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Clinical Updates

Two-hourly repositioning is ‘unintentional institutional abuse,’ claims study

The researchers highlight that the chronic sleep deprivation such regular turning causes could constitute “torture”.



elderly man in bed

Two-hourly pressure area care could constitute torture or  “unintentional institutional elder abuse”.

The practice of repositioning patients who are at a ‘high risk’ of developing ulcers may be interrupting their natural sleep rhythms and could be classed as “unintentional institutional elder abuse”, a new study has claimed.

Researchers from the University of New South Wales examined the records of eighty patients living in eight different care homes in Australia. A key limitation of the study is its size and narrow focus.


The controversial study found that despite nearly all of the patients being repositioned every two hours, even through the night, more than one-third of them still had one or more of the “excruciating” pressure ulcers when they died.

‘Chronic sleep deprivation’.

In their paper,  published in Bioethical Enquiry, the researchers Catherine Sharp, Jennifer Schulz Moore and Mary-Louise McLaws write, “For decades, aged care facility residents at risk of pressure ulcers have been repositioned at two-hour intervals, twenty-four-hours-a-day, seven-days-a-week. Yet, pressure ulcers still develop.”

“We concur with others who have shown that the ritualistic practice of waking residents every two hours for the purpose of repositioning contributes to severe sleep deprivation and behaviours of concern”.

“Sleep is a fundamental phenomenon in most organisms and the sleep–wake cycle is a physiological rhythm which modulates endogenous neuronal activity in the brain.”

“Chronic sleep deprivation can cause significant and cumulative physiological deficits and the disruption of normal neurophysiological mechanisms.”

Adding that the chronic sleep deprivation caused by regular turning causes could be in violation of the Optional Protocol to the Convention against Torture.

The team also questioned the ethical implications of repositioning patients who lack the ability to consent to two-hourly repositionings, such as those with severe dementia.

An alternative.

Rather than two-hourly repositioning, the researchers suggest the use of alternating pressure air mattresses (APAMs).

“Pressure relief should be provided in the form of an APAM, not waking residents up for the purpose of repositioning,” the researchers say.

“An APAM provides pressure relief to all parts of the body every few minutes throughout the twenty-four hours without waking residents, whereas repositioning for pressure relief is usually only carried out two-hourly.

While APAMs have been shown to prevent pressure ulcers, the research dates back to 1967.

Clinical Care

Hourly rounding ‘may not be the best way for nurses to deliver care’, finds study

Hourly rounding places an emphasis on ‘tick box’ care.



Nurse with patient in bed

Hourly rounding made a minor contribution, if at all, to the way nurses engage with patients.

A new report by researchers at King’s College London has found that the widespread practice of hourly or intentional rounding, may not be the best way for nurses to deliver care to patients.

The report also found that rounding makes a minor contribution, if at all, to the way nurses engage with patients.


Hourly or intentional rounding involves standardised regular checks with individual patients at set intervals and was introduced in hospitals in England in 2013, with 97% of NHS acute Trusts in England implementing it in some way.

The majority of NHS trusts adopted the ‘4Ps’ (Position, Pain, Personal needs, Placement of items) model of rounding.

The research was commissioned and funded by the National Institute for Health Research (NIHR) and was led by Professor Ruth Harris in the Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care.

Hourly rounding places an emphasis on ‘tick box’ care.

The NIHR report – Intentional rounding in hospital wards to improve regular interaction and engagement between nurses and patients: a realist evaluation – is the first study of its kind in the world.

The study found that rounding placed an emphasis on transactional ‘tick box’ care delivery, rather than individualised care. However, patients were found to value their interactions with nursing staff, which the study argues could be delivered during other care activities and rather than through intentional rounding.

The report also found that rounding was implemented without consultation, careful planning and piloting in the interests of political expediency following the Francis Inquiry Report into care failures in the NHS.

Ruth Harris, Professor of Health Care for Older Adults at King’s College London, said; “Checking patients regularly to make sure that they are OK is really important but intentional rounding tends to prompt nurses to focus on completion of the rounding documentation rather than on the relational aspects of care delivery.

“Few frontline nursing staff or senior nursing staff felt intentional rounding improved either the quality or the frequency of their interactions with patients and their family.”

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Clinical Updates

Nurses’ ‘worry’ better than most early warning scores, finds study

Nurses were asked to grade patients between ‘no concern’ and ‘extreme concern’. 




A sense of worry can provide important information for the detection of acute physiological deterioration.

Nurses’ worry has a “higher accuracy” than most published early warning scores (EWS) at predicting if a patient is becoming more unwell, according to a recent study.

The study looked at 31,159 patient-shifts for 3185 patients during 3551 hospitalisations across two surgical and two medical wards. Researchers compared if the nurses were worried about a patients potential for deterioration using ‘the Worry Factor’ with early warning score indicators.


Nurses were asked to grade each patient between “no concern” and “extreme concern”.

The Worry Score

Out of 492 potential deterioration events identified, researchers found that when nurses had an increasing worry factor the patient was more likely to require emergency medical treatment – 7 cardiac arrest calls, 86 medical emergency calls and 76 transfers to the intensive care unit.

The study also revealed that accuracy rates were significantly higher in nurses with over a year of experience.

The researchers concluded that “nurses’ pattern recognition and sense of worry can provide important information for the detection of acute physiological deterioration” and was often more reliable than traditional early warning systems.

They also noted that the worry score could be used alone or easily incorporated into existing EWS to potentially improve their performance.

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