Intentional rounding: a realist evaluation using case studies in acute and care of older people hospital wards.

BACKGROUND: In response to concerns about high hospital mortality rates, patient and carer complaints, a Mid Staffordshire NHS Foundation Trust public inquiry was conducted at the request of the UK government. This inquiry found serious failures in the quality of basic care provided and as a consequence, recommended that patients should have more regular visits, organised at predictable times from nursing staff. Intentional rounding, also known as nursing ward rounds, was widely adopted to meet this need. OBJECTIVE: To test, refine or refute eight programme theories to understand what works, for whom, and in what circumstances. SETTING: Six wards (older people and acute wards) in three NHS trusts in England. PARTICIPANTS: Board level and senior nursing managers (N = 17), nursing ward staff (N = 33), allied health and medical professionals (N = 26), patients (N = 34) and relatives (N = 28) participated in an individual, in-depth interview using the realist method. In addition, ward-based nurses (N = 39) were shadowed whilst they conduced intentional rounds (240 rounds in total) and the direct care of patients (188 h of patient care in total) was observed. METHODS: The mixed methods design included: Phase (1) Theory development - A realist synthesis was undertaken to identify any programme theories which were tested, refined and/or refuted, using data from phases 2 and 3; Phase (2) A survey of all English NHS acute Trusts; Phase (3) Six case studies of wards involving realist interviews, shadowing and non-participant observations, analysis of ward outcome and cost data; and Phase (4) Synthesis of findings from phases 1, 2 and 3. RESULTS: The realist synthesis identified eight programme theories of intentional rounding: 'Consistency and comprehensiveness', 'Accountability', 'Visibility of nurses', 'Anticipation', 'Allocated time to care', 'Nurse-patient relationships', 'Multi-disciplinary teamwork and communication' and 'Patient empowerment'. Key findings showed that of the original eight programme theories of intentional rounding, only two partially explained how the intervention worked ('Consistency and comprehensiveness' and 'Accountability'). Of the remaining six programme theories, the evidence for two was inconclusive ('Visibility of nurses' and 'Anticipation') and there was no evidence for four ('Allocated time to care'; 'Nurse-patient relationships'; 'Multi-disciplinary teamwork and communication'; and 'Patient empowerment'). CONCLUSIONS: This first theory-informed evaluation of intentional rounding, demonstrates that the effectiveness of intentional rounding in the English healthcare context is very weak. Furthermore, the evidence collected in this study has challenged and refuted some of the underlying assumptions about how intentional rounding works. This study has demonstrated the crucial role context plays in determining the effectiveness of an intervention and how caution is needed when implementing interventions developed for the health system of one country into another.

Perceived impact on efficiency and safety of experienced American physician assistants/associates in acute hospital care in England: findings from a multi-site case organisational study.

OBJECTIVES: To investigate the contribution, efficiency and safety of experienced physician associates included in the staffing of medical/surgical teams in acute hospitals in England, including facilitating and hindering factors. DESIGN: Mixed methods longitudinal, multi-site evaluation of a two-year programme employing 27 American physician associates: interviews and documentary analysis. SETTING: Eight acute hospitals, England. PARTICIPANTS: 36 medical directors, consultants, junior doctors, nurses and manager, 198 documents. RESULTS: Over time, the experienced physician associates became viewed as a positive asset to medical and surgical teams, even in services where high levels of scepticism were initially expressed. Their positive contribution was described as bringing continuity to the medical/surgical team which benefited patients, consultants, doctors-in-training, nurses and the overall efficiency of the service. This is the first report of the positive impact that, including physician associates in medical/surgical teams, had on achieving safe working hours for doctors in training. Many reported the lack of physician associates regulation with attendant legislated authority to prescribe medicines and order ionising radiation was a hindrance in their deployment and employment. However, by the end of the programme, seven hospitals had published plans to increase the numbers of physician associates employed and host clinical placements for student physician associates. CONCLUSIONS: The programme demonstrated the types of contributions the experienced physician associates made to patient experience, junior doctor experience and acute care services with medical workforce shortages. The General Medical Council will regulate the profession in the future. Robust quantitative research is now required.

The delivery of compassionate nursing care in a tick-box culture: Qualitative perspectives from a realist evaluation of intentional rounding.

BACKGROUND: Compassion is integral to professional nursing practice worldwide and a fundamental value in healthcare. Following serious care failures at a healthcare provider in the United Kingdom, a government commissioned report (the Francis Report) made several recommendations for strengthening compassion in nursing care and consequently 'intentional rounding' was incorporated into nursing practice in the United Kingdom. Intentional rounding is a structured process implemented primarily in the United Kingdom, North America and Australia, whereby nurses conduct 1-2 hourly checks on every patient using a standardised protocol and documentation. OBJECTIVES: To examine the role of intentional rounding in the delivery of compassionate nursing care in England from multiple perspectives. METHODS: This paper reports qualitative findings from one phase of a realist evaluation of intentional rounding which used a mixed-methods approach. Individual, semi-structured interviews were undertaken with 33 nursing staff, 17 senior nurse managers, 34 patients and 28 family carers from three geographically spread case study hospital sites in England. Interviews elicited detailed reflections on the contexts, mechanisms and outcomes of intentional rounding and how it impacted the interviewee and those around them. RESULTS: This study found little evidence that intentional rounding ensures the comfort, safety or dignity of patients or increases the delivery of compassionate care. The systematised approach of intentional rounding emphasises transactional care delivery in the utilisation of prescribed methods of recording or tick boxes rather than relational, individualised patient care. It has the potential to reduce the scope of nursing care to a minimum standard, leading to a focus on the fundamentals as well as the prevention of adverse events. Its documentation is primarily valued by nursing staff as a means of protecting themselves through written proof or 'evidence' of care delivered, rather than as a means of increasing compassionate care. CONCLUSIONS: This large-scale, theoretically-driven study of intentional rounding - the first of its kind - demonstrates that intentional rounding prioritises data collection through tick boxes or a prescriptive and structured recording of care. Thus, intentional rounding neither improves the delivery of compassionate nursing care nor addresses the policy imperative it was intended to target. This study raises questions about the role, contribution and outcomes from intentional rounding and suggests a need for a wider, international debate within the nursing profession about its future use. If an intervention to increase compassionate nursing care is required, it may be better to start afresh, rather than attempting to adapt the system currently implemented.

What is the contribution of physician associates in hospital care in England? A mixed methods, multiple case study.

OBJECTIVES: To investigate the deployment of physician associates (PAs); the factors supporting and inhibiting their employment and their contribution and impact on patients' experience and outcomes and the organisation of services. DESIGN: Mixed methods within a case study design, using interviews, observations, work diaries and documentary analysis. SETTING: Six acute care hospitals in three regions of England in 2016-2017. PARTICIPANTS: 43 PAs, 77 other health professionals, 28 managers, 28 patients and relatives. RESULTS: A key influencing factor supporting the employment of PAs in all settings was a shortage of doctors. PAs were found to be acceptable, appropriate and safe members of the medical/surgical teams by the majority of doctors, managers and nurses. They were mainly deployed to undertake inpatient ward work in the medical/surgical team during core weekday hours. They were reported to positively contribute to: continuity within their medical/surgical team, patient experience and flow, inducting new junior doctors, supporting the medical/surgical teams' workload, which released doctors for more complex patients and their training. The lack of regulation and attendant lack of authority to prescribe was seen as a problem in many but not all specialties. The contribution of PAs to productivity and patient outcomes was not quantifiable separately from other members of the team and wider service organisation. Patients and relatives described PAs positively but most did not understand who and what a PA was, often mistaking them for doctors. CONCLUSIONS: This study offers new insights concerning the deployment and contribution of PAs in medical and surgical specialties in English hospitals. PAs provided a flexible addition to the secondary care workforce without drawing from existing professions. Their utility in the hospital setting is unlikely to be completely realised without the appropriate level of regulation and authority to prescribe medicines and order ionising radiation within their scope of practice.

Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why.

BACKGROUND: Intentional rounding (IR) is a structured process whereby nurses conduct one to two hourly checks with every patient using a standardised protocol. OBJECTIVE: A realist synthesis of the evidence on IR was undertaken to develop IR programme theories of what works, for whom, in what circumstances and why. METHODS: A three-stage literature search and a stakeholder consultation event was completed. A variety of sources were searched, including AMED, CINAHL, MEDLINE, PsycINFO, HMIC, Google and Google Scholar, for published and unpublished literature. In line with realist synthesis methodology, each study's 'fitness for purpose' was assessed by considering its relevance and rigour. RESULTS: A total of 44 papers met the inclusion criteria. To make the programme theories underpinning IR explicit, we identified eight a priori propositions: (1) when implemented in a comprehensive and consistent way, IR improves healthcare quality and satisfaction, and reduces potential harms; (2) embedding IR into daily routine practice gives nurses 'allocated time to care'; (3) documenting IR checks increases accountability and raises fundamental standards of care; (4) when workload and staffing levels permit, more frequent nurse-patient contact improves relationships and increases awareness of patient comfort and safety needs; (5) increasing time when nurses are in the direct vicinity of patients promotes vigilance, provides reassurance and reduces potential harms; (6) more frequent nurse-patient contact enables nurses to anticipate patient needs and take pre-emptive action; (7) IR documentation facilitates teamwork and communication; and (8) IR empowers patients to ask for what they need to maintain their comfort and well-being. Given the limited evidence base, further research is needed to test and further refine these propositions. CONCLUSIONS: Despite widespread use of IR, this paper highlights the paradox that there is ambiguity surrounding its purpose and limited evidence of how it works in practice.

Physician associates in primary health care in England: A challenge to professional boundaries?

Like other health care systems, the National Health Service (NHS) in England has looked to new staffing configurations faced with medical staff shortages and rising costs. One solution has been to employ physician associates (PAs). PAs are trained in the medical model to assess, diagnose and commence treatment under the supervision of a physician. This paper explores the perceived effects on professional boundaries and relationships of introducing this completely new professional group. It draws on data from a study, completed in 2014, which examined the contribution of PAs working in general practice. Data were gathered at macro, meso and micro levels of the health care system. At the macro and meso level data were from policy documents, interviews with civil servants, senior members of national medical and nursing organisations, as well as regional level NHS managers (n = 25). At the micro level data came from interviews with General Practitioners, nurse practitioners and practice staff (n = 30) as well as observation of clinical and professional meetings. Analysis was both inductive and also framed by the existing theories of a dynamic system of professions. It is argued that professional boundaries become malleable and subject to negotiation at the micro level of service delivery. Stratification within professional groups created differing responses between those working at macro, meso and micro levels of the system; from acceptance to hostility in the face of a new and potentially competing, occupational group. Overarching this state agency was the requirement to underpin legislatively the shifts in jurisdictional boundaries, such as prescribing required for vertical substitution for some of the work of doctors.

What aspects of intentional rounding work in hospital wards, for whom and in what circumstances? A realist evaluation protocol.

INTRODUCTION: Intentional rounding (IR) is a structured process whereby nurses in hospitals carry out regular checks, usually hourly, with individual patients using a standardised protocol to address issues of positioning, pain, personal needs and placement of items. The widespread implementation of IR across the UK has been driven by the recommendations of the Francis Inquiry although empirical evidence of its effectiveness is poor. This paper presents a protocol of a multimethod study using a realist evaluation approach to investigate the impact and effectiveness of IR in hospital wards on the organisation, delivery and experience of care from the perspective of patients, their family members and staff. METHODS AND ANALYSIS: The study will be conducted in four phases. Phase 1: theory development using realist synthesis to generate hypotheses about what the mechanisms of IR may be, what particular groups may benefit most or least and what contextual factors might be important to its success or failure which will be tested in subsequent phases of the study. Phase 2: a national survey of all NHS acute trusts to explore how IR is implemented and supported across England. Phase 3: case studies to explore how IR is implemented 'on the ground', including individual interviews with patients, family members and staff, non-participant observation, retrieval of routinely collected patient outcomes and cost analysis. Phase 4: accumulative data analysis across the phases to scrutinise data for patterns of congruence and discordance and develop an overall evaluation of what aspects of IR work, for whom and in what circumstances. ETHICS AND DISSEMINATION: The study has been approved by NHS South East Coast-Surrey Research Ethics Committee. Findings will be published in a wide range of outputs targeted at key audiences, including patient and carer organisations, nursing staff and healthcare managers.

Physician assistants in English general practice: a qualitative study of employers' viewpoints.

OBJECTIVE: Effective use of staff is a major aim in all health-care systems both to maximize their impact and to minimize costs. In England, a few general practitioners (GPs) have been recruiting physician assistants (PAs) to work in their practices, independent of any pilot schemes. Our objective was to study the motivation of GPs and practice managers who employed PAs and to understand the factors that sustained their employment. METHODS: A qualitative study using semi-structured interviews, analysed thematically, was carried out with 13 GPs and three practice managers from 15 general practices employing PAs in five areas of England. RESULTS: All practices were employing USA-trained PAs. Motivating factors for their employment included increasing the general practice capacity to manage patient demand within government targets for access, broaden the skill-mix in the practice team and financial considerations. The issues that needed to be taken into account in employing PAs included: the requirement for medical supervision; the PAs current lack of a regulatory framework and prescribing authority; and some patients' lack of familiarity with the concept of the PA. CONCLUSIONS: General practice employers view PAs as a positive addition to a mixed skill team for meeting patient demand within a practice's finances. There is a need to develop stronger governance and regulatory frameworks for this emerging profession.

The workforce in health and social care services to older people: developing an education and training strategy.

Planning workforce development across the health and social care services for older people presents a formidable challenge. In England, Workforce Development Confederations are responsible for commissioning the education and training of the current and future health and social care workforce. This article reports on an analysis of local issues in planning the workforce for older people's services undertaken in one Confederation. It reports on the perceived priorities for developing the workforce in older peoples services in a policy environment where multiple initiatives were competing for attention. It highlights the key challenges in planning a strategy that embraces numerous service and education providers and offers practical solutions. Although this analysis was in one Confederation, the issues raised have relevance for other Confederations and their education and service partner organisations.