Patient safety and satisfaction are central priorities of healthcare, and any new initiative in the delivery of care should include a focus on these priorities.
One such initiative we encountered as student nurses is intentional rounding (IR), also known as hourly rounding.
IR involves nurses checking on their patients at regular intervals to assess and manage their care1. Typically, IR occurs hourly but can increase if the patient is more vulnerable2. However, does IR increase the quality of care for patients and, if it does, is it practical and useful for nurses?
In this article we examine the use of IR and its practicality in a hospital setting. We also reflect on our experiences of IR and compare them with relevant literature. Finally, we provide a recommendation about how we think IR can work for both patients and nursing staff.
Prompted by concerns about bedside care
The idea of intentional rounding (IR) stems from ‘back rounds’ which were hourly to two hourly checks conducted by nurses to assess patients’ skin integrity3.
Over time nursing care became more individualised to accommodate patients’ needs. However, there were concerns that patients were missing basic bedside care as nursing became more task-oriented rather than patient-focused3. Intentional rounding was one response and a number of New Zealand hospitals have begun using IR 4,5.
Auckland District Health Board started trialing IR in two older people’s health wards in 2012 as part of a reducing falls initiativeand the same year IR was piloted in a medical ward in Bay of Plenty DHB4,5.
The Auckland model used communication boards near patient beds or the doors to patient rooms to indicate the care needed. The boards were also seen as useful in aiding communication of the care plan to the patients and the family4. Both DHB pilots reported a reduction in patient falls and Auckland also noted a reduction in call bell use by patients.
IR is defined by the ‘4ps’ which correlates to positioning, personal needs, pain and placement6. Each of the four ‘Ps’ includes the nurses asking questions of the patient and recording the responses on a form. Completed forms provide evidence that the patient’s expectations are met.
The purpose of IR is to improve patient care and satisfaction7. The aim is to encourage prompt responses to patient needs, address issues before they arise, and thereby ensure patient safety7,8. Intentional rounding also aims to prevent patients who may be reluctant to use call bells from missing out on care2.
The intended benefits of IR are decreased call bell use and more efficient use of nursing time8. However, in our clinical experience, the effectiveness of IR and attitudes towards IR were portrayed differently.
Student experience: IR fails in busy wards
During clinical placements, we observed that IR was inconsistently implemented and what was being done was also inconsistent with the principles of IR as outlined above.
IR appeared to fail when the clinical workload was high and when there were a high number of at-risk patients.
Low staffing numbers or high patient acuity meant hourly IR was an unrealistic goal for nurses to meet. A high workload often meant IR documentation was rushed and therefore care carried out was not captured and recorded.
Typically, nurses who we worked with cared for patients who required more attention, due to transfusions, postoperative care, co-morbidities, and complex wound care. As a result nurses prioritised their time according to patient needs as part of their regular practice. They could recognise when patients required regular checks and facilitated this to happen in collaboration with healthcare assistants and students.
Essentially, when IR was necessary for patients, nurses would complete the documentation and task process accurately. However, nursing staff did not always deem this necessary, particularly when time was constrained, and so directed their time toward more acute patients and tasks.
With a high workload comes the tension between completing patient cares versus completing documentation. Therefore, we reflected that in practice, IR appeared to be an unattainable standard to set in most ward environments.
Why does IR not work?
Studies indicate that nursing staff do not perceive IR as beneficial to nursing practice9,10.
Participants in an American study looking at nurses’ perception of IR reported that IR is flawed as it does not take varying patient acuity into account9. A English study examined hourly rounding in a general high-dependency unit and reported poor completion of the IRForms10. However, it was unclear whether the hourly checks were completed, but notdocumented or if the hourly checks were not completed at all10. Another study, looking at an English IR pilot, attributed this trend to nurses often not finding the time to complete IR when they had other priorities11.
An American nursing academic agreed that routine hourly rounding is easily impacted by unexpected interruptions in clinical settings, such as changes in patient plans or acuity along with phone calls from doctors, laboratories and other administrative requirements12. Furthermore, IR caused more stress for nurses because they had to stop what they were doing to perform the required rounding10.
The English IR pilot study also noted that nurses considered the IR documentation tedious, unnecessary and often incorrectly completed11. Nurses stated that they have always carried out IR, which does not always need to be documented, or felt that they already saw patients hourly hence the IR checklist was unnecessary10.
Similarly, participants in a study by Braide, an English practice development nurse, were opposed to IR as they saw it as another piece of redundant paperwork to complete2.
Nurses reported feeling ‘micromanaged’ when it was a job they had always performed and that the implication that they would not complete essential aspects of their job without a checklist was patronising10,11. Therefore, in a busy environment, it was impractical to complete IR instead of more critical tasks. Additionally, if nurses are already completing these tasks, then it may be unnecessary to have a checklist.
The English high dependency unit study concluded that IR would work in a less busy environment like an older adults’ ward or in areas that have a lower nurse to patient ratio10.
Along with studies that explored nurses’ experiences of IR, Braide examined theoutcomes of IR implementation2. He found that overall, there was no decrease in the frequency of call bells, and some wards even showed an increase.
Patients have reported feeling irritated by hourly checks, especially when they had visitors11. Patients have also expressed confusion as to why they were asked the same questions every hour11. These findings indicate that IR negatively influenced patient satisfaction.
Consequently, the authors of the English IR pilot study recommended less frequent rounding, perhaps adjusting it to twice a shift rather than every two hours11.
Conclusion and recommendation
Promptly meeting the needs of patients is a crucial part of safe and effective nursing practice.
However, the literature reveals that hourly intentional rounding can be impractical and may not be captured accurately in the documentation. IR is highly relevant in ward settings with patients of varying acuity and a high patient-nurse ratio. However, our observations suggest that the genuine benefits of hourly intentional rounding are not realised in the context of these challenges.
To improve the system, the involvement of nurses is necessary in assessing patient acuity and the need for hourly rounding. IR also requires flexible and adaptable documentation, which are vital if IR is to be adhered to by nurses. Such changes may maximise benefits for patients while simultaneously making IR achievable for nurses.
We recommend further research involving a greater variety of methods of IR that place more value on nurses’ judgement.
It is also crucial that research and future implementation of IR acknowledge the impact of high workloads and varied patient acuity.
*University of Auckland second year nursing students Ashika Rasikaran, Dalen Ba, Khadija Bari, Hannah Carter, Chelsea Price and Bianka Radojkovich wrote and contributed this article for an assignment working with their lecturerDr Kim Ward.
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