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As stated previously, the UK literature on rounding is disappointing in terms of research rigour highlighted by three of the more critical authors Mitchell et al. (2013); Snelling (2013); Forde - Johnson (2014). It was difficult to include any UK literature in the body of the review as the papers highlighted a lack of robust research methodology. Some attention does need to be given to this literature in terms of adding to the context and voice of UK rounding practice, given its wide scale implementation. I therefore mention if only to make explicit the research evidence gaps in the UK literature concerning rounding practice.

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The UK literature does have a contemporary context in terms of time span being from 2010 to 2015. The only exception is Castledine (2002) and Castledine et al. (2005) which define ‘Patient Comfort Rounds’ and their influence is discussed earlier in the historical context of rounding in chapter two. Castledine’s work was not research but explains the context and process of an antecedent to the work of Meade et al. (2006).

Within the UK literature 19 articles document the implementation of rounding in a specific NHS hospital setting. The implementation appears to be within whole hospital settings (Crossfield and Pitt 2012; Duffin 2012; Gillen 2012) to specific units within hospitals; Orthopaedic Unit (Lucas et al. 2010) Medical Assessment Unit (Fitzsimmons et al. 2011; Braide 2013) High Dependency Unit (Lowe and Hodgson 2012). Hutchings (2012) and Hutchings et al. (2013) describe implementation on several speciality wards including oncology, stroke, orthopaedic, neurology and spinal. From the NHS literature rounding appears to have been implemented in a variety of ward settings similar to the review findings. However there is little discerning evidence in terms of speciality implementation, for example no comparison of rounding on a cardiac ward compared to rounding on a stroke ward. Interestingly, Duffin (2012) explains the implementation of rounding within the UK private sector; an initiative that covered 80 patients in units delivering paediatric, adult intensive care and post-surgical care; but failed to collate any outcome data only the promise of conducting a patient survey to see what patients thought of rounding.

Four of the NHS publications relate to rounding in one hospital on initially one unit with roll out to a further 11 areas (Phillips et al. 2011; Mason 2012; Dix et al. 2012; Braide 2013) pointing to an example of rounding in a discussion paper (Fitzsimmons et al. 2011). Between the papers there is some detail in their account of the perceived benefits of rounding and their implementation. In addition there are detailed accounts of rounding implementation (Lucas et al. 2010; Hutchings 2012; Hutchings et al. 2013; Stoddart et al. 2014), although Crossfield and Pitt (2012) focus on their use of ‘rapid spread’ implementation methodology in their practice of rounding. The government and nursing leadership support for rounding is demonstrated by Gillen (2012) who provides an insight into the views of the National Lead for rounding on the governments Care Quality Forum.

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This emphases the political and policy context of rounding practice. According to Gillen (2012 p12) the national lead for rounding clarifies that;

‘Rounding with intention to care is not the old back round. It is about being highly visible to your patients at least every hour and providing personalised care at that point should it be required.’

Rounding according to the national lead is:

 The 4 Ps (checking patient’s pain, personal needs, positioning, possessions)

 Requires professional judgement

 Is about communicating with patients

 Proactively delivers care to patients

 Patients won’t be left ringing bells

The UK national lead positively promotes rounding by making clear its capacity to prevent poor care, and that rounding can give relatives reassurance that their loved one will receive good care (Gillen 2012). All of these assertions can be found in the literature review however within the UK there is no research evidence to substantiate these statements. Two further articles both examine the approaches to rounding, expose the lack of research evidence, but yet positively promote the practice of rounding (Fitzsimmons et al. 2011; Policy Plus document, National Nursing Research Unit 2012) Fitzsimmons et al. (2011 p20) encapsulates the UK approach to rounding:

‘The evidence base is sparse but intuitively and anecdotally rounding makes sense. The question is: patients like it and it has benefits for all?’

Through my own professional experience it is perhaps difficult to agree with this point of view and the literature reviewed potentially contradicts the assertion that patient like it and it has benefits for all.

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Snelling (2013) is scathing in his critique of rounding and its implementation in the NHS, as he highlighted the misrepresentation of US evidence into the UK literature. I would argue that it is disappointing that the UK literature has a poor citation rate and upon wider examination of the US literature beyond three key studies: Meade et al. (2006); Studer Group (2007); Tea (2009). Crossfield and Pitt (2012) do not cite any studies on rounding; Duffin (2010) cites one; Fitzsimmons et al. (2012) two; Dix et al. (2012) and Hutchings (2012) cite four papers each; Policy Plus (2012) cites seven papers. A paper by Braide (2013) cites eight relevant papers related to rounding of which only four are considered of sufficient quality to be included in this review (Meade et al. 2006; Culley 2008; Halm 2009; Tea et al. 2009). The NHS studies cross cite each other; Braide (2013) cites Lucas et al. (2010); National Nursing Research Unit (2012) cites Dix et al. (2012). Stoddart et al. (2014) cite only UK literature apart from Meade et al. (2006) reinforcing a lack of UK studies within the literature on the process of rounding.

Eight NHS studies provide some audit type commentary on the outcomes of rounding but much of this is against the context of scant methodology in terms of any type of research design (Lucas et al. 2010; Crossfield and Pitt 2012; Dix et al. 2012; Hutchings 2012; Braide 2013; Dewing and Lynes O’Meara 2013; Stoddart et al. 2014; Kenny and Norton 2015). Dix et al. (2012) report on the pilot linked to the larger work reported by Braide (2013); all of the work adopts before and after measures used by Meade et al. (2006), but there is little debate of variables or equivalency of measurement. Similar outcomes are assessed; call bell usage, falls, and pressure ulcers but with less rigour. Three studies emphasise that other implemented interventions may have influenced results, for example training and awareness in pressure ulcers, falls prevention programme and the use of electronic patient assessment documents (Crossfield and Pitts 2012; Hutchings 2012; Braide 2013). Stoddart et al. (2014) present a detailed account of rounding implementation and percentage reduction in falls and call bell usage coupled with patient and staff satisfaction improvements however there is little detailed evidence and analysis of the data presented to provide confidence in their findings.

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Four clear positive benefits of the implementation of rounding are articulated across some papers but these results are subjective as no paper provides any statistical evidence (table 8).

Table 8: Benefits of rounding implementation (UK) Reported benefit Studies

Reduced call bells Lucas et al. 2010; Dix et al 2012; Hutchings 2012; Braide 2013; Stoddart et al. 2014

Reduced falls Lucas et al. 2010; Crossfield and Pitt 2012; Hutchings 2012; Stoddart et al. 2014

Reduced pressure ulcers Hutchings 2012; Braide 2013 Reduced complaints and

better patient feedback

Crossfield and Pitt 2012; Dix et al. 2012; Hutchings 2012; Lowe and Hodgson 2012; Braide 2013; Dewing and Lynes O’Meara 2013; Stoddart et al. 2014

A strong theme within all the papers was the suggestion albeit subjective that the implementation of rounding was problematic. From the NHS articles large amounts of resources notably time was required to engage staff and implement the process of rounding but despite this staff were not always convinced of the benefits of rounding (Lucas et al. 2010; Crossfield and Pitt 2012; Dix et al. 2012; Hutchings 2012; Lowe and Hodgson 2012; Braide 2013; Hutchings et al. 2013; Dewing and Lynes O’Meara 2013). Kenny and Norton (2015) provide a review of the rounding process in their organisation as a first stage in planning a quality improvement project. Their feedback also concluded staff were not always convinced of the benefits of rounding as well as finding patients were not aware of the process of rounding.

For me the main conclusion drawn from the UK literature was the existence of a research evidence gap, a lack of high quality robust studies to measure the impact of rounding in UK practice. The suggestion that it was difficult for staff to engage with the process of rounding indicates to me that the process does not intuitively make sense to all nurses.

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