El control social como función de la política social

The term ‘routine’ encompasses the action of the rounding, the defined rounding practice associated to the particular study context. This includes the time of the rounding, the two- hour frequency of rounding, an introduction of the rounder to the patient and the use of the questions “Is there anything I can do for you?” and “Do you have any worries or concerns?” A record of the patient visit is documented on the rounding sheet an A3 size chart (appendix 2). Although not explicit in the rounding document as part of the rounding process the rounder is expected as part of their rounding process to check the patients call bell is within

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their reach. The cultural theme of playing the routine identified itself through the behaviours and values the ward staff demonstrated when performing the practice of rounding. There appeared to be an accepted and adjusted rounding process which ward staff participated in, as part of the ward culture.

In the cultural theme of Presence the field notes attested to an inconsistent approach to the rounder introducing themselves to patients which some staff attributed to being busy. In playing the routine the rounder’s appeared to signal to patients they were busy and patients appeared to adapt their response to this.

One of the most explicit examples of this was from the field note data of the nurse observers in that standing outside the doorway for patients in side rooms was a signal that the rounder didn’t want to enter the room to have any further interaction with the patient. This approach was also apparent when the rounding process was carried out in bays.

The rounding appeared rushed by the nursing assistant, most patients I believe did not actually ask for anything because they were not invited to do so they were only asked are you okay to which they replied yes thank you or just yes. I got the

impression the nursing assistant avoided engaging too much with patients as she was very busy (Obs 11)

The patients in side rooms did not make any requests for assistance or engage in any conversation, I did wonder if this was because they were being addressed from the doorway which gave the impression the nurse was in a rush and also does not avail for much confidentiality if patients wanted to talk about worries and concerns (Obs 28)

The nurse was busy, had to leave what she was doing to do the rounding this resulted in the nurse appearing distracted and disengaged in the process at times, no patients asked for anything (Obs 32)

The potential use of signalling by the rounders to patients, to prevent patients asking for further assistance was not highlighted by the rounders as an overt tactic to lessen their obligations of rounding. From the patient perspective it was noted by two patients that

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sometimes there was no consideration or reflection given to the patient interaction during the rounding process.

No it’s just, hi can I do anything to help you, and when you say no they move on, pleasant when they approach, but that’s it “Do you want anything?” really it’s the same as the first question and they don’t go into any depth about it all (P 30) I don’t ask for any help, there’s no time for the nurses to talk so it’s not fair to put pressure and work on them by asking for extras (P 36)

Playing the routine was further demonstrated in that some staff (noted in 8 out of the 38 rounding observations) amended and abridged the statement questions explicit in the rounding process. The actual questions used in the rounding process “is there anything I can do for you?” and “Have you any worries and fears?” was reduced in context and combined therefore the most frequent rounding question asked was “Are you ok?” or “Can I help you?” As well as this part of the playing routine the study site culture negated an explanation to the patients of the rounding process which was highlighted in the data from the field notes (noted in 9 observations) and patient interviews. A possible justification for this may have been that staff on the ward, were not fully aware or trained as to the purpose and process of rounding in order to be able to explain rounding practice to patients. From my own experience I know that no formal training in rounding practice takes place, staff had learnt rounding by watching other staff members and a reduced or combined question appeared to have become normal practice. However, rounding is an intentional process with a deliberate and planned structure aimed at achieving defined outcomes. The field notes highlighted this wasn’t captured in everyday practice during the study period and that the rounding process seemed a simplistic single question process reduced in length and structure suggesting the value of the rounding process was not fully recognised by all the ward staff.

The question wasn’t clear but some patients just answer yes but I am not sure they knew the question (Obs 3)

Didn’t explain what they were doing (Obs 4)

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Some patients did look confused when asked is there anything I can do for you, no explanation given about the purpose of the question or rounding (Obs 25)

Some patients in fact quite a lot of the patients looked puzzled when asked if they were ok, some relatives asked what was it all about, reply quite vague and didn’t add impact or reason for rounding (Obs 30)

From the observational data there were five occasions when it was noted that patients appeared confused or didn’t understand the question that was being asked as part of the rounding process and that no explanation of the rounding process was given to patients. The patient interview data also highlighted the use of an abridged rounding question and a lack of explanation about rounding, leading to a confused process which hindered the patient’s response and limited the value of rounding to them.

I didn’t know what it was about, if a series of questions had been added I would have been better informed, all the question asked was ‘are you okay’ and ‘do you need anything’, you need to know what is provided do you need help with the toilet, do you need help with this, do you need help with that (P 36)

I was just saying, I think you need to change your question, because it’s too open ended so you could ask me that but I don’t know what the options are so its I don’t know whether I can ask you for painkillers for instance or kind of it’s a set of list of things to be asked for, so the question may need to be clarified a bit more (P 38)

However from five different observations, all different registered nurses, there appeared to be an awareness of the purpose and process of rounding, with the registered nurses carrying out a more complete rounding process for the patients for that round. These rounds took between 15 to 25 minutes to complete but didn’t fall into the category of rounds taking >30 minutes to complete. These rounds included checking the patients call bell was within reach (observed only on six different rounds), however patient call bells being out of reach (call bells out of reach observed on just one round seven time and a noted theme in eight observations) (table 34). These data revealed that this was an important part of the rounding process, ensuring patient call bells are in reach, was often overlooked, potentially not being seen as a key part of the rounding process (table 34).

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Table 34: Call bell positioning observation

Call bell position Observation Rounder Within patient reach

Call bells given to patients (Obs 6)

Explained to the family what they were doing with the call bell and why they were doing it (Obs 7)

Call bell moved for patient if needed (Obs 17)

Staff nurse checked the immediate environment of the patients ensuring calls bells were in reach (Obs 24) Put buzzer on beds of sleeping patients (Obs 26) Offered patients buzzers (Obs 29)

Registered nurse = 4 Non-registered nurse = 2 Out of patient reach

Didn’t seem to be aware that call bells should be in reach of the patient (Obs 4)

No call bells checked (Obs 5)

Didn’t read the situation ie moving call bells

7 call bells observed to be out of reach, no attempt made to move them within the patients reach (Obs 20) Unfortunately some of the buzzers were out of reach of the patients, the nurse did not pick up on this (Obs 23) Call bells observed out of reach (Obs 27)

Didn’t see out of reach call bells (Obs 28) No check on patient buzzers (Obs 34) Didn’t check buzzers (Obs 36)

Registered nurse = 4 Non-registered nurse = 4

It was difficult to ascertain from the data collected if the reductionist approach practiced by some of the staff related to lack of knowledge or emphasis of the rounding process and the importance of the patient’s call bell. Or if there was an inclination to perform the rounding process as quickly as possible as it interrupted or was less important than other aspects of their work. Both observations 27, 28 related to registered nurses who appeared rushed during the rounding observation.

It was worth noting however, from the documentary findings (appendix 20; table 19) that call bell data (number of call bells ringing within one hour) were unfortunately inconsistently collected and therefore has a very limited value in terms of contributing to the study findings. What it does potentially demonstrate and highlight is that there was a difference between measuring an outcome of rounding as reducing number of call bells rung compared with actually observing rounding practice to see if the rounder is checking/positioning call bells within patients reach. The observational data revealed a potentially inconsistent picture in practice which questions the effectiveness of reduced call

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bell usage as an outcome measure of rounding as from the observational data not every patient has their call bell within reach to use.

However, the importance of documenting the rounding process, emerged from the data, recorded on a large A3 chart (appendix 2). The chart was a daily chart consisting of tick and code boxes, the chart pertains to patient bed numbers and on the reserve side includes a space for writing free hand any variation to the stated rounding process, including documenting if patients have any worries or fears. The chart is not used within any ward handover process but is kept as evidence that rounding was completed.

The completion of the documentation (on review all 38 rounding observation had a coded entry against each patient and an initialled completion box on the rounding chart for the day and time of the observed round) suggests an importance was attached to the recording of the rounding process which is interesting as the same compliance wasn’t observed in relation to following the rounding protocol for example checking the 4 Ps. This perhaps gives the indication that the culture of the study setting was that there was better compliance with the completion and the recording of rounding compared to practicing the correct process of rounding, as discussed already in the findings of the presence of rounder and discussed further in Actioning care theme.

The data from the participant observations presents a clear image of the recording of the rounding process.

End of bed, didn’t enter side rooms, documentation completed (Obs 3) Documentation completed at the bedside (Obs 9)

Documentation completed at the bedside there was no physical contact with the patients (Obs 13)

He carried the clipboard and filled in the information on it after speaking to each patient (Obs 22)

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The staff interviews didn’t highlight the documentation of the rounding process as either a positive or negative experience for the rounder although no specific question about documentation was asked. The premise of the staff and patient interviews were that they were quick interviews that didn’t interrupt patient care and therefore they were limited in their scope and range. The questions focused on activities and actions of the nurses/patients during rounding process and not the documentation (appendix 6 and 7). In fact there was no mention of documentation at all in any of the answers given by the ward staff in their interviews. The patients however did mention documentation but in relation to the clip board the documentation is placed on when the rounding is carried out. Patients associated rounding with the clip boards.

Erm these times they come with the boards (P 4) Oh you mean the clip board club (P 29)

No she just had a clip board and she just asked me if I was okay (P 31)

Hence documentation and the clip board appear to be interwoven into the cultural theme of playing the routine; potentially linking in with the signalling of presence themes discussed previously, whereby rounder’s signal their presence to round on patients by presenting with the clip board.

Whilst the data emphasised that rounders played the routine of the rounding process, it was also noted that some patients played the routine of rounding too. This indicated that some patients knew and understood the process of rounding, using this knowledge to choose to participate or not in the rounding process. From the observational data the rounders understood the patient meaning and acknowledged that some patients didn’t require a rounding visit.

Patients seemed to know the question before it was asked (Obs 2)

Patients who had been there for longer seem to say ‘no’ as we walked to the bed (Obs 7)

Some of the patients appeared to be asleep as the support worker approached the bed to carry out rounding (Obs 15)

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Indeed, one patient commented that they thought the rounding was repetitive and avoided engaging with the process.

I don’t think asking someone every two hours if they are OK is right. It’s from in the morning till night time, all the time. I usually wander off if I see them coming (P 31)

The theme of patients playing the routine was also identified by staff who noted that some patients appeared to discourage the rounding interaction. Staff indicated that patients pretended to be asleep or on the phone in order to avoid a rounding visit. From one staff interview it was recognised that for the longer term patients the rounding process may be repetitive and the nurse tried to adapt her approach.

The patients see us coming round and some are suddenly asleep or on the phone but most of the time if patients don’t want anything they say no thanks (S 24)

Most patients seem to appreciate the rounding and a nurse visiting them, however I do think the rounding process is too rigid for the longer term ones especially if they are able to do things for themselves. We have to visit all the patients on the rounding but some patients don’t want a visit they have been asked ‘if there’s anything I can do for you’ loads of times. If the patients aren’t pretending to be asleep then I try and make the visit more conversational but not everyone does this. You can see some people doing the rounding and all the patients are shaking their head. It does make the round quicker (S 33)

It was interesting, as highlighted above that the patients also played the routine of rounding even to the extent of moving away from their bed space or feigning sleep (table 21; appendix 22). The focus of rounding is the patient interaction to the rounding question at their bedside. Patients who are able to play the routine realise if they are not at their bedside or appear to be sleeping the set structure of the rounding process means they are able to avoid the round. These patients appear to be one step ahead of the rounders and prepare their avoidance plan.

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The cultural theme of playing the routine suggests that although the rounding process is an established part of the everyday ward practice for all patients irrespective of age and gender the process is exposed to modification to suit some of the staff and patients. The modification of the rounding process may indicate that rounding was not seen as essential to patient care and not fully valued. Rather sadly the correct completion of the documentation appears more important than performing rounding to the correct process, this makes rounding in the study setting potentially just a tick box exercise.