New guidance from the Royal Colleges of Physicians and Nursing

Significant advances in diagnostic and therapeutic possibilities over the past few decades have created a complex modern hospital environment. The current pressures of capacity and staffing levels mean that the ‘ward round’ has become a neglected area instead of the focal point of patient care

The average hospital patient is now older, with more medical co-morbidities and often more complex social care needs. The increased specialisation in hospital means more expertise is available to match these needs, but provided by more specialists who are often geographically dispersed throughout the hospital. The Working time directive  means doctors spend less time attached to a single team and there is more frequent handover between consultants. This means that providing patient-centred care requires coordination as never before, and effective systems need to facilitate multi-disciplinary working.

Getting the basics right

Ward rounds in medicine: Principles for best practice the new report from the Royal College of Physicians (RCP) and the Royal College of Nursing (RCN) point out that there is no need to re-invent the wheel. For decades the medical professions have conducted a ward round. Perhaps because these complex clinical events are so ingrained into the fabric of the medical workplace there is a paucity of quality indicators or evidence to guide best practice in the modern environment The ward round should be an event where all disciplines share their skill and knowledge to work for the patient and with the patient with the shared goal of improving their health in the current admission and beyond.

The RCP and the RCN have highlighted the concerns of their members as this pillar of medical practice becomes side-lined and in some cases ‘not fit for purpose’ in the current medical environment. In an NHS driven to provide evidence of quality enhancing activity, the ward round has been overlooked and marginalised. Ward rounds today are often performed under great time pressure, relegated to stolen minutes between other activities (such as clinics or procedure lists) and clashing with other caring activities (such as meal times) and without the presence of a nurse who is engaged in constant care delivery.

Ward rounds in medicine sets out some principles designed to ensure high quality ward rounds again become a cornerstone of patient-centred care. A planned ward round, where all disciplines have had input will focus the clinical care for that day and the admission. It will also build stronger rapport between the patient and the health professionals, ensuring all the patient’s concerns are raised and answered. The ward round is commonly used to refine the clinical diagnosis and plan care, but it should also allow discussion about care after discharge, the limitations of treatment and the decisions around cardio-pulmonary resuscitation to be considered.  

The ward round will provide the clinical leads with areas to be covered in staff education and clinical audit. A multi-disciplinary ward round using active safety checks will make patient safety a priority for every member of the clinical team.

A change in culture to reinstate the ward round

The principles stated in the report include a commitment at all levels to make ward rounds a top priority. From board level through managerial teams and down to staff on the ward, the morning ward round should be seen as a key to coordinated patient care and an opportunity for team discussion, patient engagement, education and ensuring best practice. The ward round culture should be included in all new staff inductions.

The hospital system needs to ensure that the ward round is prioritised, time is allocated, there is no clash between clinical teams or with other activities. Senior staff from each discipline needs to be available with no competing responsibilities, to participate in the ward round. The presence of a consultant and senior nurse at the bedside together should be a familiar and reassuring sight on all wards in the NHS.  Ward rounds in medicine also recommends that if possible, patients under the care of a single clinical team should be on the same ward. The multidisciplinary team should have specific facilities to aid the round (eg a designated trolley and computer).

Communication matters

Trust between people, whether clinicians and their patients or fellow medical staff, is built up when they are given time to meet together. Breakdown in relationships between nurses and doctors has been cited as an area of concern by all professionals and the patients. Good communication is crucial to achieve high quality patient care, the ward round should be an act of formal and informal communication between the patient and the team and among the clinical team members.

Leadership and Teamwork

Strong clinical leadership has been repeatedly shown to improve patient experience. The role of the ward round lead consultant and a senior nurse are important examples of how leadership can benefit patients, drive clinical care and facilitate ward coordination. The morning ward round should set the agenda and facilitate timely completion of tasks..

As with many team-based processes preparation and utilisation of the assets of the individual team members is more likely to lead to a successful outcome. The report recommends that the ward round includes a pre-round briefing and a post-round review. The aims of the ward round (which may vary for each patient visited) must be identified and any barriers to a quality ward round must be addressed before commencing.

Local Solutions from First Principles

Ward rounds in medicine highlights the principles that should govern the practice of the medical ward round. The ward round should be a patient-centred event, where every member of the team is focused on ensuring quality of care by contributing their expertise to the discussion and reducing harm. In the diverse world of healthcare the ward round will need to adapt to meet local need. Locally devised safety checklists can be used to ensure all information has been reviewed, all tasks allocated and all documentation completed. The use of such tools would facilitate the monitoring and improvement of practice.

Preparing Patients

Just as medical staff need to prepare to get the most from a ward round so do the patients. Ward rounds in medicine propose that staff on a ward can help all patients (particularly those with dementia or learning disabilities) by clarifying the timing of a ward round, acting as a conduit when communicating their concerns, ensuring that any carers the patient wishes to be present are accommodated. Written information sheets or checklists can help patients to use the ward round to their advantage.  Receiving a written summary of important discussions and agreed plans from the ward round will help patients to communicate with their families and to reflect on the plans made. 

Conclusions

Ward rounds in medicine is one of several join projects between the Royal colleges recently. The colleges are not advocating a return to the hierarchical ‘doctors rounds’ characterised by the Carry On film but an opportunity to build on all that is best in the medical profession. There are plenty of examples of good practice around the country where teams are developing methods that use a historic practice to focus everyone’s attention on providing patient-centred care. The report from the RCP and RCN should be seen as a torch bearer for this renewal.

Dr Georgina Russell is a respiratory and general medicine trainee in London. She qualified from St Mary's London in 2001 and obtained RCP membership in 2005 and an MSc in epidemiology. Georgina has worked within the NHS and for medecins Sans Frontieres in London, Brighton, Malawi and Myanmar (Burma). She is currently seconded to the Royal College of Physicians (RCP) as part of the NHS medical directors' clinical fellow scheme.