The evidence from this study, to our knowledge the first national evaluation of IR worldwide, demonstrates that the effectiveness of IR is very weak. However, there is also clear evidence for a lack of clarity in the purpose and expectations of IR, lack of education and preparation of staff nationally and locally and a lack of resources to support the introduction and sustainability of IR. It is probable that the way in which the policy was developed, disseminated, implemented and supported influenced the effectiveness of the delivery of IR. It is clear that guidelines for good policy-making89were not adhered to in this case. In the
following sections, we set out the implications for the management of health-care services and for nursing through the voices of senior managers, the stakeholder advisory group and others.
Implications for nurses to take charge of nursing practice
The consistently strong message coming through the survey and interviews was the view of nurse leaders that IR, as an exemplar of nursing practice, should be shaped by the profession and not others:
. . . we need to, as a profession, be evolving in, and measuring ourselves and deciding going forward, you know, how do . . . we demonstrate good quality care . . . what is an outcome that we want to see, rather than a measure that we want to implement that would give us an outcome.
Director of nursing CONCLUSIONS
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. . . the risk of that is we won’t sort our own problems out. . . . what percentage of the workforce is graduates? Probably about 45, 50%? We’re not using the brains of those people because we haven’t created an environment where we’ve got leaders who are thinkers and doers.
Director of nursing
Some perceived that failure to do so had, in part, contributed to the political imperative to implement IR. We propose that the results of this study should inform a national nursing conversation about the future of IR in England. This would help NHS trusts and senior nursing managers decide which direction they want to take to respond to this new evidence and to consider whether or not there are alternative interventions that support the delivery of fundamental nursing care to patients.
Implications for nursing leadership:‘If I were you, I wouldn’t start from here’
At our final study advisory group, where the recommendations from the study were discussed, a service user member recalled the joke about a tourist who asks for directions and received the reply‘Well sir, if I were you, I wouldn’t start from here’. As explained earlier (see Chapter 1, Prime minister announcement), IR was hastily introduced at a time when government needed to be seen to be acting in response to the Francis report.1As borne out by these findings, IR as an intervention to address patient need is highly
contestable. The implications for nurse leaders is to consider how to take the findings in a review that may recommend‘de-implementation’ or ‘stopping practices that are not evidence-based’90or‘to abandon care
that wastes resources or delivers no benefit to patients’.91We suggest that there is a need for a national
discussion/debate within the nursing profession to consider whether or not IR is the best way of achieving desired outcomes, and what the desired outcomes are. It may be better to start afresh, rather than attempting to tweak a system that has been implemented. This is, arguably, an activity rarely undertaken by the profession. A director of nursing in this study said:
. . . we don’t have these professional conversations . . . we don’t have those types of forums because we’re so caught up just trying to keep it safe at the moment in most organisations . . . there’ll be more and more decisions that are made politically because we don’t have those right conversations and we’re caught on the back foot and because we don’t have a vision and a plan and a visual sense of how you do it; they can walk all over us and they implement these things because they can. That’s a cynical view.
Director of nursing
A decision to discontinue IR would be a bold undertaking and would need to be adequately resourced and supported. The NHS is under immense pressure and it is anticipated that the reassurance of the evidence that IR provides nurses would be difficult to relinquish:
. . . it is quite difficult because once things are in place, it’s really a brave person that says ‘right, stop doing that, let’s do this’.
Director of nursing Implications for an improvement agenda: intentional rounding needs to be more
purposeful and rationalised, that is‘intentional’
An alternative to discontinuation is to lead a review to implement improvements that address shortcomings identified in this research. A relaunch of IR could consider renaming and site-specific adaptations, which often exceed the US version of IR. A broader umbrella term would reflect this (e.g.‘comfort and safety rounds’). This study has identified lessons about implementation that should be considered if IR was relaunched:
l Review the purpose of IR and the level of flexibility that is acceptable. Consider the criteria for how a flexible approach should be implemented.
l Education should be provided to all nursing staff (and other staff if involved in IR) about the purpose of IR and how it should be delivered.
l The purpose of IR should be explained to patients and their carers.
l Consider involving other non-nursing staff in contributing to the record of when patients are seen and care activities undertaken.
l Documentation should not have set hourly intervals but instead have space for staff to write the specific time when the patient was attended to.
l Areas of duplication between different elements of documentation should be reduced.
l Audits of IR should focus on the delivery of IR, not the documentation of IR.
l Review the status of IR as a‘comply or explain’ intervention and devise guidelines on how IR should be included in CQC inspections.
Implications of rapid policy development to complex problems
We have argued that hasty policy-making‘on the hoof’ as a response to political crises is problematic. The development and implementation of IR as a national policy was done in a vacuum and involved importing an untested US model. A period of piloting, evaluation and refinement would support the integration of a policy of intervention into a complex system. Manski92proposes‘adaptive policy’ that remains flexible as the
mechanisms and impacts become evident in different settings, and argues against the notion that research leads to a single true number that captures the effectiveness of policy, however seductive this may appear. This study provides evidence of the need for caution in using IR documentation as a performance indicator. Much has been written about the unintended consequences of measuring activities and setting targets, and, given the evident weakness of the documentation, it would be unwise to co-opt this as any kind of data on processes of care.93