'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