Nursing Practice
Innovation
Fundamental care
Using intentional rounding on a medical assessment unit produced a drop in call bell
frequency and improved patient experience. Staff buy-in was essential to the process
Engaging staff with
intentional rounding
In this article...
Intentional rounding explained
Implementing IR and addressing staff concerns about it
Gaining feedback on IR from patients and staff
Authors Greg Dix is director of nursing and
governance; Jackee Phillips is junior sister,
medical assessment unit; Mark Braide is
practice development nurse; all at Taunton
and Somerset Foundation Trust.
Abstract Dix G et al (2012) Engaging staff
with intentional rounding. Nursing Times;
108: 3, 14-16.
This article describes the introduction of
intentional rounding on a busy medical
assessment unit and how staff
engagement and understanding of the
process is essential to its successful rollout.
Staff’s reaction to the implementation is
highlighted and the benefits to care
delivery discussed.
E
arlier this month, the prime
minister called for changes in
the way nurses deliver care. This
was in response to recent reports
drawing attention to care failings (Care
Quality Commission, 2011; Health Service
Ombudsman, 2011; Department of Health,
2010). One of the recommendations was
for nurses to undertake regular rounds to
ensure that every hour they will be able to
check that each patient is comfortable.
This method of systematically reviewing
all patients on a regular basis to ensure their
fundamental care needs are met is not a new
nursing concept. For many years, nurses
carried out regular “back rounds”, which
had a particular focus on skincare and pressure relief (Fitz-simmons et al, 2011).
Anecdotally, nurses believed regular
contact with patients had the added value
of enabling therapeutic relationships to
develop between them. The rounds made
patients feel cared for and reassured,
knowing that within a couple of hours they
would be visited by a nurse and given an
opportunity to raise any personal needs.
However, while back rounds ensured all
patients were reviewed at least every two
hours, they were task-orientated and left
little room for delivering individualised
holistic care.
Intentional rounding
Intentional rounding (IR) is a more recent
development imported from the US that
could be described as a modernised back
round. It involves nurses carrying out regular checks on individual patients at set
intervals to assess and manage their fundamental care needs with respect to six
core elements:
» Pain;
» Hydration and nutrition;
» Continence;
» Anxiety;
» Falls;
» Pressure ulcer prevention.
IR places the patient at the heart of the
ward routine by taking care back to the
patient’s bedside.
The system improves patients’ experience of care through the reassurance provided by the increased visibility of nursing
staff and the knowledge that they can raise
any concerns or needs when they are next
visited by a nurse so that they can be dealt
with promptly. These can range from
14 Nursing Times 17.01.12 / Vol 108 No 3 / www.nursingtimes.net
needs that may seem relatively unimportant to ward staff but are hugely significant to patients to potentially serious clinical concerns.
Meade and Bursell (2006) noted a significant increase in patient satisfaction and a
reduction in pressure ulcer incidence after
introducing IR, while the Studer Group’s
(2007) work on IR identified similar significant improvements in patients’ experiences of care and clinical outcomes.
Musgrove Park Hospital, part of
Taunton and Somerset Foundation Trust,
has been using IR for a year. The hospital
has more than 600 beds, 30 wards and
15 operating theatres. It serves a population of 340,000 and treats more than
450,000 patients each year.
IR was just one initiative within the
hospital’s Back to Basics campaign. It was
championed and led on the medical assessment unit by junior sister Jackee Phillips.
IR was initially tested with a bay of
patients using rapid cycle testing (plando-study-act (PDSA) cycles) on the medical
assessment unit in October 2010. It was
rolled out across the unit in January 2011.
Every patient receives an hourly or twohourly review by either a nurse or healthcare assistant, with frequency depending
on the patient’s clinical condition.
Unlike some hospitals using IR, we
include all patients rather than just those
that are at risk of falling or skin damage.
The overarching principle is that all
patients, regardless of presentation, have a
right to expect their fundamental care
needs to be identified and met promptly.
Effects of implementation
After IR was rolled out, an audit was conducted, typically at weekly intervals on different days of the week but at the same
hour (1.00-2.00pm). The audit collected the
number and frequency of call bells (Fig 1a),
Keywords: Intentional rounding/
Implementation/Personalised care/
Patient experience
●This article has been double-blind
peer reviewed
5 key
points
fig 1. the impact of intentional rounding on call bell usage
and complaints
1
Intentional
rounding
involves nurses
checking individual
patients at set
intervals to assess
and manage their
fundamental care
needs
It places the
patient at the
heart of the ward
routine
IR reduced the
frequency of
call bell use
Introducing IR
requires a
cultural change
and staff need
support to bring in
the change
IR has a
positive effect
on patient
experience
2
3
4
the completion of the IR form over
24-hours and patient feedback cards. Further metrics are now collected on pressure
ulcers, falls and patient satisfaction data.
IR has demonstrated a significant
reduction in the frequency of call bell
usage and the length of time patients wait
to have their call bells answered.
Fig 1b shows that when IR was performed consistently, call bells use reduced
from an average of eight an hour before the
system was introduced to one an hour
after. It also reduced the time taken to
respond to the calls from three minutes to
less than one (Fig 1c). Evidence demonstrates that patients frequently use call
bells for non-urgent needs as they feel it is
the only way to gain nurses’ attention (Tea
et al, 2008; Meade and Bursell, 2006).
Before IR, call bells were not prioritised
due to their frequency (they were typically
ringing for 24 minutes in every hour). IR
significantly reduced call bell use so now,
when a bell is rung, it is usually for a significant reason. The call bell is now more
audible because it is used less frequently so
not perceived as background noise.
Another positive impact demonstrated
more recently concerned the early identification of pressure ulcers. The IR tool was
amended to include a section on the form
to acknowledge the risk of pressure ulcers,
followed by a section indicating whether
27 exit card responses, all with
the patient’s skin has been
positive comments. This cominspected; this was further
The number of calls fell
pares to just four responses
developed so nurses now comdramatically when
intentional rounding
from the test bay of 12 beds
plete the SKIN bundle tool.
was introduced as did
over a same time period before
At times IR activity reduced,
their duration.
rollout – a significant increase
for example when the workload
Complaints also reduced
of approximately 58%.
was particularly demanding; Fig
While these numbers are
1a and 1b show that when this
small, there has been a noticehappened, the use of the call bell
increased, as did call bell duration. IR able rise in the number of thank-you cards
activity falling away from time to time coin- received by the ward since the introduccided with a reduction in ward support by tion of IR and a reduction in complaints
members of the IR project team. This was and concerns (Fig 1d).
fed back to the ward sister and measures
put in place to refocus the ward staff. The Staff concerns
support from the project team, led by our Before implementing IR, we anticipated
practice development nurse, was essential that staff would see the system as too timeconsuming. We therefore reviewed potenin the early stages of implementation.
In addition to reducing call bell usage, tial problems identified in each of the six
IR care domains in the pilot. It became
IR has increased patient satisfaction.
Musgrove Park Hospital uses many apparent that most patients required little
methods of collecting patient feedback, in the way of intervention (90% of rounds
one of which is a system of feedback cards did not require any problems to be
to identify any concerns or recognition of addressed), but patients valued being
good practice. The cards are completed asked (feedback card responses valued the
voluntarily by patients or relatives and visibility of staff ).
The majority of interventions/problems
deposited in a post box before discharge.
In the pilot MAU, we received nine exit were resolved by the next round (85% in the
card responses (eight beds) over a three- trial period audit).
In addition, persistent problems are
week period compared with just four from
the rest of the ward (12 beds). In the first more readily identified and documented,
three weeks after IR had been implemented and, since the effectiveness of intervenacross the whole unit (20 beds), we received tions becomes clear quite quickly, this
www.nursingtimes.net / Vol 108 No 3 / Nursing Times 17.01.12 15
Al Grant
5
Nursing Practice
Innovation
Box 1. Staff comments
“Since the implementation of IR, there
has been a marked improvement on the
MAU. Our complaints have reduced, the
unit has a feel of calmness.
“I have worked on the unit for two
years and never witnessed a quiet period
after lunch, when patients could have a
quiet hour. Since implementing IR, we are
now able to turn the lights off on the unit
from 1.00-2.00pm …
“I have witnessed first hand where
pain control issues have been identified
quite early as a result of IR ... IR has
enabled better safer practice on MAU to
be established, we have reduced our
complaints, falls, and pressure area care
has been monitored.
“This service improvement has
brought clinical governance alive in the
workplace. Our standards on MAU are
improving.”
Jackee Phillips, junior sister, June 2011
“Since starting IR on the MAU, we have
seen a significant increase in the number
of thank-you cards and many positive
comments on the exit cards. We have
also seen the number of complaints
greatly reduced.”
Amanda Carr, MAU sister, June 2011
“It is very reassuring to know that every
single patient will be checked upon every
two hours, regardless of their needs – so
any changes in their clinical conditions
are going to be rapidly detected. ”
Andrew Thompson, MAU consultant,
July 2011
improves management and reduces the
risk of simply repeating interventions that
have not worked. For example, systematic
evaluation and documentation of pain
management means analgesia is more
likely to be altered as needed.
While some staff cite the time taken up
by IR as a concern, it is difficult to quantify
how long it takes to manage failings in care
such as avoidable pressure ulcers, or to deal
with complaints. Providing IR is implemented consistently, the time taken to carry
it out can be offset against time savings
from improved patient management.
However, this requires staff to support
the initiative and to adapt their working
practices. Initially, there was resistance by
a small majority of staff primarily driven
by time concerns. Over time, this resistance has diminished with the active
intervention of the ward manager, matron
and director of nursing. This issue was also
highlighted in similar work carried out on
an orthopaedic ward at Whipps Cross University Hospital (Lucas et al, 2010).
Staff evaluation
A questionnaire was circulated to staff at
the time of rollout (January 2011) asking
questions on their perceptions of patient
care; a follow-up sent out in June 2011
included additional questions directly
comparing how they scored care out of 10
before IR and after IR. The response rate
for the first survey was 28%, which
improved slightly to 36% for the follow-up.
The results were mixed.
There was no perceived change in the
ability to provide individualised care
during the initial pilot phase of implementing IR. Surprisingly, staff perceived
they had less time to spend with each
patient. Some comments from the questionnaire suggest that performing IR on
well patients is seen to be to the detriment
of those who are unwell as it takes staff
away from these patients.
Staff were also asked to rate their own
satisfaction with the care they were able to
provide. Data appeared to show that staff
were less satisfied since the implementation of IR. However, despite the negative
evaluations of the impact of IR on staff
time and satisfaction, when they were
asked to compare the quality of care in January with that in June, they appear to
report a significant improvement since IR
was implemented.
Other comments on the questionnaires
suggested that some staff did not fully
understand the concept of IR. For example,
several staff interpreted hydration to mean
simply offering hot beverages at twohourly intervals, which would be difficult
to achieve and is neither necessary nor the
purpose of including hydration as an element of IR.
We did, however, receive a significant
number of positive comments, some of
which are shown in Box 1.
Staff buy-in to IR is essential for successful implementation. It is imperative
that all staff are provided with education
and training before implementation and
the director of nursing and senior nursing
team are IR champions.
Staff perceptions of the IR process need
to be managed carefully and it should be
emphasised that the patient should always
be at the heart of the organisation.
As with any change process, there is
always an element of resistance, which has
to be managed sensitively.
16 Nursing Times 17.01.12 / Vol 108 No 3 / www.nursingtimes.net
Conclusion
Although some staff expressed concerns
about the appropriateness of IR on a busy
MAU, it has proved effective and not
required additional staff.
The only obvious costs so far have been
around the production and supply of the
IR tool, and in maintaining the audit
process. However, the latter is minimal as
we already had a well-established ward
audit process.
With minimal organisational cost but a
fundamental shift in ward routine, huge
improvements in care have been achieved
through implementing IR to the rest of the
organisation over the past year.
The key to success is to reorientate ward
activity to fit around the system rather
than trying to fit IR into existing activity.
Conducting checks on patients simply
with the intention of filling in a form will
not resolve their problems. Perversely, it
will take valuable time and will act as selffulfilling prophecy for those wishing to
dismiss the system as a paper exercise.
This is still a problem in a small group of
staff, despite clear evidence showing that
when IR is done properly and consistently,
patient experience significantly improves
and improvements in the quality of care
can be achieved.
It is also important that senior management recognise that staff need to be supported in implementing IR, through the
provision of continued training.
The system requires a cultural change
so managers cannot assume that, because
IR focuses on fundamental care, it is easy
to achieve. NT
References
Care Quality Commission (2011) Dignity and
Nutrition Inspection Programme. London: CQC.
tinyurl.com/CQC-dignity-report
Department of Health (2010) Robert Francis
Inquiry report into Mid-Staffordshire NHS
Foundation Trust. London: DH. tinyurl.com/
mid-staffs-inquiry
Fitzsimmons B et al (2011) Intentional rounding: its
role in supporting essential care. Nursing Times;
107: 27, 18-21.
Health Service Ombudsman (2011) Care and
Compassion? Report of the Health Service
Ombudsman on Ten Investigations into NHS Care
of Older People. London: Health Service
Ombudsman. tinyurl.com/care-compassion
Lucas et al (2010) Report on – Proactive Patient
Rounding: Developing Nursing Practice to Improve
the Quality of Patient Care. Whipps Cross
University Hospital Trust, London.
Meade CM, Bursell LK (2006) Effects of nursing
rounds on patients’ call light use, satisfaction and
safety. American Journal of Nursing; 106: 9, 58-70.
Studer Group (2007) Best Practices: Sacred Heart
Hospital, Pensacola, Florida. Hourly Rounding
Supplement. Gulf Breeze, FL: Studer Group.
Tea C et al (2008) Proactive patient rounding to
increase customer service and satisfaction on an
orthopaedic unit. Orthopaedic Nursing; 27: 4,
233-240.