Exploring influences on clinicians' and patients' involvement in ward rounds

Background Ward rounds are a routine, normalised, formalised, daily activity that occur on wards to plan, coordinate and review patient care. Nevertheless, they comprise a complex series of processes, confounded by the knowledge and practice intricacies of medical, nursing, allied health and patient interactions. The assumed shared understanding of ward rounds impacts teamwork, care delivery and patient experiences and outcomes. Effective transfer of knowledge about the patient and treatment plan between clinicians and patients is vital to safe care delivery. Therefore, the aim of the study was to explore health professionals' and patients' understanding and experiences of ward rounds to identify the influencing factors to their participation. Method A two-phased mixed method study was undertaken. Data were collected in four wards across medical and rehabilitation specialties, within a metropolitan teaching hospital, in Sydney, Australia. In Phase One, a purpose-designed survey tool was administered to 77 clinicians. The survey had three areas of focus. The first was on clinicians' experience of teamwork, to provide insight into the skills and attributes of positive teamwork that could facilitate effective ward rounds. The second investigated if interdisciplinary team members shared an understanding of ward rounds and involvement in patient care planning. The third focus examined the usual practice of interdisciplinary bedside rounds (IBRs) in the hospital. In Phase Two, observations were conducted of clinicians and patients during ward rounds. Purpose-designed observation and semi-structured interview tools were developed and administered. Ward rounds of 14 patients were observed, with all patients subsequently participating in in-depth interviews. These explored the patient understanding and experience of ward rounds, and the factors that influenced their willingness and capacity to participate in the round. Results Phase One Shared understanding of ward rounds differed between acute medicine and rehabilitation specialties. There was more consistency between the professional groups of medical officers, nursing, and allied health clinicians than when they were working as an interdisciplinary team and in a specific speciality. Self-reported attendance at ward rounds was higher than attendance perceived by colleagues. Despite this, clinicians considered their team's communication for patient care to be effective. Benefits and challenges of IBRs were described more consistently within disciplines. The benefits were commonly patient focused. Clinicians desired rounding processes that facilitated safe patient care and increased clinicians' capacity to contribute to care planning. The challenges to IBRs had origins in competing care priorities, workforce structures and actual or perceived professional and organisational culture. Clinicians consistently reported staff attributes that enabled collaborative teamwork in ward rounds, such as when there was clear leadership. An understanding of roles and responsibilities ensured appropriate communication and task allocation. Phase Two Patients sought involvement in their ward round. Participation was influenced by their own understanding of ward rounds based on previous experiences and confidence to participate. Patients who were more familiar with the health service had a greater sense of taking responsibility for providing clinicians with information and being prepared for the round discussion. Patients prioritised talking with medical officers during rounds, and they perceived information provided by the consultant as the most reliable. Discussion/Conclusion Ward rounds represent a web of processes integrating complex health system and human factors. The stakeholder groups who influence rounding processes and experiences are: the health service, health professionals and patients. This thesis provides a unique exploration into ward rounds. Previous studies considered these influences‚ÄövÑvp in silos. This series of studies investigates them together to explore the impact they have on each other. Four themes were identified that influence stakeholders: understanding and recognition of rounding processes between interdisciplinary teams; actual, or perceived, clinicians' and patients' behaviour such as a perceived medical hierarchy; delivering person-centred care through collaborative teamwork; and workforce structure challenges leading to each health discipline having different located patients. Each stakeholder had a different level of influence on ward round participation. In our study clinical specialty did not meaningfully influence ward round participation. Study findings led to the development of the Hierarchy of influence on ward round participation‚ÄövÑvp, a unique empirically based model representing the factors that influence participation in ward rounds.