Will hourly rounds help nurses to concentrate more on caring?
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 of The King's Fund 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.
Jocelyn is Director of The Point of Care programme at The King’s Fund.Notes
1. The Health Foundation’s Hospital Pathways programme is run in partnership with The King’s Fund as part of The Point of Care programme and works with patients, families, healthcare staff and hospital boards to improve the patient experience.
2. This blog post was originally posted on The King's Fund website.
We have long been urging nurses (and other professionals) to take up the mantel of Evidenced Based Practice without similarly urging them to consider the values of their practice. Values Based Practice sits along side EBP as it encourages nurses to engage in active understanding of what they are seeking to achieve and why. It is an opportunity to reframe our discussions around the needs of a patient and their family rather than the needs of a service or organisation. Values Based Practice helps us have a deeper and person centred understanding of the evidence.
There is an acknowledgement that these are important issues for patients as concluded by any number of commission reports. Patients wish to be seen as people first and a diagnosis second. Encouraging nurses to walk a ward is only one step in the process in fully and purposefully engaging with people/patients.
There are frameworks to assist this process such as, The Essential Shared Capabilities programme in mental health services, the ‘Whose Values’ workbook and the core values programme to support children and young people from the National CAMHS Support Service. However these approaches are localized but have application right across the care and age spectrum.
http://pioneer513.wordpress.com/the-death-of-nursing/
I am afraid the answer is all in the training. My Great Aunt trained in 1914, and saw the Great war, the Flu pandemic and the second world war.Nurse training was five years, and you started by learning to clean the wards.
Once the principles of hygiene had been understood, not only were you aware what a clean ward looked and smelled like, you could direct you juniors to attain the same standards.
The other important elements missing today I have identified in my blog.
It is also disappointing that the success of hourly ward rounds is attributed to the States - as a nurse who trained in the 70s this was a significant part of our role, and one thta was deemed to be improtant.
It is also imprortant to clarify the issue of paperwork that nurses have to deal with. There is some paperwork that is crucial to the well-being of the patient e.g. fluid charts, nurse records, prescription charts etc. and that which is for the benefit of the organisation and its managers.
Those in charge of NHS organisations need to reflect on its purpose. It is there to meet the needs of the patient, not the managers or policy makers who depend on it to further their carers.
The woeful lack of registered nurses on wards cannot be ignored. Healthcare assistants (HCAs) do not have sufficient training and thus competencies to undertake many of the nursing responsibilities they now seem to have. The ability to see or be aware of a situation, understand the possible outcomes, decide what early interventions or emergency actions need to be taken and what this will mean to the patient, team and ward/community setting is crucial and requires a certain level of expertise.
Hourly ward rounds are a red herring. Speaking with, listening to and anticipating the emotional and physical needs of patients was second nature during my practice and patients were seen more often than hourly but usually as needed depending on your assessment of their condition/situation. Let us not ignore the decimation of the numbers of registered nurses on wards. Sufficient numbers are needed to direct and oversee quality, with effective and timely interventions based on appropriate assessments; with an understanding of intended and unintended consequences. It is notable that the unacceptable low numbers of registered nurses in many wards across England is not addressed by the Care Quality Commission during inspections, neither are Trust Boards held to account.