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.
Comments
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.
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.
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.
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
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.
Could I request some assistance from Annette Bartley for a tool in which to review the process
Thank you Heather Blackwell
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!!
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!
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.
and remember to tell all your friends as the more reviews we get the more choice there will be
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.
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