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