I may never recover from the trauma.

At a major nursing conference recently, I went along to a session on ‘Intentional Rounding’.

I know, I should have known better. I should have listened to all the alarm bells ringing. I should have re-read Willis et al.’s exquisite paper (2015), Rounding, Work Intensification and New Public Management. I should have looked for a session on urine drinking or a ‘concept analysis’ of 1990s Models of Nursing, but I didn’t.

The aberration that is ‘Intentional Rounding’ (IR) has come to exemplify almost everything that is wrong with our amazing profession.

Where to start is the big problem.

Who came up with that doozie of a name and what on earth would ‘non-intentional rounding’ look like?

Is that a kind of nursing somnambulism, or do we perhaps still have nurses who know the value of staying close to and knowing important things about their patients, and don’t need an institutionalised ‘model’ or new ‘initiative’ to tell them when and how to do this?

Back at the nightmare.

As an earnest nurse described the tick-box straitjacket that Intentional Rounding has donned, we discovered that a key assumption of IR is that nurses are fundamentally stupid and that trusting their professional judgment would be a grievous error in terms of patients’ safety.

To stop them from making such an error and to ‘prove’ to someone that nursing has actually happened, the entire process is infantilised into yet another tick box and pointless checklist that will become further fodder for ‘The Regulatory Beast’ that must be fed (Nursing Standard 2012).

All of this is bad enough, but when I saw the actual ‘tick box’ that IR relies on, I almost fell off my chair.

Delicate readers, nurses who perhaps trained more than a few years ago, or those who are or were Ward Sisters / Charge Nurses may need to look away at this point.

Not only are nurses deemed too stupid or untrustworthy to check and connect with their patients because that is their job, they apparently won’t manage to do this without the ‘correct tools’ – i.e. a four-box checklist.

If could possibly get worse, it did.

We learned that this checklist has to be alliterated to the ‘4 Ps’ to make it even more child-friendly, so that the nurses we charge with the responsibility of people’s lives won’t forgetty-wetty any of the four boxy-woxies.

They are, and believe me, I am not making a word of this up:

1) Pain

Ask the patient if they are in any pain. Wonderful. Thank goodness nurses have a ‘tool’ to help them do this.

2) Position

Always good to make sure that Mrs Smith isn’t hanging out of her bed or maybe not the best idea to have Mr Bloggs with his emphysema and congestive heart failure lying as flat as a pancake.

3) Possessions

Does Mrs Smith have her handbag handy and can Mr Bloggs reach his slippers, phone or water jug?

All of this so far is not a whit different from what your nurse tutor or clinical teacher would have told you was involved in ‘leaving the patient comfortable’ after you’d done anything with them.

Can we have a drum roll please for #4…..

4) Potty

Yes, you read this correctly. Have they been to the toilet recently or do they need any help to go now?

It is almost beyond human comprehension. How many patients out there above the age of two, noticing that their nurse has just ticked a box called ‘potty’ would not leap out of the bed and throw that nurse directly out of their room and with our applause?

I just did not believe this until I did a simple google search of ‘potty’ and ‘rounding’ and there it is, in file after file, document after document, all lauding this wonderful new ‘patient safety’ initiative and its required ‘4Ps’, dashboards and toolkits (all available at a price, of course).

A few days after the conference I was having tea with the nurse who was more like a hero than a mentor to me and who had been a Ward Sister of a busy medical ward ‘back in the day’. I wish someone could have filmed me trying to explain the concept of a ‘new nursing initiative’ that involved nurses going round their patients and checking that all is well, to a nurse whose generation of colleagues did that as easily and regularly as breathing.

One of the smartest nurses and women I have ever known simply could not grasp what I was talking about and you could see the puzzled look of “But isn’t that what we’ve always done?” spread across her face.

One of the many tragedies of the IR débâcle is that somehow, nurses and nursing took its eye off the ball so dramatically that we had to endure the spectacle of British PM, David Cameron, standing up in the House of Commons in 2012 to tell nurses that they need to go round their patients regularly to see how they were as part of ‘quality’ nursing care (Kirkup 2012).

The shame still burns like lava.

What happened? Did a memo come round from somewhere, saying that nurses must stop ‘rounding’ and checking on their patients? Did senior nurses visiting wards and units stop asking the nurse in charge ‘How is everyone today?’ or ‘Please take me round the ward?’

So now we have yet another checklist and boxes to tick that allegedly improve care, safety, quality or whatever and another mini-empire will spring up of IR toolkit-sellers, IR trainers and accreditors, perhaps levels of IR expertise (Senior IR Facilitator anyone?)

Don’t laugh. Remember the nonsense of Lean/Six Sigma Black Belts etc?

IR becomes almost the endgame of a movement that has sought to render all of nursing as little more than a series of documents to sign or boxes to check – a movement that has equal measures of distrust and contempt for the very idea of professional nursing judgment.

IR will now of course need its own ‘body of knowledge’ and research careers will be built on studying this ‘innovation’ about which ‘little is known’.

Further comment is superfluous.


This blog artifice by the Monash University nursing professor and consultant was first published on Ausmed.


References

5 COMMENTS

  1. Thanks Phillip
    The inexorable destruction of nursing identity, intellect, image and initiative ( I can play word games too) under New Public Management is now beyond belief. I share your horror and distress at the infantilisation and the remorseless march of mindless tick boxing.

  2. I have loved you all of my nursing career Phillip and have gained so much from many of your writings and conference presentations over the years. So I am not surprised that you have written this excellent blog in challenging ‘where is nursing going’. I am nearing the end of my nursing career and do worry that the fundamentals of what we in nursing education still recognize and teach as essential work of nursing is being required to be ‘tick boxed’. It is truly distressing that the intellect of nurses is being questioned in such a demoralizing manner in the public arena.

    • Thanks Norma. Very kind and much appreciated. It’s so sad that EVERYTHING is now reduced to a tick box checklist. SOME checklists are great and we should value them. Eg, we’d never give a blood transfusion or do an operation without some very careful checks, and rightly so, but IR sure isn’t one of them.

  3. Talked about this very thing in my 2012 Vivian Bullwinkel oration Philip, nothing seems to have changed…..tickboxes and pathways…..can’t be person centred! Cheers, Molly

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