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To compare the contribution of physician associates to the processes and outcomes of emergency medicine consultations with that of foundation year two doctors-in-training. Mixed-methods study: retrospective chart review using 4 months' anonymised clinical record data of all patients seen by physician associates or foundation year two doctors-in-training in 2016; review of a subsample of 40 records for clinical adequacy; semi-structured interviews with staff and patients; observations of physician associates. Three emergency departments in England. The records of 8816 patients attended by 6 physician associates and 40 foundation year two doctors-in-training; of these n=3197 had the primary outcome recorded (n=1129 physician associates, n=2068 doctor); 14 clinicians and managers and 6 patients or relatives for interview; 5 physician associates for observation. The primary outcome was unplanned re-attendance at the same emergency department within 7 days. consultation processes, clinical adequacy of care, and staff and patient experience. Re-attendances within 7 days (n=194 (6.1%)) showed no difference between physician associates and foundation year two doctors-in-training (OR 0.87, 95% CI 0.61 to 1.24, p=0.437). If seen by a physician associate, patients were more likely receive an X-ray investigation (OR 2.10, 95% CI 1.72 to 4.24), p

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\ud Background: Intentional rounding (IR) is a structured process whereby nurses conduct one to two hourly checks with every patient using a standardised protocol. \ud Objective: A realist synthesis of the evidence on IR was undertaken to develop IR programme theories of what works, for whom, in what circumstances and why. \ud Methods: A three-stage literature search and a stakeholder consultation event was completed. A variety of sources were searched, including AMED, CINAHL, MEDLINE, PsychINFO, HMIC, Google and Google Scholar for published and unpublished literature. In line with realist synthesis methodology, each study’s ‘fitness for purpose’ was assessed by considering its relevance and rigour. \ud Results: A total of 44 papers met the inclusion criteria. To make the programme theories underpinning IR explicit, we identified eight a priori propositions: (1) When implemented in a comprehensive and consistent way, IR improves healthcare quality, satisfaction and reduces potential harms; (2) Embedding IR into daily routine practice gives nurses ‘allocated time to care’; (3) Documenting IR checks increases accountability and raises fundamental standards of care; (4) When workload and staffing levels permit, more frequent nurse-patient contact improves relationships and increases awareness of patient comfort and safety needs; (5) Increasing time when nurses are in the direct vicinity of patients promotes vigilance, provides reassurance and reduces potential harms; (6) More frequent nurse-patient contact enables nurses to anticipate patient needs and take pre-emptive action; (7) IR documentation facilitates teamwork and communication; (8) IR empowers patients to ask for what they need to maintain their comfort and wellbeing. Given the limited evidence base, further research is needed to test and further refine these propositions. \ud Conclusions: Despite widespread use of IR, this paper highlights the paradox that there is ambiguity surrounding its purpose and limited evidence of how it works in practice.

Background Intentional rounding (IR) is a structuredprocess whereby nurses conduct one to two hourly checkswith every patient using a standardised protocol.Objective A realist synthesis of the evidence on IR wasundertaken to develop IR programme theories of whatworks, for whom, in what circumstances and why.Methods A three-stage literature search and a stakeholderconsultation event was completed. A variety of sourceswere searched, including AMED, CINAHL, MEDLINE,PsycINFO, HMIC, Google and Google Scholar, for publishedand unpublished literature. In line with realist synthesismethodology, each study’s ‘fitness for purpose’ wasassessed by considering its relevance and rigour.Results A total of 44 papers met the inclusion criteria. Tomake the programme theories underpinning IR explicit, weidentified eight a priori propositions: (1) when implementedin a comprehensive and consistent way, IR improveshealthcare quality and satisfaction, and reduces potentialharms; (2) embedding IR into daily routine practice givesnurses ‘allocated time to care’; (3) documenting IR checksincreases accountability and raises fundamental standardsof care; (4) when workload and staffing levels permit, morefrequent nurse–patient contact improves relationships andincreases awareness of patient comfort and safety needs;(5) increasing time when nurses are in the direct vicinityof patients promotes vigilance, provides reassurance andreduces potential harms; (6) more frequent nurse–patientcontact enables nurses to anticipate patient needs andtake pre-emptive action; (7) IR documentation facilitatesteamwork and communication; and (8) IR empowerspatients to ask for what they need to maintain theircomfort and well-being. Given the limited evidence base,further research is needed to test and further refine thesepropositions.Conclusions Despite widespread use of IR, thispaper highlights the paradox that there is ambiguitysurrounding its purpose and limited evidence of how itworks in practice.