Ways to Implement Patient Rounding Peer Reviewed Article

• Journal List
• BMJ Open
• v.vii(1); 2017
• PMC5223681

BMJ Open up. 2017; 7(1): e014776.

What aspects of intentional rounding work in hospital wards, for whom and in what circumstances? A realist evaluation protocol

Ruth Harris

^oneFlorence Nightingale Kinesthesia of Nursing and Midwifery, Male monarch's College London, London, UK

Sarah Sims

¹Florence Nightingale Faculty of Nursing and Midwifery, Male monarch'south College London, London, U.k.

Ros Levenson

ⁱⁱContained Consultant, London, UK

Stephen Gourlay

^threeKingston Concern School, Kingston Academy, Kingston-Upon-Thames, London, Britain

Fiona Ross CBE

⁴Faculty of Wellness, Social Care and Education, Kingston Academy and St George'due south, University of London, London, U.k.

Nigel Davies

⁵Faculty of Health and Social Sciences, University of Bedfordshire, Luton, U.k.

Sally Brearley

¹Florence Nightingale Kinesthesia of Nursing and Midwifery, Male monarch's College London, London, U.k.

Giampiero Favato

^sixInstitute of Leadership and Management in Wellness (ILMH), Kingston University, Kingston-Upon-Thames, London, UK

Robert Grant

⁴Kinesthesia of Health, Social Care and Educational activity, Kingston University and St George'due south, Academy of London, London, United kingdom of great britain and northern ireland

Received 2016 Oct nineteen; Accepted 2016 November 21.

Abstract

Introduction

Intentional rounding (IR) is a structured process whereby nurses in hospitals acquit out regular checks, usually hourly, with individual patients using a standardised protocol to address issues of positioning, pain, personal needs and placement of items. The widespread implementation of IR across the U.k. has been driven past the recommendations of the Francis Research although empirical bear witness of its effectiveness is poor. This paper presents a protocol of a multimethod report using a realist evaluation approach to investigate the touch on and effectiveness of IR in hospital wards on the arrangement, delivery and experience of care from the perspective of patients, their family members and staff.

Methods and analysis

The study volition be conducted in four phases. Phase 1: theory development using realist synthesis to generate hypotheses about what the mechanisms of IR may exist, what particular groups may do good nigh or least and what contextual factors might be important to its success or failure which volition be tested in subsequent phases of the study. Phase 2: a national survey of all NHS acute trusts to explore how IR is implemented and supported beyond England. Stage 3: instance studies to explore how IR is implemented 'on the ground', including individual interviews with patients, family unit members and staff, non-participant observation, retrieval of routinely nerveless patient outcomes and cost analysis. Phase 4: accumulative data analysis across the phases to scrutinise data for patterns of congruence and discordance and develop an overall evaluation of what aspects of IR work, for whom and in what circumstances.

Ethics and dissemination

The written report has been approved by NHS Due south East Declension—Surrey Research Ideals Committee. Findings will be published in a wide range of outputs targeted at key audiences, including patient and carer organisations, nursing staff and healthcare managers.

Strengths and limitations of this study

• The study will clearly articulate the preliminary theories and assumptions nigh intentional rounding (IR) and how it is expected to work.

• The study will test and refine these theories throughout the study using existing empirical evidence, a national survey to investigate implementation and local case studies.

• The study blueprint allows these theories to be examined in different acute intendance delivery contexts allowing established assumptions nearly IR and the outcomes of IR to be examined.

• Applying a realist evaluation arroyo can be challenging, and there may exist express testify to support some elements of the programme theory.

Introduction

'Patients first and foremost'¹ is the priority for the NHS. However, as demand for health services is increasing so are concerns that the delivery of patient intendance is lacking in compassion and less tailored to individual patient need, particularly for older people.² These concerns were highlighted in the Francis Inquiry,³ which examined evidence about the reasons for the failures in patient care at Mid Staffordshire NHS Trust and made primal recommendations to strengthen local systems to deliver safe, empathetic, patient-centred care. Engagement with patients is highlighted every bit a mechanism to promote well-beingness and improve patients' feel of healthcare treatment and this is seen every bit principally the role of nursing staff (Vol III, p1606). One of the Enquiry's recommendations states that 'Regular interaction and engagement between nurses and patients and those close to them should be systematised though regular ward rounds' (Vol III, p1610) and refers to the use of a regular ward round as suggested by the Prime Minister in January 2012. Following this annunciation, the majority of NHS trusts have introduced intentional rounding (IR), a structured process whereby nurses in hospitals carry out regular checks, unremarkably hourly, with individual patients using a standardised protocol to address issues of positioning, hurting, personal needs and placement of items. Conducting hourly rounds is not a new nursing concept, and 'care rounds' or 'comfort rounds' have been carried out for many years by nurses.^{4 five} Still, IR offers a more structured version of this procedure, using a standardised protocol purposively aimed at keeping patients comfortable and safe (see figure 1 for typical IR protocol).

Typical IR schedule in acute ward settings.^5–7

Evidence in the form of local audits and published studies has highlighted numerous benefits of IR, including a reduction in call bell use, falls and force per unit area sores as well as increased patient satisfaction and the delivery of intendance that demonstrates compassion.^{four 7–9} However, there is limited research to back up this and most of this has been conducted in Usa hospitals, therefore findings may non exist applicative to other international healthcare contexts. Substantial limitations to the evidence base for IR have likewise recently been highlighted by Snelling,¹⁰ who states that results asserting the benefits of IR should be interpreted with caution due to concerns around selection bias, potential disharmonize of interest, written report design and data assay. Other reviews take likewise highlighted weaknesses in the blueprint of IR studies.^{5 11}

Lilliputian is also known about how NHS healthcare trusts in the Britain currently ascertain IR, whether there is consistency in its implementation or whether it has had any unintended consequences on other aspects of nursing activity. These central issues have been highlighted as requiring further investigation.^{v 10 11} Thus, while IR is intuitively a good thought and implemented in a majority of NHS hospital trusts, there is currently no robust inquiry testify to support its widespread adoption in the UK and internationally. With the increased scrutiny as a upshot of the Francis Inquiry and fiscal pressures on the NHS, it is of import to found bear witness of the effectiveness and costs of IR by finding out what works (or otherwise), for whom and in what circumstances.

Aims and objectives

This report aims to investigate the impact and effectiveness of IR in hospital wards on the organisation, delivery and experience of care from the perspective of patients, their family members and staff. The research question is: 'What is it about IR in hospital wards that works, for whom and in what circumstances?' We volition investigate this at the three levels of the organisation and commitment of health services: national, service provider organisation and individual ward/unit of measurement. We will identify the means in which the context (ie, the environment and organisation) at each of these levels influences the mechanisms (ie, the assumptions and theories nigh the means in which IR achieves its objectives) and the outcomes or impact. The written report started in September 2014. Nonetheless, it has been delayed due to unforeseen circumstances and now will be completed in March 2018. The study objectives are to:

1. Determine how many NHS trusts in England take implemented IR and analyse how this has been developed and supported.

2. Identify how IR has been implemented 'on the basis' and evaluate its contribution to the delivery of patient intendance as a whole and how it fits in aslope other approaches to improving quality and rubber.

3. Explore nursing staff, healthcare assistants and other clinical and management staff experiences of IR and how information technology affects the way they deliver care.

4. Explore patients' and their family members' experiences and perceptions of how IR influences their experiences of intendance.

5. Investigate the possibility of identifying trends in patient outcomes (retrieved from routinely collected NHS ward data) within the context of the introduction of IR and other care improvement initiatives that accept been introduced by using statistical process controls methods such equally CUSUM charts.

6. Examine the barriers and facilitators to the successful implementation of IR.

7. Conduct a lesser-up analysis of the costs of IR by identifying the resource used by case study wards to develop and implement it.

8. Synthesise the information from each of the study phases to place which aspects piece of work, for whom and in what circumstances.

Project methodology

Study design and conceptual basis

A multimethod study blueprint will be undertaken cartoon on a realist evaluation approach¹² (run into effigy 2). A randomised, experimental report blueprint is non possible as the implementation of IR has been strongly advocated and promoted by the UK government and very few trusts are reported non to have implemented it. Realist evaluation is a theory-driven approach designed for evaluating circuitous social interventions such equally IR,¹³ where the outcomes of an intervention are influenced by the way it is delivered and the context in which it is delivered.^{14 15} It does not seek to answer the question 'does this intervention work?' but instead acknowledges that complex social interventions only ever piece of work for certain people, in item circumstances. The primal chore of a realist evaluation is to empathise and explain these patterns of success and failure by request the exploratory question: what is it about this intervention that works, for whom and in what circumstances?^{12 15} Information technology achieves this through the identification of context–mechanism–outcome configurations.

The study will be conducted in four phases: (1) theory evolution; (2) national survey of all NHS acute trusts in England; (iii) individual interviews with healthcare staff, patients and their family members, observations of IR and nurse shadowing, retrieval of routinely collected ward outcome information and analysis of costs and (four) synthesis of study findings. The written report will exist guided throughout its duration by a multistakeholder advisory grouping consisting of 9 NHS senior managers and healthcare professionals and 9 patient and carer representatives.

Phase 1: theory evolution

As with all social interventions, it tin can be assumed that IR will piece of work for unlike stakeholders in diverse settings in different ways. However, available theory on its potential is limited. Therefore, we will brainstorm with a period of theory development drawing on principles of realist synthesis¹⁶ to generate hypotheses on what the mechanisms may be, what detail groups may do good virtually or least and the contextual factors that might be important to its success or failure. These hypotheses will be interrogated and tested in phases ii and iii of the study.

Literature volition be identified from electronic searches of databases, including MEDLINE, BMJ Journals, CINAHL, Embase, Internurse, RCN Archive, PsychINFO, HMIC and the Cochrane Library. Reference lists of relevant papers volition be scanned and citation searches conducted. Skillful advice about generating relevant search terms will exist sought from Information Sciences Specialists and revised as additional key words are generated. Gray literature relating to policy and organisational-based material will be sought by searching government and other specialist websites. Papers and other information that satisfy whatsoever of the following criteria will exist identified equally potentially relevant and volition be retrieved for review:

• describe or evaluate IR,

• item its implementation or development in various settings,

• address the experience of private team members, squad leaders, policymakers, patients or their family members around implementing, conducting or experiencing intentional rounds,

• describe the organisational or political context of IR,

• reviews of IR.

Only English language language documents volition be included. In line with realist methodology, nosotros will not have specific predetermined inclusion and exclusion criteria based on research method or quality, merely we will written report areas of general weakness in evidence and private report weakness where appropriate. The abstracts of all papers identified past searches will be screened for suitability. All potentially relevant papers will be retrieved and assessed by a member of the enquiry squad using a structured data extraction form. The following data will be recorded for each potentially relevant paper:

• literature item details (type of particular, eg, descriptive, evaluative, review),

• area in which the intentional circular is situated (eg, astute care, intendance of older people),

• details of the intentional round (eg, frequency, elapsing, who it is conducted by),

• outcomes (eg, reduction in call bell utilize, falls and pressure sores),

• enablers and inhibitors (eg, factors recorded equally enabling or inhibiting the implementation or delivery of intentional rounds).

Each data extraction form will be independently examined by at least ii members of the research team for inclusion. Information or information from each of the studies selected volition be analysed thematically to provide a comprehensive description of the purported mechanisms of IR. Contexts that appear to trigger or inhibit the mechanisms volition be identified and outcomes for patients and their family members, healthcare staff, teams and organisations when the mechanism is nowadays or absent-minded will exist noted.

In add-on to the literature review a stakeholder consultation event will exist held, in which primal figures associated with IR (eg, Directors of Nursing of NHS hospitals, healthcare staff) plus the written report's informational group will exist asked to elicit realist theories on the mechanisms. This process is recommended in realist evaluation, as understanding what primal stakeholders know virtually an intervention and their reasoning for or confronting its implementation is essential to understanding information technology. Data from the literature review and the stakeholder consultation event will be synthesised to provide a rich and detailed moving-picture show of the intervention of IR.

Phase 2: national survey of non-specialist NHS acute trusts in England

Phase 2 will explore how IR is currently being implemented and supported nationally within NHS astute trusts across England and the way in which organisational context has influenced its implementation. The findings volition inform the in-depth instance studies conducted in phase 3, including case study site option.

A national survey of all NHS acute trusts in England volition be undertaken using an online structured questionnaire (see figure 3 for examples of survey questions) administered to a senior trust manager with responsibility for implementing nursing services. Nosotros were advised by local trust nursing directors and managers that this would be the best approach to maximise the response rate. Each trust'southward Director of Nursing will be contacted directly and asked to complete the survey or forward to a colleague who would exist able to complete information technology. Up to three email reminders will be sent and a clear inspect trail will be maintained. Reponses to the survey volition be entered into STATA, collated and subjected to quantitative analyses to explore and provide a detailed film of how IR has been implemented nationally.

Examples of survey questions to be included in the national survey.

Phase iii: In-depth case studies

Phase three will explore the extent to which the concepts of IR identified in phase 1 are compatible with or relevant to modernistic health service commitment and the experiences of healthcare staff, patients and their family unit members.

Case study settings

Iii geographically spread hospitals in England will be purposively selected based on the findings of the national survey in stage 2 to place sites where IR has been implemented differently (ie, maturity of intervention, structure of process). Within each of these case report locations, the following data will be collected from two wards (1 acute, ane intendance of older people):

Individual interviews

Within each hospital, individual semistructured interviews will exist conducted with a senior trust manager with responsibility for nursing to provide detailed information about the implementation of IR within the trust, including why IR was implemented, staff training needs to conduct rounds and how these were addressed, future development needs and the implementation of other nursing innovations to improve the quality of nurse/patient interactions. On each ward, individual qualitative interviews will be conducted with the ward managing director (n=1), ward nursing staff and healthcare assistants (due north=five), patients (n=5), family unit members (n=5) and other stakeholders, for case, doctors, not-nursing managers and therapy staff (n=5). Interviewees will be purposively sampled to attain a range of genders and ethnicities. Healthcare staff will also be purposively sampled to attain a range of professions and grades. Informed consent will exist gained from all participants and all interviews will exist sound-recorded unless the interviewee requests otherwise.

Interview schedules will exist informed by the findings from phase 1 and specifically designed to arm-twist detailed reflections on how the different mechanisms and contexts of IR influence the interviewee and others around them. The findings from phase 1 will be discussed with participants who will be asked how they relate, if at all, to their experience. If the findings are non considered relevant, the reasons for this volition be explored. Predictable cardinal questions for healthcare staff and managers are detailed in figure four.

Anticipated questions to be included in interview schedules for patients, family members and staff.

Information technology is predictable that patients and their family unit members may not exist explicitly aware of the term 'intentional rounding' and if this is the case the term volition not exist straight used. Where the interviewee is unaware of the term, the interviewer will instead talk nigh 'hourly nursing rounds' or inquire nearly the regular contact that the patient or their family member has with nursing staff. Predictable primal questions for patients and their family members are detailed in effigy four.

It is anticipated that each interview will last up to an hour. Private interviews will be transcribed and analysed using framework analysis¹⁷ to place themes inside the data and to facilitate comparing between case studies.

Non-participant observation and nurse shadowing

Non-participant observation of direct patient intendance will be carried out on each ward over a period of two–iii weeks to observe how IR is implemented 'on the footing'. For each case study site, researchers volition produce a detailed description of the ward environs, including nursing shift patterns, staffing information, sickness levels and vacancy rates: factors related to ward ecology, including the layout of the ward and screening of beds; and factors related to how IR was implemented, including how the change in practice was initially introduced, staff preparation and training and ongoing development and sustainability. Observational methods will include 'shadowing' nursing staff to explore how they interact with patients and each other in relation to IR. Researchers volition find nursing handovers and describe how decisions are made over who conducts intentional rounds (grade of staff, permanent or temporary staff etc), whether the same person conducts the rounds consistently throughout the course of a shift, whether rounds are conducted as they are intended, how they are recorded and what happens afterwards. Researchers volition also observe individual interactions between the patient and nurse during a series of intentional rounds. Quality Patient Care Scales (QUALPACS) will also be completed for five patients in each ward. QUALPACS¹⁸ is an established musical instrument for assessing the quality of intendance a patient receives from a nurse using 68-items across the post-obit areas of care: concrete, full general, psychosocial, communication and professional implications. The instrument is patient-focused, with observations based on who attends the patient'southward bedside to provide care and how frequently.¹⁹ The observer watches the care received by selected patients over a 2-hour period and rates each aspect of this care on a scale of i (poorest care) to 5 (best care).^{xix 20} Researchers volition observe at least 100 individual IR interactions between the patient and nurse and betwixt nurses on each ward using these various methods. In all observations, the researcher will record the duration of each individual interaction, how often interactions occur, what patients are asked during their interaction and what care is provided. External factors that touch on on the delivery of IR will also be recorded. This will enable u.s. to institute how the intervention fits within the whole nurse experience of the delivery of care and the whole patient feel of receiving care. Ascertainment data will be analysed using descriptive statistics and thematic analysis of ethnographic field notes to identify and draw the mechanisms of IR. The contexts and, where possible, the outcomes associated with the mechanisms will likewise be identified.

Retrieval of routinely collected outcome information

Routinely collected upshot data from the NHS Condom Thermometer volition be retrieved for each of the case study wards. The NHS Safety Thermometer is 'a local improvement tool for measuring, monitoring and analysing patient harms and "harm free" care' (http://www.hscic.gov.united kingdom/thermometer). Data collected from the NHS Prophylactic Thermometer are available online subject to appropriate permissions but tin can also exist retrieved from the specific example study sites. Quantitative analyses of the NHS Safety Thermometer data will be exploratory and, as per the realist approach, will be specifically tailored to the individual circumstances associated with the implementation of IR on each ward. For example, if IR was introduced on a ward on a prepare date and had operated without issue always since, the analyses could compare the NHS Safe Thermometer data from half dozen months prior to the introduction of IR to 6 months after its implementation. If, still, IR was introduced on a ward, and so terminated for a period of fourth dimension before starting over again, analyses of the NHS Safety Thermometer data could be conducted on a month-by-month footing to explore whether there were any differences in outcomes during these periods. The aim was not to attribute crusade and event just to investigate the possibility of identifying trends in patient outcomes within the context of the introduction of IR and other care improvement initiatives that have been introduced. Statistical process controls methods such as CUSUM charts will be used.

Assay of costs

An exploratory analysis of the costs of IR volition be undertaken. The design and consistency of resource use to undertake IR volition exist assessed on each ward every bit in that location may be day-to-day variation in completion of IR and grade of staff conducting IR as well as variation betwixt case study wards. A bottom-up approach to costing IR activity will be employed using information collected in the staff interviews, not-participant observation and shadowing and detailed data well-nigh ward context. Resource use data will include:

• Elapsing of IR—time with private patients and time for the ward as a whole,

• Class of staff involved in direct contact with patients during IR and in the 24-hour interval-to-twenty-four hours organization of IR,

• Costs of consumables used in IR, for example, documentation, time sheets/clocks,

• Costs to gear up IR, for instance, time spent by staff to develop operational guidelines and to change practice,

• Training costs for staff team at initial set up and ongoing training and development needs.

The overall costs of the development and ongoing implementation on a daily basis will be estimated for each case study ward. This volition enable comparison of the costs of different approaches to IR development and implementation and provide details of how instance study sites differ. The possibility of assessing the costs for the proposed mechanisms generated in the realist synthesis and the contexts within which they are situated will be explored.

Information from the case studies volition be subject field to within-case and across-case analysis. The half-dozen case studies will provide an in-depth realist evaluation of the diverse contexts, mechanisms and outcomes of IR and will increase understanding of when, how and for whom it has almost outcome. The researchers will accept an iterative approach betwixt and within phases 1, two and 3 and may need to render to the literature as new evidence identified in phases 2 and 3 changes the focus and direction of the literature searching, opening upwardly new areas of theory.

Phase four: synthesis of findings

Phase 4 involves the accumulative information analysis from phases 1, 2 and 3. Using the realist evaluation framework, the patterns of outcomes produced past IR volition exist mapped and the researchers will explore whether the hypothesised contexts and mechanisms fairly explained these patterns. Each phase of this study generates data giving unlike perspectives of IR and these data volition be scrutinised for patterns of congruence and discordance to develop an overall evaluation of what aspects of IR work, for whom and in what circumstances. As office of the synthesis procedure, attendees from the stakeholder consultation effect held in phase 1 will exist invited to interrogate the findings and consider how they fit with their own noesis and experience of IR. The synthesised study findings will constitute the potential outcomes of the intervention, place the underlying mechanisms which explain how it produces these effects and highlight the key contextual factors that impact its success or failure. Recommendations tin then be fabricated as to how trusts can best target or develop the intervention for particular groups in various settings.

Broadcasting

This study does non alter clinical care and then there are no potential adverse effects. All participants will exist informed that they are free to refuse to participate or withdraw from the written report at any time.

The team will disseminate the findings to a range of stakeholders within a planned plan. Nosotros will draw on the networks and expertise of the study advisory group and collaborators to disseminate the enquiry outputs widely and accordingly. Key audiences include patient and carer organisations, clinical nursing staff, nursing managers and directors of nursing who take responsibility for the provision of nursing care, managers and directors within healthcare organisations with responsibility to provide loftier-quality services inside budget and healthcare policymakers, nationally and internationally. The study has a designated Twitter business relationship (@Nursing_Rounds) to support broadcasting.²¹

Discussion

The government's initial response to the Francis Inquiry reports that the majority of hospitals take now implemented IR on their wards. Still, there is currently no robust research show available to support the benefits of IR or promote its widespread adoption across the Britain. The nursing and healthcare workforce are a valuable resource, and it is important that their time and effort is employed in the best fashion possible to meet patient needs. It is specially important to ensure that the structured procedure of conducting IR does non simply become a 'tick-box' exercise for nursing staff that takes up valuable time without leading to benefits for patients. Equally with all healthcare interventions, it is as well of import to provide evidence of the effectiveness and price of IR, especially given the increased scrutiny placed on NHS care as a result of the Francis Inquiry and the financial pressures the NHS currently faces. Therefore, there is an urgent need to find out what works in IR, for whom and in what circumstances. The findings of this written report will provide robust data most what good practise of IR looks like, how it is delivered and the factors that facilitate or hinder implementation. It will besides shed low-cal on poor or ineffectual practice and the factors that influence this. This inquiry will provide benefit by enabling trusts to target their attempt and resources on supporting adept practice (and redirecting resources from aspects of IR that are not useful) and will inform operational guidelines and policies directing the delivery of direct patient care.

Footnotes

Contributors: RH conceived the report and RH and SS drafted the protocol. RL, SG, FRC, ND, SB, GF and RG contributed to reworking and refining the study objectives, design and methodology. RH drafted the newspaper and SS, RL, SG, FRC, ND, SB, GF and RG have reviewed and provided comments to improve the paper. All authors have read and approved the final version.

Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research (HS&DR) (projection number thirteen/07/87).

Competing interests: None alleged.

Ideals blessing: The study has been approved past NHS Wellness Research Dominance South Eastward Coast—Surrey Enquiry Ethics Committee, REC reference: xiv/LO/1977.

Provenance and peer review: Not commissioned; peer reviewed for ethical and funding approval prior to submission.

Data Sharing Statement: A protocol was formulated during the grant application process and submitted to NIHR HS&DR http://www.nets.nihr.ac.uk/projects/hsdr/130787

Department of Health Disclaimer: The views and opinions expressed therein are those of the authors and do not necessarily reverberate those of the HS&DR, NIHR, NHS or the Department of Health.

References

1. Section of Wellness. Patients first and foremost: the initial government response to the written report of the Mid Staffordshire NHS Foundation Trust public inquiry. London: The Stationary Office, 2013. [Google Scholar]

2. Cornwell J, Levenson R, Sonola L et al. . Continuity of care for older infirmary patients: a call for action. London: King's Fund, 2012. [Google Scholar]

three. Department of Health. Report of the Mid Staffordshire Foundation NHS Trust public inquiry, vol 1–iii. HC-898-I-3. London: The Stationery Office, 2013. [Google Scholar]

4. Dix G, Phillips J, Braide Thousand. Engaging staff with intentional rounding. Nurs Times 2012;108:14–16. [PubMed] [Google Scholar]

v. Halm MA. Hourly rounds: what does the evidence indicate? Am J Crit Care 2009;18:581–4. 10.4037/ajcc2009350 [PubMed] [CrossRef] [Google Scholar]

6. Bartley A. The Rex'southward Fund Hospital pathways programme. Making information technology happen: intentional rounding. London: The Rex'south Fund and The Health Foundation, tinyurl.com/Bartley-making-it 2011 (accessed Nov 2016). [Google Scholar]

7. Studer Group. All-time practices: Sacred Heart Hospital, Pensacola, Florida. Hourly rounding supplement. Gulf Breeze, FL: Studer Group, 2007. [Google Scholar]

8. Meade CM, Bursell AL, Ketelsen 50. Furnishings of nursing rounds: on patients' phone call low-cal apply, satisfaction and safety. Am J Nurs 2006;106:58–70. 10.1097/00000446-200609000-00029 [PubMed] [CrossRef] [Google Scholar]

9. Sherrod BC, Brown R, Vroom J et al. . Circular with purpose. Nurs Manage 2012;43:32–8. ten.1097/01.NUMA.0000409925.39096.19 [PubMed] [CrossRef] [Google Scholar]

10. Snelling PC. Ethical and professional concerns in research utilisation: intentional rounding in the Great britain. Nurs Ethics 2013;20:784–97. 10.1177/0969733013478306 [PubMed] [CrossRef] [Google Scholar]

12. Pawson R, Tilley N. Realistic evaluation. London: Sage, 1997. [Google Scholar]

xv. Hewitt G, Sims S, Harris R. The realist approach to evaluation research: an introduction. Int J Ther Rehabil 2012;19:250–9. 10.12968/ijtr.2012.19.5.250 [CrossRef] [Google Scholar]

17. Ritchie J, Spencer L. Qualitative information analysis for applied policy enquiry. In: Bryman A, Burgess R, eds. Analyzing qualitative data. London: Routledge, 1994:173–94. [Google Scholar]

18. Wandelt MA, Stewart DS. The slater nursing competencies rating scale. New York: Appleton-Century-Crofts, 1975. [Google Scholar]

19. Spilsbury K, Adamson J, Atkin 1000 et al. . Evaluation of the development and impact of assistant practitioners supporting the work of ward-based registered nurses in acute NHS (Hospital) trusts in England. Concluding written report. London: NIHR Service Delivery and Organisation program, 2010. [Google Scholar]

20. Norman IJ, Redfern SJ. The validity of Qualpacs. J Adv Nurs 1995;22:1174–81. x.1111/j.1365-2648.1995.tb03120.x [PubMed] [CrossRef] [Google Scholar]

21. Schnitzler Thou, Davies N, Ross F et al. . Using Twitter™ to drive enquiry impact: a discussion of strategies, opportunities and challenges. Int J Nurs Stud 2016;59:15–26. 10.1016/j.ijnurstu.2016.02.004 [PubMed] [CrossRef] [Google Scholar]

---

Articles from BMJ Open up are provided hither courtesy of BMJ Publishing Group

---

coffmanwhaviely.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5223681/