Will hourly rounds help nurses to concentrate more on caring?

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 the Hospital Pathways Programme, his support for hourly nursing rounds on inpatient wards and for the ‘visible figure of nursing authority’ on all wards is welcomed.

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.