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Paul Snelling: 'Rounding is an evidence-free idea driven by political whim'


Maintaining the public gaze on superficial initiatives, such as rounding, diverts it from where proper scrutiny should be, says Paul Snelling

No nurse can deny these are difficult times for the profession, and that a robust response is required to restore public confidence.

The government’s response to the Francis report, announced last week, reiterated that all hospitals would be urged to introduce nurse rounding, the practice where all patients are checked hourly according to a standard protocol.

Impressive claims for the effectiveness of rounding have been made and it has been heavily promoted by the prime minister and the Nursing and Care Quality Forum. Robert Francis QC also stated that change would not be achieved by top-down pronouncements, and yet the “urging” of rounding appears to be an example of this. But it was also recommended that professional bodies (note: not the government) work on devising evidence-based standard procedures; perhaps the implementation of rounding can be justified here, supported by robust evidence?

The problem is there is very little evidence for intentional rounding. What evidence there is consists almost exclusively of poor-quality studies from the US, undertaken by hospitals and management consultancies with a financial interest in promoting it to reduce call bell use and increase patient satisfaction. Much healthcare in the US is based on profit and competition between providers that spend nearly three times per person as in the UK. Hospitals in the most influential US study on rounding had over eight hours per person of direct nursing care per day (I’ll leave you to do the sums for your ward). Surely, there must be some good-quality evidence that can be transferred to the UK? I have looked very hard and found none, and no systematic review is available.

“Rounding represents the politicised search for simple solutions to complex problems”

I do not want to be misunderstood. Like every nurse, I am in favour of any intervention that is shown to improve care, part of which is patient satisfaction. I say “part” because, as the National Institute for Health and Care Excellence recognises, patient satisfaction is widely acknowledged to be a poor indicator of care quality. This hasn’t stopped the implementation of the Friends and Family Test, described as “unsuitable for use in NHS settings” in a study for the Care Quality Commission. As they distribute questionnaires, few nurses will know that the test was designed, again in the US, to help business growth, and that it is ineffective even at that. But, as with undertaking rounding, nurses will administer the test because the government says they must.

Rounding may work, so why I am I so sceptical? First, it is the opposite of individualised care that forms the foundation of good, professional nursing. Second, it has been implemented following evidential claims that are always flimsy and sometimes simply false. Third - most importantly - it represents the politicised search for simple solutions to complex problems. Maintaining the public gaze on superficial initiatives diverts it from where proper scrutiny should be - on resources and political micromanagement.

It is not known whether intentional rounding will improve care, but it is known that, unsurprisingly, higher numbers of better educated nurses will.

I’m heartened by the acknowledgement in Compassion in Practice that evidence-based staffing levels are needed. Let’s hope for progress there but, in the meantime, we do ourselves and our patients no good at all by meekly allowing politically driven and evidence-free interventions to dominate the post-Francis nursing environment.

Paul Snelling is senior lecturer in adult nursing and programme leader, MSc specialist practice, at UWE Gloucester


Readers' comments (17)

  • Hah, I've been saying this for well over a year since I too took some time to look into the evidence base for Cameron's favourite nurse-bothering silver bullet. The one thing you can track fairly consistently in the reports on rounding is a small increase in patient satisfaction indexes, nothing like making your patients feel looked after while not meaningfully impacting clinical outcomes. Is that what we really want to mean by "compassionate care"? Frankly, anyone who can't think of a better use of their time than rounding shouldn't be working in healthcare, it seems to be thoroughly derided by staff at my trust.

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  • looks like it came out of the top of Cameron's head during his hospital visits in response to complaints instead of being carefully thought through along with all the other improvements required (such as more staffing) without consulting any evidence whatsoever.

    These visits, sleeves rolled up, chatting to nurses was just one big jolly PR stunt early on in his PM career in which made him appear very naive about the real and very serious issues facing patients and staff.

    Convince him wards need a round wih reindeer at Christmas and he would endorse it 'as the right thing to do' regardless of any clear evidence base on standards of hygiene !

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  • Interesting article. It backs up everything that all nurses have known since the idea was floated.

    However, although I see many articles and comments about how unacceptable these schemes and initiatives are, I see no solutions. I see no appetite within the nursing profession (individuals and /or unions) to do anything about them.

    " the meantime, we do ourselves and our patients no good at all by meekly allowing politically driven and evidence-free interventions to dominate the post-Francis nursing environment."

    But 'meekly allowing' is precisely what nurses do. We need to move beyond simply criticising these policies and start doing something effective to oppose them.

    Refuse to implement them. That would be a start.

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  • Individualized patient care is becoming a long forgotten goal.
    Nursing care is being so eroded and diluted by covering all the cracks in healthcare services. If there is any area that is failing, lets invent a reason why it is the fault of the nursing staff or lets just tell them it is their job to react. (After all the patients will blame them for every failing that occurs anyway.) Short of porters - nurses can do that; short of physiotherapy hours - nurses can do that; labs cannot bleep doctors with urgent results as they are too busy - nurses can do that. BUT perhaps we will all be so much more attentive through rounding and filling in the rounding forms
    that actually we will not have time to do all these things .... but because they do not get comes full circle back to being the fault of nurses!

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  • mags | 2-Apr-2013 7:55 am

    Anonymous | 2-Apr-2013 8:13 am
    Stop doing everyone elses job then. And stop accepting the blame.

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  • If you tick a box to say Patient A was fine at 11.00am, does that mean if you find him not fine at 12.00 then everything will be okay because you ticked your box and performed your hourly round?

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  • Anonymous - you seem to have misunderstood - Nurses do not "accept" the blame it is thrust upon us because we are at the coal face.

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  • Anonymous | 2-Apr-2013 4:36 pm

    I have misunderstood nothing. Nurses do nothing to defend the profession or their patients. Blame would not be 'thrust upon' nurses if they put up a decent fight against those who find them such an easy target. This will not change until nurses stop behaving like victims and coal face martyrs. But they don't like to hear that either, preferring to hope that 'someone' will come along and fix everything.

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  • You sound like just the person we need to lead the way.

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  • 'evidence free' - I like that, didn't nursing become a degree only course so that everything was evidence based - what a joke.

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