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Intentional Rounding: Evidence-Based Care or Care-Based Evidence?

March 17, 2013

Ladies and gentlemen! Pray be upstanding for a roll-call of some of nursing’s greats: Florence Nightingale, who made the occupation respectable and articulated our first conceptual framework; Virginia Henderson, who described the Nursing Process; Alan Pearson (and others), who showed us the power of Primary Nursing; Pennine Care NHS Foundation Trust, who have gifted us…’Meaningful and Individualised Moments’. Meaningful and Individualised Moments? Run that one past me again? Are we really saying that nursing, the all-graduate aspirant profession, is drawing its inspiration from something that wouldn’t sound out of place on a soft-focus advert for an internet dating site? You couldn’t make it up.

‘Meaningful and Individualised Moments’ is Pennine Care’s new name for Intentional Rounding (IR). A new name is needed, a Trust spokesman explained, because Intentional Rounding is ‘jargon’ and ‘sounded like you were herding people’. As the point of Intentional Rounding is to make systematic hourly- or two-hourly visits to each patient to check if there is anything they need and (where appropriate) to assist them to change position, use the toilet, take some fluid or get themselves clean, one might be forgiven for wondering why it needs a fancy name at all. Why not call it just…well…nursing?

Proponents of Intentional Rounding often verge on the evangelical. Reading them, you could easily conclude that the idea they champion so passionately is a ground breaking innovation whose widespread adoption will herald a bone fide revolution in patient care. It isn’t and it won’t. As any seasoned nurse will tell you, it’s all a matter of fashion. Intentional Rounding is simply the traditional ‘back round’ – out of favour for the last twenty years on the grounds that it was ‘ritualistic’ and ‘task-orientated’ – re-packaged and re-branded for the twenty-first century with one crucial addition: every patient now has to have an IR chart and on that chart, every IR intervention has to be signed off.

There is no standardised NHS-wide format for these charts; individual trusts are free to come up with whatever design suits their own requirements. What they typically produce is a sheet of A4 filled with a box-grid. Times (at hourly intervals) run across the top and nursing interventions (positioning, hydration, continence care, skin check etc.) are listed down the left-hand side. When a care-giver has completed an individual action from the list, he or she ‘signs it off’ by ticking the box that lies at the intersection of the the appropriate action column and time line. The interaction as a whole is then signed off, usually with a signature at the foot of the page. What’s not to like?

At first sight, IR appears to offer very few opportunities for criticism. Patients who cannot meet their personal care needs without help or prompting should obviously be subject to regular checks on their pain levels, comfort, dietary and fluid intake and continence; and nurses should, obviously, offer them whatever assistance they are found to be in want of. This is the absolute heart of nursing. No one could argue with it. But objections to IR have nothing to do with the interventions authorized at its behest. Instead, they stem firstly from what one might term ‘the politics of IR’ – the dangers inherent in the reasons for its introduction and continuing popularity; and secondly from broader concerns about what nursing’s current infatuation with IR says about its overall intellectual health. Below, I examine these points in more detail.

1. Intentional Rounding may sustain a culture where documentation takes priority over care. IR is a top-down initiative whose implementation is driven by management’s need, in the face of an increasingly complaint-happy and litigious general public, for documentary evidence that nursing care has actually occurred. To put it another way, the focus in IR may be less on the delivery of evidence-based care and more on the delivery of care-based evidence. So where wards are too short-staffed to lay on the full ‘IR package’ for every patient every two hours, but are still subject to aggressive auditing regimes (and this describes a lot of wards), there is a danger that the cry that goes up will be not ‘have we done the care?’ but ‘have we done the charts?’

2. Intentional Rounding risks creating conflicting versions of the truth. If IR is about producing more robust evidence of nursing interventions, it has a glaringly obvious flaw: IR documentation is mostly completed by the people who do the hands-on care – health care support workers. Nursing Kardexes are mostly completed by people who supervise the care – nurses. But both of them will be reporting on the same events. See the problem? Unless all grades of staff collaborate very closely, there will always be a risk that what is documented on the IR charts and what is documented in the kardexes will not concur. And conflicting evidence is as bad as no evidence, because how to do you know which version is the correct one?

3. Intentional Rounding is routine-centred rather than patient-centred, something which puts it at odds with other recent trends in nursing. Adaptations of IR have tried to address this – for example the Trust mentioned in the opening paragraph is also ‘interviewing patients to see what they would like to be asked during hourly rounds’. Similar attempts to reconcile the ‘task-orientated’ IR model with modern cultural expectations that care should be ‘personalised’, ‘holistic’ and ‘tailored’ are likely to become something of a growth industry in the next few years. Watch this space.

4. Intentional Rounding is not a substitute for adequate staffing. Simply saying ‘we are doing Intentional Rounding’ is not enough. IR, when done properly, is both time-consuming and labour-intensive. It can never work effectively if there are not enough staff to carry it out.

5. Intentional Rounding dumbs down nursing. The message it sends out is that nurses are incapable of thinking for themselves. Nursing calls itself a profession, but show me another profession that needs an idiot board to remind its practitioners to perform the most fundamental – and I mean the most fundamental – parts of the job? Doctors? Lawyers? I don’t think so. And where is the peer-reviewed research to show that IR actually improves outcomes anyway? Even the National Nursing Institute admits that ‘In the UK a range of outcomes for patients and staff have been reported in the literature, but the quality of the evidence is limited because the small number of studies that do exist are descriptive rather than using comparative or controlled methods’. Apologists of IR routinely give it credence by reporting that after its adoption, frequency of call-bell use goes down. But compared to what? Where is your control of variables? Couldn’t it simply be that reduced call-bell usage is the result of increased nursing visibility in bed bays, rather than of IR per se?

6. Intentional Rounding dumbs down nurses. At its worst, IR really is nursing by tick-box. Although it encourages nurse-patient interaction, there is nothing in the IR users’ manual to prevent that interaction from being brief, hurried and completely defined by the the agreed IR ‘script’. Neither does IR encourage practitioners to think about wider issues such as nurse-patient relationships; or about nursing itself – its position within the NHS, the ideology of caring it espouses.

So where do we go from here? It seems unlikely that Trusts will abandon IR any time soon. Instead, the signs are that they will continue to use it but also to refine and evolve it in line with their own local conditions. The challenge will be to ensure that these refinements are driven not by management paranoia or political expediency, but by solid evidence-based research. Below are listed a very few suggestions for ensuring that this is what actually happens.

  • Nurse Academics/Researchers must get to work on comparatively evaluating different systems of care delivery. We have known since the work of Sylvia Lelean in 1973 that simply telling nurses that a patient needs (for instance) two-hourly turns is no guarantee that two-hourly turns are what he will get. How is it that forty years on, we still haven’t found a solution to this problem? We don’t know if IR will supply it, but for what can only be described as ‘operational reasons’ we have implemented it anyway. In the twenty-first century, surely nursing should be on a firmer footing than this?
  • Managers should look at ways of using new technology to enable staff to record whatever care is given in real time. Check-lists per se are not a bad thing – their use has been shown to improve safety in areas like aviation and even medicine. But let’s also build in some acknowledgement of patients’ individual circumstances and some respect for practitioners’ judgement. For example, an electronic device could ask ‘Has the patient taken oral fluid?’ If the answer is ‘yes’ the next question would be ‘how much?’. A negative response would trigger a request for the reason (Nil by Mouth, End of Life Care, Fluid Restriction, Patient Refused) and open a new screen asking if the patient has received oral care. An intake below an agreed threshold or a repeated refusal to drink would flag up an alert. Once information has been stored in this way, there should be no need for other staff to waste time reprising it in a secondary version on a different database.
  • Nurses should never be pressurised into implying that they have completed an action when they have not. If you didn’t do the care, don’t tick the box.
  • A certain NHS Foundation Trust in the North-West of England needs to have a rethink. To them I say: I don’t doubt that you are providing a first-rate service. I respect Meaningful and Individualised Moments as part of that. But please, please, please, in the name of all that’s common sense – can’t you call it something less embarrassing?

Lelean, S (1973): Ready for Report, Nurse?; London; Royal College of Nursing.

National Nursing Research Unit (2012) Intentional Rounding: What is the evidence? In Policy Plus; Issue 35: April 2012. Available to download at: http://www.kcl.ac.uk/nursing/research/nnru/policy/By-Issue-Number/Policy–Issue-35final.pdf

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One Comment
  1. Our hospital is now in the process of attempting to introduce written “Rounding” sheets once more… the first attempt failed miserably with sheets that were far too involved and complicated and took at least five minutes or more to fill out per patient, let alone if you got interupted during the process to do one of the things you had just asked about, or to see to the confused patient who’s bed alarm has just gone off again three rooms away. When i go to a patients call, i attend to the patient first and worry about turning off the call bell as a second…Call bell times mean nothing…and are not realistic of any statistic. Our hospital doesnt have assistants in care or any of the other names you want to give to “nurses aids”… it is nurses only.. each staff member is looking after 4 patients on morning shift, or 5 patients on an evening shift… and 8 patients overnight… we do everything, medications, both oral and parenteral,feeding those who cant feed themselves, mobilisation, wound care and dressings, pressure area care, hygiene, toileting, and more for these patients.
    We already document fluid charts input and output… food intake charts, 15 minute visual charts, delerium charts, vital signs charts, medicaion charts, care plans each shift, , bowel charts,, daily falls risks charts. pressure risk charts, alcohol withdrawal charts, Venous thrombosis risks charts, medication charts….intravenous therapy charts, wound care charts, Stroke pathways, Cardiac pathways… an this isnt even all of the charts……
    i just dont know where another five minutes to fill out another form in my shift, will come from….and where will endless forms finnish

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