Title: Intentional rounding in hospital wards: What works, for whom and in what circumstances?
Funder: Department of Health and Social Care

Abstract: Research question: What is it about intentional rounding (IR) in hospital wards that works, for whom and in what circumstances? Aim: 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. We will investigate this at the 3 levels of the organisation and delivery of health services: national, service provider organisation and individual ward/unit. We will identify the ways in which the context (i.e. the environment and organisation) at each of these levels influences the mechanisms (i.e. the assumptions and theories about the ways in which IR achieves its objectives) and the outcomes or impact. Method: A multi method study design will be undertaken drawing upon a realist evaluation approach. The study will be conducted in 4 phases. As available theory on IR is limited, phase 1 will involve theory development, drawing upon principles of realist synthesis. Searches of the relevant academic and grey literature and a stakeholder consultation event will be held to generate hypotheses on what the mechanisms of IR may be, what particular groups may benefit most or least from it and what contextual factors might be important to its success or failure. These hypotheses will be interrogated and tested in phases 2 and 3. Phase 2 will involve a national survey of non-specialist NHS acute trusts to explore how IR is implemented and supported across England. Phase 3 will purposively select 6 case study wards across 3 geographically spread hospitals in England using findings from the national survey. Within each of the 3 hospitals, a range of data will be collected from 2 wards (1 acute, 1 care of the elderly): qualitative interview with ward manager (n=1), individual interviews with ward nursing staff and healthcare assistants (n=5), patients (n=5), family members (n=5) and other stakeholders (n=5). Nurse shadowing and observations of IR will be conducted, routinely collected ward outcome data retrieved from the NHS Safety Thermometer and a bottom-up analysis of costs undertaken. The framework approach will be used for qualitative analysis of interview data. Observation data will be analysed using descriptive statistics and thematic analysis of ethnographic fieldnotes. Quantitative analyses of the NHS Safety Thermometer data will be exploratory and tailored to the individual circumstances of IR on each ward. Phase 4 will involve accumulative data analysis across the phases. Data will be scrutinised for patterns of congruence and discordance to develop an evaluation of what aspects of IR work, for whom and in what circumstances. Main benefits: This research will provide robust information about what good and poor practice of IR looks like, how it is delivered and the factors that facilitate and hinder implementation. This research will provide benefit by enabling trusts to target their effort and resources on supporting good practice (and redirecting resources from aspects of IR that are not useful) and will inform operational guidelines and policies directing the delivery of direct patient care. Impact to NHS: IR has been extensively implemented throughout the NHS, therefore this study will have widespread impact. The findings will directly inform nursing practice and provide policy messages for the Care Quality Commission of what good IR looks like and advice on the type of data to collect for quality monitoring.

Lay abstract: One recommendation made by the Francis Inquiry was that, “Regular interaction and engagement between nurses and patients and those close to them should be systematised though regular ward rounds”. This recommendation received strong support from the government and the majority of NHS trusts in the UK have now introduced ‘intentional rounding’ (IR), a structured process whereby nursing staff carry out regular checks, usually hourly, with individual patients to address their positioning, pain, personal needs and placement of items. Some published studies in the USA have found benefits of IR for patient care, including a reduction in call bell use, falls and pressure sores and increased patient satisfaction. However, there is little research to support this in the UK and what research does exist has been criticised for its design weaknesses (e.g. Snelling, 2013; Halm, 2009). This study therefore seeks to generate an evidence base for IR which will provide the necessary information to successfully guide the development and implementation of IR across the UK. The research seeks to answer the question: ‘What is it about IR in hospital wards that works, for whom and in what circumstances? A multi method study design will be undertaken drawing upon a realist evaluation approach (Pawson and Tilley, 1997). Realist evaluation acknowledges that complex interventions such as IR only ever work for certain people in particular circumstances, therefore IR may have a very positive influence on experience in one hospital ward but a negative impact in another. The key task of this evaluation is to understand and explain these patterns of success and failure so that NHS trusts can target or develop IR so that it has the greatest chance of success with their patients and within their setting and redirect their resources away from aspects of IR that are not useful in their setting. The study will be conducted in four phases. As available theory on the potential of IR is limited, phase 1 will involve theory development. Literature searches and a stakeholder consultation event will be held to generate hypotheses on what the mechanisms of IR may be, what particular groups may benefit most or least from it and what contextual factors might be important to its success or failure. These hypotheses will be interrogated and tested in phases 2 and 3 of the study. Phase 2 will involve a national survey of all non-specialist NHS acute trusts in England to explore how IR is currently being implemented and supported. In Phase 3, six case study wards will be selected across three geographically spread hospitals based upon findings from the survey. Within each hospital, the following data will be collected from two wards (one acute, one care of the elderly): qualitative interview with a ward manager (n=1); individual interviews with ward nursing staff and healthcare assistants (n=5), patients (n=5) family members (n=5) and other stakeholders (n=5); observations, including the 'shadowing' of nurses during IR; and the retrieval of routinely collected ward outcome data to establish what changes occurred in outcomes alongside the introduction of IR. An analysis of costs will also be undertaken to identify the resources used by case study wards to develop and implement IR. Phase 4 involves exploring the data from all phases to establish the potential outcomes of IR, the underlying mechanisms which explain how it works and the key contexts that impact its success or failure.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE