Will hourly rounds help nurses to concentrate more on caring?
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Like the curate's egg, the Prime Minister's announcement on improving the quality of nursing care on acute wards is good in parts. Given The King's Fund's and Health Foundation's work on nursing rounds with our Hospital Pathways programme, we welcome his support for hourly nursing rounds on inpatient wards and for the visible 'figure of nursing authority' on all wards.
However, his proposals include yet more measures – introducing the NHS Safety Thermometer – and inspections (albeit patient-led), so it is inevitable that they will add to the bureaucracy he claims to be fighting. The timing is also unfortunate: he might have been better advised to wait for the Francis report on Mid Staffordshire NHS Foundation Trust before wading into the debate on how best to monitor and regulate the quality of care.
Active nursing rounds – variously known as 'intentional' or 'care and comfort' rounds – are still relatively new. What is important is that it is patient- rather than task-focused: every hour, a nurse checks in with the patient, not to 'do something to' her, but to find out if she is comfortable and if there is anything she needs. It started in the United States and has been adopted in some UK hospitals, including some hospital trusts participating in our Hospital Pathways programme.
One of the problems with the Prime Minister's announcement is that it implies nursing rounds are the solution to poor-quality care everywhere. It is not. It is relevant to some – but not all – wards. It will not compensate for inadequate staffing and it will not work where there are not enough qualified nurses on the ward. But we do know that quality is not completely dependent on resources, and that poor care does happen on adequately staffed wards. But where there are enough staff, nursing rounds can ensure that nurses deliver a reliable standard of care to every patient.
We will need a rigorous, independent evaluation of the cost effectiveness of nursing rounds, but the outcomes from our hospitals reflect data from the United States, which shows that rounds are associated with significant increases in patient satisfaction and with equally significant reductions in the use of call bells and in the frequency of falls, pressure ulcers and complaints. We have seen the difference it makes to patients and nurses. It will improve nursing practice and the atmosphere on the ward if it is introduced carefully – not as a tick-box exercise. Patients will begin to feel confident that help is available when they need it, and will ring the call bell less. The ward will become calmer, the nurses will be able to take their breaks, and, when the shift ends, they will leave feeling less stressed and less worried about how they've treated their patients.
The visible nursing authority on the ward is very important. Patients and families really do want to know 'who is in charge' on the wards and who they can talk to about the patient's overall plan of care and progress. For trust boards, an important consequence of the Prime Minister's announcement must be the recognition that effective nurse leadership is a full-time job. There is a growing body of evidence and nursing opinion, for example, in Health Service Management Centre's Time to Care report, which says if ward managers are responsible for quality 24/7, they should have the time and the authority to do the job properly. Inevitably, the role involves some paperwork, but fundamentally, it is about people and relationships. Ward managers should be fully involved and responsible for the recruitment, the selection and, if necessary, the removal of staff in their own clinical areas, for staff supervision and support, and for real team building. They should be available to accompany consultants on ward rounds and to speak to patients and visitors. And – as Chris Ham discussed in a recent article in the British Medical Journal – as clinical leaders, they should be directing education and training, monitoring standards, and actively improving nursing systems and processes.
While the Prime Minister is right to take concerns about the quality of nursing care in acute hospitals seriously, he must resist the temptation to tell frontline staff how to do their jobs. Adding to the many demands already being made on hospitals to report externally will not help to free up time for nurses to care.
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Comments
The issue of nurse leadership and the visibility of 'those in charge' is critical and something that I was happily able to share some good practice on in my blog at advocatingexcellence.co.uk/2012/01/06/a-lesson-in-nurse-leadership-for-mr-cameron/ Mr Cameron and others in leadership could do worse than to emulate these particular nurses.
my letter in the letters page of the herald on 7th Jan says it all.
This is not new.
It is right.
Time to admit the baby of careing went out with the bathwater of handmainship and all the public(in the nhs otherwise known as the taxpayer or AKA the employer)sees is the loss of careing.
evidence,skillmix and professionalism does not mean we cant nurse to the traditional values the public expects and pays for.
One easy way to boost the quality and capacity of nursing is to provide them tools that increase their clinical skills. A US medical school found that providing their final year medical students with the Isabel diagnosis checklist system (isabelhealthcare.com) increased their diagnostic accuracy by over 20% ncbi.nlm.nih.gov/pubmed/21330845
This video- tinyurl.com/75n5qld - shows a physician and nurse talking about how they use the system and, most interesting, is how the nurse practitioner tells of a cancer save she made where the 2 physicians who had seen the patient previously had not considered a cancer diagnosis at all.
Increasing the clinical skills of nurses would make a big difference and can be done quickly by the provision of simple, cost effective and validated tools.
The first Francis Inquiry found that nurses and doctors were understaffed at mid Staffs and were not supported by senior management. So getting nurses to do their job is not a solution on its own. Senior managers and the board must be accountable for patient care and safety. Targets can achieve focus and sufficient funding or can lead to gaming to meet the target rather than the patient need.
After more than 20 years in nursing, most of which spent in the acute sector, I find it extremely frustrating to be told by academics and politicians how I should be doing my job better or need more training. Most of these people will have had very little, if any, direct experience of the work being done by nurses in hospital. If they really want to know why nursing care can be so poor at times and if they are serious about finding solutions to the problems affecting care quality they should come and work with me or any of my colleagues for a few days and they would soon discover why good nurses can be made to give such poor care.
I am a staunch advocate for "intentional rounding", which I came across whilst working in the USA a few years ago. Irecognised the potential it had and its transferability to the UK setting. It built upon traditions many of us nurses will recall such as the old 'back rounds' however it was more structured and evidence based .When executed effectively it is not merely a ticking the box exercise but a thoughtful, considered, patient focused intervention designed to achieve an outcome/s. The process is linked to a range of measures which enable staff to see if they are making a difference to patients. It helps understaffed and busy units to organise the care they deliver in a more organised and systematic way and this does not mean it removes a nurses ability to offer individualised care within the confines of a structured process.It should be helpful to nurses and not seen as an added burden.
My concern with the Prime Ministers laudable support is that there will be a predictable knee jerk reaction to follow it and this intervention with such potential will be enforced upon an NHS with frontline staff already under considerable strain.
Rounding needs to be tested and implemeted carefully in order to achieve the outcomes seen a number of other organisations across the UK including NHS Salford. In the Hospital Pathways programme the Kings Fund has been working to test rounding with a number of sites and to begin to collate an evidence base and intelligence regarding what works etc.
It is unlikely that more staffing will be provided at the frontlines of care so we need to recognise and be sensitive and supportive to staff placed under enormous pressures and ensure that when we introduce rounding it is done a pace that meets the staff where they are at! Otherwise this will prove to be yet another promising idea set up to fail.
I am an advocate for international rounding, and believe that this isapplicable to all wards and should not be seen as being task orientated, but good practice. This will make the patients feel cared for, I have recently been an hospital inpatient and the staff where very visible on the ward. They spoke to every patient every hour, unless they where sleeping., and asked did we need anything, this ranged from pain relief to providing fresh water. There was not one member of staff who was not know to me during my stay.
This should be basic care on all wards , in particular where the elderly and infirm are. this can only be good for the NHS as nurses are no longer trained to undertake what I deem asone off the basics that all patients should receive
I have found - from my own experiences, in several hospitals, that as an almost 100 % rule "a good caring and disciplined consultant" has a good team, he and his staff run a tight ship which reflects on the clinical and ward staff and so to the care of the patients - a point usually overlooked. They protect their patients and staff from the poor management and frequently officious ward managers, frequently with difficulty. Inferior doctors and bad management most usually result in poor care and demoralised ward staff. Natural leadership is not indoctrinated as aspired by the expensive NHS "innovation and Improvement" with its manpower inspired leadership courses - a costly and poor NHS experiment, wasting much needed funds
I have found - from my own experiences, in several hospitals, that as an almost 100 % rule "a good caring and disciplined consultant" has a good team, he and his staff run a tight ship which reflects on the clinical and ward staff and so to the care of the patients - a point usually overlooked. They protect their patients and staff from the poor management and frequently officious ward managers, frequently with difficulty. Inferior doctors and bad management most usually result in poor care and demoralised ward staff. Natural leadership is not indoctrinated as aspired by the expensive NHS "innovation and Improvement" with its manpower inspired leadership courses - a costly and poor NHS experiment, wasting much needed funds
Nice insightful piece.
Intentional rounding and its iterations are just second hand eloquence for practices that have been around for a millennia and nudged out by each successive new initiative. Spinning meaningful contact into a tokenistic hourly ward round will be at best a tick box exercise in banality.
No panacea absent of context is ever useful. In wards with complex patients like the very ill elderly, this suggests drastically reducing the regular contact which is much more continuous. For simple patients, in pathway based convalescence, every hour is going to be annoying (I know I've been there)!
The only place for hourly ward rounds is the godforsaken emptiness of those coffinesque individual rooms where loneliness not illness kills you. Normal human social interaction is a core element of recuperation and the hourly check will be an excellent way of confirming on a statistical process control chart that you haven't died yet.
Cameron is insulting for even suggesting that we view care with the same system used to check the toilets in Weatherspoons! Classic crap that undermines the compassion and integrity of the vast majority of practitioners. The word 'Quality' is similarly used to mean anything good. Everything has qualities and in different situations the same quality can be both good and bad. I like my gin to taste of juniper and I like my sausages to be cheap, so which has the most qualities posh gin or cheap sausages.
Hourly ward rounds have all the hallmarks of cheap gin and posh sausage and one of those ends up in a Weatherspoons toilet.
RE Intentional Rounding
Could I request some assistance from Annette Bartley for a tool in which to review the process
Thank you Heather Blackwell
Is there any one who has a tool that is working well to document that hourly rounding is taking place that they would be willing to share. We have been using a tool but feel it is turning out as a tick box exercise as too detailed. It is an excellent idea and have seen it's benefits but need a simpler tool to document it is being done. thank you.
Oh my word!! I feel people are missing the point entirely! Why do so many take offence at someone (Cameron) trying to make suggestions on how to improve a system that is clearly lacking the basic human element of care? Yes, I agree that there are fabulous nurses out there that do a grand job, that don't take the pressures of minimum staffing and resources out on the patients but, there are way too many nurses who allow themselves to get sucked into a vaccuum of bitterness and anger which ceases their ability to care anymore. Their attitudes towards their leaders and employers dictate how they will treat patients. They no longer think for themselves or want to learn anything new therefore, no government initiative or policies (no matter how good they are) will have the desired outcome or improve their attitudes towards patients.
Nurses lack inspiration and motivation! It used to be a profession you would aspire to. Goodness knows why some people come into it now.
At the end of the day, we are delivering a SERVICE which should be 5star at all times and if we cannot, the patient is certainly entitled to an explanation instead of the cold shoulder whether we think they deserve it or not!
Having been a patient that received poor care delivery, I felt extremely let down by my profession. However, it has taken some time to realise that these people were good people that just can't see the patients from the politics. A universal knowledge of good communication, customer service, manners and etiquitte is what is missing in most cases!!
This is a basic element to nursing care and should be done anyway!
In theory I think this move is a great way of increasing the presence of the Nurse at the bedside, however, without increased resouces within an already pushed to breaking point environment, I fear this may become a tick box exercise contributing to a steep mountin of paperwork.
We need more Nurses, not more ideas!
Happy to help please contact me via e-mail and will send some thoughts/info
I really don't accept the concept of compulsory "rounding" by RNs on their patients. If nurses are true professionals, the last thing we need is to be told the minutiae of how to do our job. Workload management is a major issue for nurses and just as our medical colleagues make assessments of clinical priorities, so do we. I am appalled and ashamed of reports of basic care being abandoned by my nurse colleagues this shouldn't happen but it is a matter of shared responsibility between the professional judgements of the nurses involved and management seeking to make staffing ratios "efficient" whilst at the same time making unrealistic demands of staff (like "lets start compulsory documented rounding").
To illustrate: just last evening I had sole care of six patients; three were immediate post operative after spinal surgery, one was a new admission who had recently had CABG and was returning with a chest infection for IV therapy, another was an obese man four days post a total knee replacement with occasional urinary incontinence wearing pads but unable to stand without x2 assist and difficult to roll in bed. The final patient was a young man with a chest drain following a spontaneous pneumothorax; he and one of the post-op patients had a PCA requiring regular observations. And did I mention my concern about one of the post-op patients who was borderline narcotised after the morphine given in Recovery?
Now, do you think I need the threat of some tick box compulsory rounding sheet to fill out in this situation? No. What I really need is commitment from management to adequately resource the level of care I want to provide and those six patients deserve. Oh, and I left my shift 40 minutes after shift end just to try and get everything done, for no extra pay and no thanks.
The single most important improvement to care for patients I feel is mandated care ratios.
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Whilst going round the wards seeing the acutely ill patients i am frustrated by what i see and hear. There is a lack of compassion and the way staff sometimes speak to patients/relative can often come across like they just don't care. Staff should never hang about the corridor/nurses station gossiping like i sometimes see. If nurses have quiet spells they should be checking notes, charts, medications, making sure patients are hydrated and fed, talk to patients, check stock, clean bedside tables, read protocols, teach. There is always something to do.
staff read vital signs from a machine rather than looking at the patients and checking vital signs manually. Patients should be looked at holistically instead of having obs rounds then medication rounds, then someone else doing the urine output and bm's etc.
Staff should be giving the impression that nothing is too much trouble. Nurses seem to always complain they "haven't got time" but then have time to stand telling you how busy they are.
I could go on and on.
I do not need a tick box to remind me to check pts comfort at timed intervals. I need pairs of hands to help me attend to individual pt needs in a timely safe and appropriate manner. However i also need to provide evidence of task completed. It is not enough anymore to state vocally somefhing has been undertaken Nor is it sufficient to document in any one piece of paperwork. Truplicate documnting is now a minum requirement. It takes more time..and collating it onto computerised records removes me further from hands on care. Our healthcare assistants responsibilities increase but the RN has overall responsibility for checking the work of HCA has been appropriately undertaken. Too often the RN is unable to clarify this in a timely fashion due to other tasks requiring attention at the same time. What of the telephone calls going unanswered..the visitor demands remaining unattended to...sorry but we are too busy trying to meet pt needs with an undermanned workforce!!
Gossipping staff..?...how do you know that?....we are often involved in writing up notes..passing on important information between each other related to pt care...computer access at nurses station...completing info often involves verbal discussions with other staff..as does rota changes...bed managing...issues arising with staff which then nees to gain privacy for...?...gossipping??..please..do not judge a book by its cover!!...not all ward areas have the private areas they should and staff need to be able to ask initially so they can be supported appropriately in whatever they do!!..gossiping indeed!!!...next time stand back and think a bit before you wade in with size tens!!
Quiet spells???..those moments when you can catch up with paperwork..draw breath from the constant work onslaught...grab a quick sip seeing as you never got your break...reassure the colleague who struggles with an aspect of care or pt outcome...take a few moments to ease those aching muscles which age and overwork result in...a few moments to zone out or in from a difficult episode of care..so you can carry on appropriately with the care needs of others..and the visitors who think it is acceptable to demand priority attention because they think you are merely gossiping!!!...little do they know a planned action of care is being put in motion!!
Such negativity is what drains the workforce!!!...if you ask we will explain how busy we are..if you wonder why something hasnt been achieved..we will explain how busy we are..stock checks??..you have no idea!!!..fluid intake ..probably just finished helping pt....so easy to pre judge isnt it!!!..much harder to appreciate what has been done dont you think??
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