we need to do something about this now! On a more personal note my mum has been in hospital recently and thankfully the wards she has been on did do intentional rounding and she received relaibly the essential aspects of care she needed. I have to say if they had not got rounding in place I would have been extremely concerned for her safety given their heavy workload. Busy nurses cannot remember everything,they are only human. Creating a process that "assures" essential nursing care happens and does not just :"assume" it will happen, is vital in this environment otherwise care will be inconsistent and patients will be harmed. We need to pull together and focus our efforts on positively addressing the reality in practice and helping support nurses to do the right thing for patients.I think Bev's point is well made.

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  • Hi Jenny - thanks for your comment. One of the main points I was trying to put across was the importance of working with the staff on the ward to implement any new changes to ward routines - no two wards are alike, staffing levels and the intensity of work vary enormously. It is only by listening carefully to what staff have to say and responding to local circumstances that new initiatives can be introduced well.

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  • Thank you for responding.

    The point I was making is that people in "Senior Positions", those who, by the very nature of the posts they hold, have little or no practical knowledge of the situation most ward/dept nurses contend with every day.

    New "initiatives" are to be applauded, however, Senior Nurse Managers and Academics need to concentrate on basics!

    The basics are associated with providing for adequate nurse staffing levels linked to patient dependency. The down-skilling of the nursing workforce by skill mix dilution must stop and be reversed.

    Listen. listen carefully, nurses have been indicating what is needed to secure good care!

    Good care is, in the first instance, totally dependent on appropriate staffing not "initiatives"

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  • The problem with intentional rounding is the lack of applicability in too many settings. It supposes the problems but offers no solutions except the rounding itself. It creates a false paradigm that trusts can and have seized upon to pretend to show improvements whilst making no changes. Rounding and its theory do not make any mention of the time factors involved in performing the activity itself. It merely assumes a priori that minor issues like call bells and waiting are the issue and not the symptom itself. No mention is made on what the call bells were for thus the reader is given the false impression that bells are always rung for an issue to do with the provision of care. It places no burden on finite time. Yes i can ask twelve people pre-determined questions that are obvious but the time taken to do things that are necessary but not asked for occupies those same units of time. Rounding pre-supposes that i am free from anything that prevents me from doing anything else nor does it take into account that actually most of up rarely do one thing at a time. It attempts to induce a style of nursing that is not particularly suited to nursing and once again attempts to solve today's issues with yesterdays thinking by seeming to reduce the impact of my role to far less than it is. It also assumes that my patients are dupes, unable to express themselves and that i must tease their wants and needs out of them. The issues about patient satisfaction are obvious. Of course they are more satisfied, it looks like they are getting more than they really are however the question ought to be 'does this correlate to a better outcome?' I don't think the answer is yes compared to should i be able to decide as an autonomous professional to take my time on things that make a difference to a persons health, well-being and recovery? Rounding merely confuses caring and healing. We do both but one inherently suffers when the other is given greater priority

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