Ward round or individual patient review?

The traditional ward round, which took place perhaps once a week, is outdated. Rounds now take place more frequently - sometimes twice a day - to reflect the pace of patient turnover.

It is important to distinguish between ward rounds and ad-hoc individual clinical reviews of individual patients: unlike clinical reviews, ward rounds should involve the multidisciplinary team, while individual clinical reviews - which are additional to ward rounds - take place when the registrar or another specialist (perhaps a consultant or nurse specialist) needs to review specific investigations with the patient in question. Ward rounds have a number of characteristics, which are discussed below.

Stages of a ward round

There are three distinct stages to ward rounds, each of which has equal importance.

Antecedents (before)

Key activities before a ward round takes place are:

• Establishing results of investigations;
• Preparing patients - in most cases this simply involves letting them know the round will be taking place;
• Encouraging patients to think about any questions they may have, which may help to avoid their forgetting what is important to them;
• Chasing up any multidisciplinary perspectives of care to discuss on the ward round.

Critical attributes (during)

This refers to the key activities, and perhaps type of structure, that is integral to a ward round:

• Review of unstable or deteriorating patients;
• Decision making and documenting of care;
• Review of patients going home (pre-discharge);
• Review of patients’ progress during their inpatient stay.

Consequences (after)

Once the ward round is over, a number of activities will be necessary:

• Team organisation;
• Progression of tasks;
• Communications;
• Repetition of information to the patient;
• Motivation of the ward team.

Nurses’ role in ward rounds

There should be no debate about whether or not nurses should be involved in ward rounds. The only debate, perhaps, is how to reinvigorate the nurse’s role among what are often regarded as competing priorities such as medicine rounds, theatre lists, observations - particularly if these are due to take place at the same time as the ward round. However, the presence and participation of registered nurses increases their commitment to patient-centred care.

Nurses’ workload has increased over recent years, and patients in hospital beds are more acutely ill; as such, ward rounds must be taken into account alongside numerous other skilled interventions when staffing levels and patient dependency are being reconsidered in relation to budget setting.

The key aspects of the nurse’s role on ward rounds can be defined using the acronym ACTION:

• Advocate;
• Chaperone;
• Transitions;
• Informative;
• Organiser;
• Nurse-centred.

Advocate

As members of the ward team attending the round, nurses need to know their patients. “Knowing” arises from taking a nursing handover and looking after a group of patients, so handovers and ward rounds are inextricably linked if nurses are to successfully represent those patients in their care (Jugessur and Iles, 2009). In the context of ward rounds, being an advocate involves:

• Adequately preparing for the ward round (safeguarding patients’ interests);
• Empowering patients to ask questions on the ward round (being included);
• Communicating with the multidisciplinary team after a ward round.

Chaperone

As with any other examination or intervention, protecting patients’ dignity and privacy is a priority for nurses during ward rounds. If this role is delegated to another team member, that person should be aware of what chaperoning involves, which is as follows:

• Preparing the patient for examination through communication and positioning;
• Taking responsibility for dignity and privacy;
• Minimising any anxiety and potential embarrassment;
• Respecting cultural wishes throughout the process.

Transitions

The need to minimise the length of inpatient stays means there has never been greater emphasis on patient progress along the care pathway. Multiple hand-overs during transitions between wards or between acute, intermediate and community care can lead to care being fragmented. The continuity and safe transition of information between care settings depends on the nurses who participate in the ward round, making sure all relevant information is communicated to the next stage of the pathway. This may involve the following:

• Noting any ongoing investigations and communicating these to the patient and team;
• For patient transfers, documenting any incomplete investigations/actions on a handover checklist;
• For patient discharges, documenting any relevant information on the discharge checklist (NHS Institute for Innovation and Improvement, 2009; Lees et al, 2006; Department of Health, 2004);
• For specialty referrals, completing a management plan indicating any next steps in the care pathway.

The aim is to promote transparency and continuity, and to reduce potential duplication or omissions of care during transitions.

Informative

Nurses also play a crucial role in ensuring patients have realistic expectations of ward rounds, and receive and understand all the relevant information about their care. Where possible, patients should be actively involved in making decisions about their care rather than being passive recipients. In order to execute this process, nurses should:

• Reiterate information during or after a ward round;
• Prepare the patient for the next steps in the care pathway;
• Explain anything (along the way) that the patient may not understand;
• Encourage the patient to ask questions or express concerns;
• Report back to the nursing team.

Organiser

All team members will have their own jobs to complete during the ward round. Organising the outputs emerging from ward rounds ensures nurses can assess, progress and communicate as needed to the family, bed managers, care agencies and social-work team - depending on the complexities of patient care. The organisation of activities can involve:

• Delegating effectively to different team members;
• Arranging transport and medication to take home;
• Requesting specific items of equipment that are required;
• Organising care packages.

Nurse-centred

Nurses at the bedside during ward rounds must be clinically competent to understand and anticipate the complexities of multifaceted patient situations, and able to view the patient and carer situation holistically rather than as a series of unrelated tasks. Systems such as team nursing, task-allocated nursing or primary nursing may require some adaptation but for nurses to properly represent their patients, they should be one of the following:

• A nurse responsible for a bay or allocated number of patients, who will undertake the ward round for those patients;
• A nurse in charge of a whole ward or unit who is clinically overseeing all areas of the ward and will feed back to nurses after the ward round;
• A nurse who is not responsible for any patients but is acting in a coordinating capacity for the shift and will be responsible for feeding back information after the ward round to the nurses who are in those bays.

In each of the above functions, having a nurse at the bedside during ward rounds is pivotal to enable and empower the team. Although there will be some variation according to how the ward is organised and how the nursing team works, the nurse will focus on the “here and now” during the ward round, and anticipate and respond to related actions.