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.

Intentional rounding in hospital wards to improve regular interaction and engagement between nurses and patients: a realist evaluation

© Crown copyright 2013. Contains public sector information licensed under the Open Government Licence v3.0© Queen’s Printer and Controller of HMSO 2019. This work was produced by Harriset al.under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.20132019Crown copyrightQueen’s Printer and Controller of HMSO

Background

The government response to the care failures at the Mid Staffordshire NHS Foundation Trust led to the policy imperative of ‘regular interaction and engagement between nurses and patients’ (Francis R.Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013. © Crown copyright 2013. Contains public sector information licensed under the Open Government Licence v3.0) in the NHS. The pressure on nursing to act resulted in the introduction of the US model, known as ‘intentional rounding’, into nursing practice. This is a timed, planned intervention that sets out to address fundamental elements of nursing care by means of a regular bedside ward round.

Objectives

The study aims were to examine what it is about intentional rounding in hospital wards that works, for whom and in what circumstances.

Design

A multimethod study design was undertaken using realist evaluation methodology. The study was conducted in four phases: (1) theory development; (2) a national survey of all NHS acute trusts in England; (3) in-depth case studies of six wards, involving individual interviews, observations, retrieval of routinely collected ward outcome data and analysis of costs; and (4) synthesis of the study findings.

Setting

The study was conducted in acute NHS trusts in England.

Participants

A total of 108 acute NHS trusts participated in the survey. Seventeen senior managers, 33 front-line nurses, 28 non-nursing professionals, 34 patients and 28 carers participated in individual interviews. Thirty-nine members of nursing staff were shadowed during their delivery of intentional rounding and the direct care received by 28 patients was observed.

Review methods

A realist synthesis was undertaken to identify eight context–mechanism–outcome configurations, which were tested and refined using evidence collected in subsequent research phases.

Results

The national survey showed that 97% of NHS trusts had implemented intentional rounding in some way. Data synthesis from survey, observation and interview findings showed that only two of the original eight mechanisms were partially activated (consistency and comprehensiveness, and accountability). The evidence for two mechanisms was inconclusive (visibility of nurses and anticipation); there was minimal evidence for one mechanism (multidisciplinary teamwork and communication) and no evidence for the remaining three (allocated time to care, nurse–patient relationships and communication, and patient empowerment). A total of 240 intentional rounds were observed within 188 hours of care delivery observation. Although 86% of all intentional rounding interactions were observed to be documented, fidelity to the original intervention [i.e. the Studer Group protocol (Studer Group.Best Practices: Sacred Heart Hospital, Pensacola, Florida. Hourly Rounding Supplement. Gulf Breeze, FL: Studer Group; 2007)] was generally low.

Limitations

Intentional rounding was often difficult for researchers to observe, as it was rarely delivered as a discrete activity but instead undertaken alongside other nursing activities. Furthermore, a lack of findings about the influence of intentional rounding on patient outcomes in the safety thermometer data limits inferences on how mechanisms link to clinical outcomes for patients.

Conclusions

The evidence from this study demonstrates that the effectiveness of intentional rounding, as currently implemented and adapted in England, is very weak and falls short of the theoretically informed mechanisms. There was ambivalence and concern expressed that intentional rounding oversimplifies nursing, privileges a transactional and prescriptive approach over relational nursing care, and prioritises accountability and risk management above individual responsive care.

Future work

It is suggested that the insights and messages from this study inform a national conversation about whether or not intentional rounding is the optimum intervention to support the delivery of fundamental nursing care to patients, or if the time is right to shape alternative solutions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Stable, predictable and training-free operation of superconducting Bi-2212 Rutherford cable racetrack coils at the wire current density of 1000 A/mm2

High-temperature superconductors (HTS) could enable high-field magnets stronger than is possible with Nb-Ti and Nb3Sn, but two challenges have so far been the low engineering critical current density JE, especially in high-current cables, and the danger of quenches. Most HTS magnets made so far have been made out of REBCO coated conductor. Here we demonstrate stable, reliable and training-quench-free performance of Bi-2212 racetrack coils wound with a Rutherford cable fabricated from wires made with a new precursor powder. These round multifilamentary wires exhibited a record JE up to 950 A/mm2 at 30 T at 4.2 K. These coils carried up to 8.6 kA while generating 3.5 T at 4.2 K at a JE of 1020 A/mm2. Different from the unpredictable training performance of Nb-Ti and Nb3Sn magnets, these Bi-2212 magnets showed no training quenches and entered the flux flow state in a stable manner before thermal runaway and quench occurred. Also different from Nb-Ti, Nb3Sn, and REBCO magnets for which localized thermal runaways occur at unpredictable locations, the quenches of Bi-2212 magnets consistently occurred in the high field regions over a long conductor length. These characteristics make quench detection simple, enabling safe protection, and suggest a new paradigm of constructing quench-predictable superconducting magnets from Bi-2212.

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.

The determinants and consequences of adult nursing staff turnover: a systematic review of systematic reviews

BACKGROUND

Nurses leaving their jobs and the profession are an issue of international concern, with supply-demand gaps for nurses reported to be widening. There is a large body of existing literature, much of which is already in review form. In order to advance the usefulness of the literature for nurse and human resource managers, we undertook an overview (review of systematic reviews). The aim of the overview was to identify high quality evidence of the determinants and consequences of turnover in adult nursing.

METHODS

Reviews were identified which were published between 1990 and January 2015 in English using electronic databases (the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, Applied Social Sciences Index and Abstracts, CINAHL plus and SCOPUS) and forward searching. All stages of the review were conducted in parallel by two reviewers. Reviews were quality appraised using the Assessment of Multiple Systematic Reviews and their findings narratively synthesised.

RESULTS

Nine reviews were included. We found that the current evidence is incomplete and has a number of important limitations. However, a body of moderate quality review evidence does exist giving a picture of multiple determinants of turnover in adult nursing, with - at the individual level - nurse stress and dissatisfaction being important factors and -at the organisational level - managerial style and supervisory support factors holding most weight. The consequences of turnover are only described in economic terms, but are considered significant.

CONCLUSIONS

In making a quality assessment of the review as well as considering the quality of the included primary studies and specificity in the outcomes they measure, the overview found that the evidence is not as definitive as previously presented from individual reviews. Further research is required, of rigorous research design, whether quantitative or qualitative, particularly against the outcome of actual turnover as opposed to intention to leave.

TRIAL REGISTRATION

PROSPERO Registration 17 March 2015: CRD42015017613 .

Interventions to Reduce Adult Nursing Turnover: A Systematic Review of Systematic Reviews

BACKGROUND

Nurse turnover is an issue of concern in health care systems internationally. Understanding which interventions are effective to reduce turnover rates is important to managers and health care organisations. Despite a plethora of reviews of such interventions, strength of evidence is hard to determine.

OBJECTIVE

We aimed to review literature on interventions to reduce turnover in nurses working in the adult health care services in developed economies.

METHOD

We conducted an overview (systematic review of systematic reviews) using the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, Applied Social Sciences Index and Abstracts, CINAHL plus and SCOPUS and forward searching. We included reviews published between 1990 and January 2015 in English. We carried out parallel blinded selection, extraction of data and assessment of bias, using the Assessment of Multiple Systematic Reviews. We carried out a narrative synthesis.

RESULTS

Despite the large body of published reviews, only seven reviews met the inclusion criteria. These provide moderate quality review evidence, albeit from poorly controlled primary studies. They provide evidence of effect of a small number of interventions which decrease turnover or increase retention of nurses, these being preceptorship of new graduates and leadership for group cohesion.

CONCLUSION

We highlight that a large body of reviews does not equate with a large body of high quality evidence. Agreement as to the measures and terminology to be used together with well-designed, funded primary research to provide robust evidence for nurse and human resource managers to base their nurse retention strategies on is urgently required.

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.

A summary of the recommendations for smoking cessation interventions: the quality assurance in the treatment of drug dependence project

This report presents outlines for approaches to smoking cessation. These recommendations are based on a meta-analysis of the treatment-outcome literature, a survey of current treatment practices and the views of a panel of experts. Face-to-face intervention to assist smokers to stop smoking needs to be considered in the context of a public policy approach to reducing the prevalence of smoking. The nature of face-to-face interventions is determined by the time available to practitioners. Where there is no time to intervene (e.g. in some primary health care settings) quality self-help materials should be prominently displayed. Where there is only 10 minutes or less, attention should be focused on personalizing the health effects of smoking, providing firm advice to quit, providing self-help material, setting a quit date (if appropriate), identifying social support for cessation and organizing a follow-up visit. If there is more time to intervene (up to one hour) the previous techniques can be expanded on and supplemented with nicotine replacement and discussion of methods for dealing with high-risk situations. Longer interventions would use all of these methods, presenting them in more detail, and may also address stress management and minimization of weight gain.

Continuous vs intermittent albuterol, at high and low doses, in the treatment of severe acute asthma in adults

Adult patients suffering from acute asthma presenting to the Emergency Department with an FEV1 of less than 40% of predicted were randomized into four treatment groups. They were treated with nebulized albuterol at a high (7.5 mg) or standard (2.5 mg) dose given either continuously through 1 h, or intermittently every hour, for 2 h. When the FEV1 improvements for the different groups at 2 h were compared, the groups treated with continuous nebulization had the greatest improvement. The improvements (1.07 L for the high-dose group, and 1.02 L for the standard-dose group) were significantly greater than the improvement seen with standard-dose intermittent treatment (0.72 L; p < 0.05). The improvement in FEV1 of the high-dose, hourly treated group was intermediate in magnitude between these (0.09 L). There was no difference in the improvement seen between the two groups treated with continuous nebulization. The potassium fall, present in all groups, was more pronounced in the groups treated with high doses of albuterol. Only one person (high dose, continuous treatment group) developed hypokalemia of less than 3.0 mmol/L. The high-dose hourly treated group had the highest incidence of side effects, and the standard-dose continuously treated group had the lowest. The standard-dose continuous-treatment regimen had the greatest improvement in FEV1 with the least number of side effects.

Isoetharine versus albuterol for acute asthma: greater immediate effect, but more side effects

PURPOSE

To compare the magnitudes of the immediate effects of the nebulized beta-agonists isoetharine and albuterol in the treatment of acute severe asthma.

PATIENTS AND METHODS

Fifty-one adults presenting with severe asthma exacerbations (forced expiratory volumes in the first second of exhalation [FEV1] <40% of predicted) to the emergency department were randomized (double-blind) to receive hourly inhaled nebulization treatment with either isoetharine (5 mg) or albuterol (2.5 mg). The FEV1 was measured immediately before and after each nebulized treatment. Any side effects were recorded.

RESULTS

Immediately after the first nebulized treatment, the isoetharine group improved its mean FEV1 (+/-SEM) by a significantly greater amount than did the albuterol group: 60% +/- 11% versus 39% +/- 5%, respectively (P <0.05). One hour later the mean FEV1 were equivalent. This pattern repeated itself after the second hourly treatment. The two groups did not differ in any outcome parameters (FEV1 at discharge, number of nebulized treatments required, the number of inpatient admissions, number of clinical relapses after discharge). More patients treated with isoetharine had side effects (36% versus 4% for albuterol, P <0.01), 1 of whom required discontinuation from the study.

CONCLUSIONS

Both medications were equally effective in alleviating bronchospasm. The immediate effect of isoetharine was significantly greater, but equalized that of albuterol within an hour after treatment. There were more side effects with isoetharine.

The pros and cons of transdermal nicotine therapy

OBJECTIVE

To review current knowledge of the efficacy, safety and cost of transdermal nicotine therapy for smoking cessation.

DATA SOURCES AND STUDY SELECTION

1. Published and unpublished reports of randomised, double-blind trials of at least 12 weeks' duration, in smokers motivated to cease smoking, identified by a search of the MEDLINE database, article and book bibliographies, Current contents, and by a request to the Medical Department of Ciba-Geigy (Australia) Ltd. 2. A clinical trial of 1500 smokers using transdermal nicotine (S Gourlay, unpublished data).

DATA SYNTHESIS

Transdermal nicotine more than doubles the success rates of smoking cessation attempts in motivated subjects who smoke at least 10-15 cigarettes per day (odds ratio 12 months after quitting, 2.3; 95% confidence interval, 1.6-3.4). Application site reactions are not uncommon (erythema or burning < or = 16%, transient itch < or = 50%) and cause discontinuation of therapy in up to 10% of subjects. Sleep disturbance due to nocturnal nicotine absorption occurs in up to 13% of subjects when patches are worn overnight. Smoking or nicotine chewing gum used concurrently with transdermal nicotine could raise peak nicotine levels but is unlikely to adversely affect individuals with established tolerance to nicotine. Smoking and (theoretically) nicotine replacement therapies should be avoided in pregnancy or patients with unstable coronary artery disease. In such patients, the risk-benefit ratio of nicotine replacement therapies may be favourable for nicotine-dependent smokers unable to cease smoking by alternative methods.

CONCLUSIONS

Transdermal nicotine is an effective smoking cessation therapy for motivated, nicotine-dependent smokers. As most smokers can cease smoking on their own, and the patches are costly, they should be recommended only for smokers who are unable to quit by simpler means and those likely to suffer severe nicotine withdrawal symptoms.

A placebo-controlled study of three clonidine doses for smoking cessation

BACKGROUND AND OBJECTIVE

Clonidine in doses of 150 to 450 micrograms per day has been reported to reduce symptoms of craving associated with tobacco withdrawal and, in some cases, to improve long-term abstinence rates of smoking cessation programs. However, subjects frequently experienced symptoms of dry mouth and drowsiness. This study investigated the lower end of the effective dose range of clonidine for smoking cessation to identify the lowest useful dose and thus minimize the adverse effects of the drug.

METHODS

A randomized, double-blind, four-way crossover design compared the effects of clonidine doses or placebo within individual subjects for 4 consecutive weeks. Smokers who were highly nicotine dependent were randomly assigned to different sequences of placebo and 300, 200, and 100 micrograms clonidine per day. Subjects were treated for 4 days of each treatment week and began smoking cessation from the end of day 2. Smokers recorded withdrawal symptoms on multiple visual analog scales during days 3 and 4 before resuming normal smoking until the next period of smoking cessation.

RESULTS

A statistically significant dose-response effect was found for craving scores (dose-response gradient, -3.8/100 micrograms; 95% confidence interval [CI], -6.2 to -1.5; p = 0.002) but not for pooled tobacco withdrawal scores. The dose of 300 micrograms per day reduced mean craving scores significantly (-16%; 95% CI, -31% to -1%). Dosing with 200 micrograms approached statistical significance (-14%; 95% CI -30% to 1%) but dosing with 100 micrograms did not (-6%; 95% CI, -22% to 9%). Troublesome adverse experiences were reported by more than 67% of subjects during 200 and 300 micrograms dosing.

CONCLUSIONS

This study showed a statistically significant dose-response effect of clonidine on tobacco withdrawal craving and a reduction in mean craving scores of 16% during 300 micrograms dosing. However, its clinical usefulness is doubtful because of frequently reported adverse experiences.

Differences in the acute and chronic antihypertensive effects of lisinopril and enalapril assessed by ambulatory blood pressure monitoring

Although lisinopril and enalapril are equipotent angiotensin converting enzyme (ACE) inhibitors lisinopril has been reported to produce greater inhibition of plasma ACE 24 hours after single doses. This study compared the antihypertensive effects of once daily 10mg doses of the drugs using a randomised, double-blind, two period cross-over design with ambulatory blood pressure monitoring. Lisinopril lowered mean 24 hour systolic blood pressure significantly more than enalapril after 4 weeks of treatment (14/7 +/- 2/1mmHg & 9/6 +/- 2/1mmHg, respectively, adjusted SBP difference 4.8mmHg, P < 0.01). This difference was confined to the second 12 hours of the daily dosage interval (adjusted SBP difference 13-24 hours after dosing 9.9mmHg, P < 0.001). The diastolic pressure showed a similar trend but this was not statistically significant. The side effects of each agent were minor. We conclude that chronic, once daily therapy with 10mg of lisinopril reduces systolic blood pressure more effectively than an equal dose of enalapril due to its greater effect in the latter half of the 24 hour dosage interval.

Optical mapping of the thoracoabdominal wall

An optical technique has been developed for mapping the size and shape of the thoracoabdominal wall and the change in its shape with breathing. A fixed pattern composed of stripes of light is projected on to both sides of the trunk. These stripes become distorted when viewed from in front and behind, forming contours over the trunk surface. The contours are photographed and then encoded digitally. The digital information can be used to compute automatically the volume of the trunk, the position of any point on its surface, and its cross sectional shape at any level. The technique has been tested on rigid objects (a globe, a cone, and two dummy torsos) that can be measured precisely. With this optical technique linear dimensions can be calculated to within 0.5 mm, cross sectional area to within 5%, and volume to within 1.6-3.7%. These results suggest that this non-invasive technique measures the shape and volume of complex three dimensional surfaces with sufficient accuracy to be tried in clinical practice.