Communication during ward rounds in internal medicine. An analysis of patient-nurse-physician interactions using RIAS

Interprofessional ward rounds in an adult intensive care unit: an appreciative inquiry into the central collaboration between the consultant and the bedside nurse

Done well, ward rounds (WRs) promote effective, safe care and collaboration; but WR quality varies. An improvement-focused appreciative inquiry (AI) into a large intensive care unit's WR practices identified a pivotal axis of collaboration between the most senior medical role (the consultant) and the bedside nurse (BSN). This paper examines that axis of interprofessional collaboration (IPC) to deepen understanding of its implications. Data included ethnographic observations, interviews, and co-constructed AI with groups of staff. Four key concepts emerged from cyclical interpretive analysis: "need," "presence," "ability" and "willingness." BSNs and consultants needed the interprofessional WR to enable their work; WR effectiveness was affected by whether they were both present, then able and willing to participate in IPC. BSN presence was necessary for effective and efficient IPC between these key roles. Indirect contributions, based on prior exchanges with colleagues or through written notes, reduced the joint problem-solving through discussion and negotiation that characterizes IPC to less efficient asynchronous interprofessional coordination. Factors affecting "presence," "ability" and "willingness" are discussed alongside potential mitigations and acknowledgment of asymmetric power. Appreciative examination of interprofessional WRs identified mechanisms supporting and undermining effective WR IPC and the centrality of consultants' and BSNs' collaboration.

Patient Care Boards - A tool to promote patient participation during hospital ward rounds

Objective

This pre-post intervention study investigated the effectiveness of the Patient Care Board (PCB) as a tool to increase the participation of patients and relatives during hospital ward rounds.

Methods

Using The Activity Barometer (TAB), we rated 121 video-recorded rounds to compare participation before and after implementing the PCB into clinical practice. Associations between scores for the extent to which patients ask questions or express preferences and concerns were tested with multiple linear regression.

Results

TAB-scores tended to be higher after implementing the PCB, especially for the relatives. However, no significant differences were found. The greatest impact on participation was time spent on rounds (p < 0.001). Preparing questions in advance of the round, as well as using anatomical drawings for explanations, increased patient participation (p = 0.041, 0.024). Furthermore, the implementation of the PCB led to higher nurse attendance (p = 0.003).

Conclusion

Although we found tendencies towards higher participation, the study could not confirm a significant impact of the overall intervention.

Innovation

Our results suggest that further research is needed, to ensure a higher degree of preparation among the patients, better opportunities for relatives to participate as well as integration of visual information in the rounds.

Physician behaviors associated with increased physician and nurse communication during bedside interdisciplinary rounds

BACKGROUND

Effective team communication during interdisciplinary rounds (IDRs) is a hallmark of safe, efficient, patient-centered care. However, there is limited understanding of optimal IDR structures and procedures.

OBJECTIVE

This study aimed to analyze direct observations of physician and nurse interactions during bedside IDR to identify behaviors associated with increased interprofessional communication.

DESIGNS, SETTINGS AND PARTICIPANTS

Trained observers audited general medicine ward rounds at an academic medical center using a standardized tool to record physician and nurse behavior and communication in 1007 patient encounters in October 2019 to March 2020.

RESULTS

There were significant differences in physician and nurse interaction time among physicians with different levels of training, with attendings demonstrating higher interaction time than residents (5.4 ± 4.6 vs. 4.3 ± 3.7 min, p = .02) and interns or medical students (3.0 ± 3.2 min, p = .002). Attendings were more likely to initiate a conversation about nurse concerns (76.9%) compared to residents (67.9%) and interns or medical students (59.3%, p = .03). Early nurse participation in bedside visits was associated with increased physician and nurse interaction time (5.0 ± 4.6 vs. 1.9 ± 1.7 min, p < .001) and physician initiative to ask about nurse concerns (74.8% vs. 64.3%, p = .04). In addition, physician initiative to ask the nurse for concerns rather than waiting for the nurse to offer concerns without being prompted was associated with a subsequent conversation about those concerns (74.5% vs. 61.8%, p < .001) and the physician asking about patient or family concerns (94.2% vs. 88.4%, p = .01).

CONCLUSIONS

Implementing IDR structures and procedures that promote attending physician involvement, physician initiative, and early nurse participation could optimize interdisciplinary communication and quality of care.

Occurrence of sensitive topics during ward round: an ancillary analysis of the BEDSIDE-OUTSIDE trial

OBJECTIVE

Discussing sensitive topics (eg, medical uncertainty, social issues, non-adherence) during ward rounds is challenging and may negatively impact patient satisfaction with the healthcare they are receiving. In the previous multicentre randomised BEDSIDE-OUTSIDE trial focusing on communication during ward rounds, we investigated the interplay between sensitive topics and low reported satisfaction with care.

DESIGN

Pre-planned secondary analysis of a randomised controlled trial. For this analysis data of the original trial was pooled across intervention groups.

SETTING

Three Swiss teaching hospitals.

PARTICIPANTS

Adult patients hospitalised for medical care.

INTERVENTIONS

We analysed predefined sensitive health topics and specific elements of communication from audiotapes recorded during ward rounds, for both patients dealing with and without sensitive topics.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was overall patient satisfaction with care; measured on a Visual Analogue Scale from 0 to 100. Secondary endpoints included duration of ward rounds and further satisfaction outcomes.

RESULTS

Of the 919 included patients, 474 had at least one sensitive topic including medical uncertainty (n=251), psychiatric comorbidities (n=161), tumour diagnosis (n=137) and social issues (n=125). Compared with patients without sensitive topics, patients with sensitive topics reported lower satisfaction with care (mean (SD), 87.7 (±14.6) vs 90.2 (±12.1), adjusted difference -2.5 (95% CI -4.28 to -0.72), p=0.006. Among patients with sensitive topics, risk factors for low satisfaction included several parameters concerning patient-physician interaction such as disagreements during ward rounds (mean (SD), 14/212 (6.6%) vs 41/254 (16.1%), adjusted OR 2.78 (95% CI 1.47 to 5.27), p=0.002).

CONCLUSIONS

A large proportion of medical inpatients must deal with sensitive health topics. This is associated with lower satisfaction with care, particularly if the patient perceives the interaction with doctors during ward rounds as unsatisfactory. Educating physicians on specific communication techniques may help improve care for these patients.

TRIAL REGISTRATION NUMBER

NCT03210987.

Registered nurse-patient communication research: An integrative review for future directions in nursing research

AIM

To explore communication research in nursing by investigating the theoretical approaches, methods, content and perspectives in research on real-time registered nurse (RN)-patient communication.

DESIGN

An integrative review of real-time communication between RNs and patients.

DATA SOURCES

Empirical research papers were searched in PubMed, CINAHL Plus and Medline. The results from the database searches were supplemented with results from manual searches in reference lists.

REVIEW METHODS

A total of 1369 articles published between January 1996 and December 2021 were screened, which resulted in the inclusion of 52 articles.

RESULTS

The integration of various theories, such as nursing or communication theories, is weak in most of the included studies. RN-patient communication appears to influence relationship building. Even when nurses strive to meet patients' needs, they often focus primarily on nursing routines and physical care. The topic of the communication varies depending on the situation and different communication styles are used. When a patient-centred approach is adopted, the interpersonal communication becomes quite symmetrical, with complementary roles of nurses and patients. Within a more asymmetric communication context, nurses dominate communication, choose topics and function as instructors. How the nurses communicated subsequently influenced the patients' communication styles and strategies.

CONCLUSION

Communication is multifaceted, contains different strategies and is important for building trust and facilitating patient-centred care. The importance of RNs' communication for interaction and relationship-building seems to be well established within research, but few studies focused on patients' communication with RNs.

IMPACT

This integrative review gives an overview of the width and depth of observational studies on RN-patient communication research. The variety of studies indicates that this area is a less well-grounded field of research. Future research is warranted to support nurses in their communication, especially regarding the exploration of patients' communication and desired communication skills in nurse-patient interactions.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was included in this integrative review.

Creating opportunities for patient participation in managing medications across transitions of care through formal and informal modes of communication

BACKGROUND

Communicating about medications across transitions of care is important in older patients who frequently move between health care settings. While there is increasing interest in understanding patient communication across transitions of care, little is known about older patients' involvement in formal and informal modes of communication regarding managing medications.

OBJECTIVE

The aim of this paper was to explore how older patients participated in managing their medications across transitions of care through formal and informal modes of communication.

METHODS

The study was conducted across two metropolitan hospitals: an acute hospital and a geriatric rehabilitation hospital in metropolitan Melbourne, Australia. A focused ethnographic design was used involving semi-structured interviews (n = 50), observations (203 h) and individual interviews or focus groups (n = 25). Following thematic analysis, data were analysed using Fairclough's Critical Discourse Analysis.

RESULTS

Data analysis revealed two major discursive practices, which comprised of an interplay between formal and informal communication and environmental influences on formal and informal communication. Self-created patient notes were used by older patients to initiate informal discussion with health professionals about medication decisions, which challenged traditional unequal power relations between health professionals and patients. Formal prompts on electronic medication administration records facilitated the continuous information discourse about patients' medications across transitions of care and encouraged health professionals to seek out older patients' preferences through informal bedside interactions. Environmental influences on communication comprised health professionals' physical movements across private and public spaces in the ward, their distance from older patients at the bedside and utilization of the computer systems during patient encounters.

CONCLUSION

Older patients' self-created medication notes enabled them to take on a more active role in formal and informal medication communication across transitions of care. Older patients and family members did not have continuous access to information about medication changes during their hospital stay and systems often failed to address older patients' key concerns about their medications, which hindered their active involvement in formal and informal communication.

PATIENT OR PUBLIC CONTRIBUTION

Older adults, family members and health professionals volunteered to be interviewed and observed.

Influence of noise manipulation on retention in a simulated ICU ward round: an experimental pilot study

Background

Noise exposure leads to a reduction in cognitive abilities in diverse settings, however, only limited data exist examining the effects of environmental ICU noise on the cognitive performance of ICU professionals. A frequently occurring and demanding retention task in ICUs are ward rounds, which are considered key for the provision of medical care. Here, we investigate the influence of noise on information retention in a simulated ward round.

Methods

ICU professionals were exposed to a recorded, ICU ward round, simulated partly with and partly without environmental ICU noise. Ward rounds were followed by specific questions about previously provided information.

Results

56 ICU professionals (aged 26–59 years) were included. A logistic mixed model showed a reduction of 27% (P < 0.001) in the ward round test performance when participants were exposed to environmental ICU noise. Furthermore, advanced age was associated with reduced retention (− 28%, P < 0.001), questions containing important information performed better (+ 36%, P < 0.001), and higher stress led to better performance in retention (+ 24%, P = 0.01).

Conclusions

Our data showed a considerable negative influence of environmental ICU noise during a simulated ward round. Therefore, reduction of environmental ICU noise is recommended. The influence of additional factors, including stress, priorities, and demographic factors should be pursued in subsequent investigations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40635-022-00430-1.

Effect of Bedside Compared With Outside the Room Patient Case Presentation on Patients' Knowledge About Their Medical Care : A Randomized, Controlled, Multicenter Trial

BACKGROUND

Although bedside case presentation contributes to patient-centered care through active patient participation in medical discussions, the complexity of medical information and jargon-induced confusion may cause misunderstandings and patient discomfort.

OBJECTIVE

To compare bedside versus outside the room patient case presentation regarding patients' knowledge about their medical care.

DESIGN

Randomized, controlled, parallel-group trial. (ClinicalTrials.gov: NCT03210987).

SETTING

3 Swiss teaching hospitals.

PATIENTS

Adult medical patients who were hospitalized.

INTERVENTION

Patients were randomly assigned to bedside or outside the room case presentation.

MEASUREMENTS

The primary endpoint was patients' average knowledge of 3 dimensions of their medical care (each rated on a visual analogue scale from 0 to 100): understanding their disease, the therapeutic approach being used, and further plans for care.

RESULTS

Compared with patients in the outside the room group (n = 443), those in the bedside presentation group (n = 476) reported similar knowledge about their medical care (mean, 79.5 points [SD, 21.6] vs. 79.4 points [SD, 19.8]; adjusted difference, 0.09 points [95% CI, -2.58 to 2.76 points]; P = 0.95). Also, an objective rating of patient knowledge by the study team was similar for the 2 groups, but the bedside presentation group had higher ratings of confusion about medical jargon and uncertainty caused by team discussions. Bedside ward rounds were more efficient (mean, 11.89 minutes per patient [SD, 4.92] vs. 14.14 minutes per patient [SD, 5.65]; adjusted difference, -2.31 minutes [CI, -2.98 to -1.63 minutes]; P < 0.001).

LIMITATION

Only Swiss hospitals and medical patients were included.

CONCLUSION

Compared with outside the room case presentation, bedside case presentation was shorter and resulted in similar patient knowledge, but sensitive topics were more often avoided and patient confusion was higher. Physicians presenting at the bedside need to be skilled in the use of medical language to avoid confusion and misunderstandings.

PRIMARY FUNDING SOURCE

Swiss National Foundation (10531C_ 182422).

"I just stand around and look friendly" - Comparing medical students' and physicians' ward round scripts

BACKGROUND

Even though ward rounds are important learning opportunities for medical students, unfavourable ward round scripts of students and physicians may hinder learning in such situations. We investigated medical students' and physicians' ward round scripts with respect to (a) the content focus of ward round activities, and (b) the potential of these activities for knowledge construction.

METHODS

We conducted standardized interviews with 50 medical students and physicians in internal medicine at different expertise stages. Activities participants labelled as typical for ward rounds were coded with respect to their content focus and their potential with regard to knowledge construction.

RESULTS

Regarding content focus, especially residents mainly named activities bound to patient care. Teaching- and learning-related activities were very rare, but more frequently mentioned by students and more experienced physicians. With respect to potential for knowledge construction, students regarded significantly more passive activities (= low potential for knowledge construction) as typical for ward rounds, especially when they described their own role.

CONCLUSIONS

Medical students should be supported in their development of conceiving ward rounds as valuable learning opportunities. Residents should be asked to take their teaching responsibility seriously, for example by demanding an active engagement of the students during ward rounds.

Simulated ward round training in the medical curriculum Munich

Conducting a ward round in a structured and goal-oriented manner is one of the central competencies of a physician's work. Despite its relevance, ward round competence was only addressed in an unstructured way in the Medical Curriculum Munich (MeCuM) prior to 2011. Therefore, the project's aim was to implement an evidence-based course on medical ward round competence. This project report provides a guideline for developing such a training course. Project planning and development was guided by the steps of the "Kern cycle", beginning with needs assessment, learning objectives definition, and selection of appropriate teaching methods, and ending with implementation and evaluation.

Relationships Between Time-at-Bedside During Hospital Ward Rounds, Clinician-Patient Agreement, and Patient Experience

Hospital medicine ward rounds are often conducted away from patients’ bedsides, but it is unknown if more time-at-bedside is associated with improved patient outcomes. Our objective is to measure the association between “time-at-bedside,” patient experience, and patient–clinician care agreement during ward rounds. Research assistants directly observed medicine services to quantify the amount of time spent discussing each patient’s care inside versus outside the patient’s room. “Time-at-bedside” was defined as the proportion of time spent discussing a patient’s care in his or her room. Patient experience and patient–clinician care agreement both were measured immediately after ward rounds. Results demonstrated that the majority of patient and physicians completely agreement on planned tests (66.3%), planned procedures (79.7%), medication changes (50.6%), and discharge location (66.9%), but had no agreement on the patient’s main concern (74.4%) and discharge date (50.6%). Time-at-bedside was not correlated with care agreement or patient experience (P > .05 for all comparisons). This study demonstrates that spending more time at the bedside during ward rounds, alone, is insufficient to improve patient experience.

Correcting medical decisions: a study in nurses' patient advocacy in (Finnish) hospital ward rounds

During daily hospital ward rounds, medical teams, led by doctors, assess the progress of an individual patient's health. It is widely reported in the research literature that nurses play a relatively passive role during these rounds, because although they may have valuable information about the patient's condition and progress, and indeed their role includes advocacy on behalf of their patients, nurses nevertheless can experience difficulties in participating during case constructions. Here we report an instance from a (gastro-surgical) ward round in a Finnish hospital, in which nurses played a key role in reversing a consultant's initial decision to discharge a patient. They did so not by directly challenging the consultant's opinion, but by employing indirect means to introduce their discrepant perspective: they provide descriptions and ask questions that draw attention to information that results in the doctor coming to a different assessment than theirs of the patient's condition, and a different decision about what should be done (the patient was not discharged from hospital). The encounter reported here is taken from a corpus of ward round discussions in a Finnish hospital. The method of our study is Conversation Analysis.

Relational autonomy in end-of-life care ethics: a contextualized approach to real-life complexities

Background

Respect for autonomy is a paramount principle in end-of-life ethics. Nevertheless, empirical studies show that decision-making, exclusively focused on the individual exercise of autonomy fails to align well with patients’ preferences at the end of life. The need for a more contextualized approach that meets real-life complexities experienced in end-of-life practices has been repeatedly advocated. In this regard, the notion of ‘relational autonomy’ may be a suitable alternative approach. Relational autonomy has even been advanced as a foundational notion of palliative care, shared decision-making, and advance-care planning. However, relational autonomy in end-of-life care is far from being clearly conceptualized or practically operationalized.

Main body

Here, we develop a relational account of autonomy in end-of-life care, one based on a dialogue between lived reality and conceptual thinking. We first show that the complexities of autonomy as experienced by patients and caregivers in end-of-life practices are inadequately acknowledged. Second, we critically reflect on how engaging a notion of relational autonomy can be an adequate answer to addressing these complexities. Our proposal brings into dialogue different ethical perspectives and incorporates multidimensional, socially embedded, scalar, and temporal aspects of relational theories of autonomy. We start our reflection with a case in end-of-life care, which we use as an illustration throughout our analysis.

Conclusion

This article develops a relational account of autonomy, which responds to major shortcomings uncovered in the mainstream interpretation of this principle and which can be applied to end-of-life care practices.

Improving physicians' surgical ward round competence through simulation-based training

OBJECTIVE

Ward rounds are an essential part of physicians' daily routine. Existing studies suggest that their practical implementation is inconsistent. Therefore, developing interventions to train ward round competence and assessing if they are effective educational tools are crucial goals for research.

METHODS

We analysed a simulation-based tutorial dedicated to fourth-year medical students, including casework and ward round simulation. We investigated the effectiveness of this intervention regarding ward round competence through a randomized controlled trial. Performance was assessed with the modified/validated surgical ward round assessment tool by two blinded and trained raters. Supplementary, motivation during the ward round tutorial was assessed for all students at different time points.

RESULTS

Analysis of the ratings show that, in contrast to the control group (pre: 66.1 vs. post: 64.8 points, p =  0.72), the ward round competence of the intervention group (pre: 62.6 vs. post: 69.6 points, p =  0.0169) improved significantly after participating in the ward round tutorial.

CONCLUSION

The results show that our simulation-based training is an effective way to improve competence of medical students in conducting surgical ward rounds.

PRACTICE IMPLICATIONS

Participation in ward round trainings is a valuable tool to prepare students for their future professional practise.

Identifying best practices in electronic health record documentation to support interprofessional communication for the prevention of central line-associated bloodstream infections

BACKGROUND

There is a paucity of research on best practices for communication through the electronic health record (EHR) to support shared decision-making and to prevent adverse events. To explore this issue, this study focused on interprofessional communication around a specific clinical issue, the prevention of central line-associated bloodstream infections.

METHODS

The Delphi technique was used to describe what information is needed to support decisions regarding central venous catheter (CVC) management, and best practices for communicating this information among the interprofessional team.

RESULTS

The expert panel, 4 physicians and 6 nurses, identified 12 information types necessary for decisions regarding CVC management and the removal of unnecessary lines. For each of the 12 information types, the panel reached agreement regarding the best channel to communicate this information, including asynchronous EHR formats and synchronous oral channels.

CONCLUSIONS

Findings address 2 important aspects of postinsertion CVC practices and a gap in the literature by moving beyond a description of current practices to a description of how the EHR ought to be used to support collaboration and interprofessional communication. Future research should examine how the communication practices identified in this study contribute to a reduction in central line-associated bloodstream infections.

Ward round competences in surgery and psychiatry - a comparative multidisciplinary interview study

BACKGROUND

The ward round is a key element in everyday hospital inpatient care irrespective of the medical speciality. The underperformance in conducting ward rounds of junior clinicians has already been described. Therefore, necessary skills and competences of clinicians need to be defined, taught and delivered for curricular instruction. In addition to published data on ward round competences in internal medicine this study aims to determine the common competences for surgical and psychiatric ward rounds in order to find differences depending on the speciality.

METHODS

Semi-structured interviews with surgical (N = 30) and psychiatric ward staff (N = 30) of a university hospital and five community hospitals were conducted. Competences necessary for performing ward rounds as well as structural aspects were identified by systematic content analysis and frequency analysis, supported by adequate statistics.

RESULTS

Relevant competences for both fields are: collaborative clinical reasoning, communication with the patient and the team, organization, teamwork, management of difficult situations, self-management, error-management, teaching, empathy, nonverbal communication, patient-management and professionalism. Clinical skills were mentioned more often in surgical interviews, while nonverbal communication was described more often in psychiatric interviews. Empathy and communication with the team were more frequently attributed to psychiatric residents.

CONCLUSION

The competences which were identified as necessary for conducting a ward round in surgery and psychiatry are similar and correspond to previously reported competences in internal medicine. Clinical skills are of greater importance in surgery than in psychiatry. Concerning empathy and nonverbal communication, further research is needed to determine whether they are of minor importance in surgery or whether there is a lack of awareness of these competences.

Implementing bedside rounds to improve patient-centred outcomes: a systematic review

BACKGROUND

Bedside rounds (BR) have been proposed as an ideal method to promote patient-centred hospital care, but there is substantial variation in their implementation and effects. Our objectives were to describe the implementation of BR in hospital settings and determine their effect on patient-centred outcomes.

METHODS

Data sources included Ovid MEDLINE, Ovid Embase, Scopus and Ovid Cochrane Central Registry of Clinical Trials from database inception through 28 July 2017. We included experimental studies comparing BR to another form of rounds in a hospital-based setting (ie, medical/surgical unit, intensive care unit (ICU)) and reporting a quantitative patient-reported or objectively measured clinical outcome. We used random effects models to calculate pooled Cohen's d effect size estimates for the patient knowledge and patient experience outcome domains.

RESULTS

Twenty-nine studies met inclusion criteria, including 20 from adult care (17 non-ICU, 3 ICU), and nine from paediatrics (5 non-ICU, 4 ICU), the majority of which (n=23) were conducted in the USA. Thirteen studies implemented BR with cointerventions as part of a 'bundle'. Studies most commonly reported outcomes in the domains of patient experience (n=24) and patient knowledge (n=10). We found a small, statistically significant improvement in patient experience with BR (summary Cohen's d=0.09, 95% CI 0.04 to 0.14, p<0.001, I²=56%), but no significant association between BR and patient knowledge (Cohen's d=0.21, 95% CI -0.004 to -0.43, p=0.054, I²=92%). Risk of bias was moderate to high, with methodological limitations most often relating to selective reporting, low adherence rates and missing data.

CONCLUSIONS

BR have been implemented in a variety of hospital settings, often 'bundled' with cointerventions. However, BR have demonstrated limited effect on patient-centred outcomes.

Exploring reasoning mechanisms in ward rounds: a critical realist multiple case study

BACKGROUND

Ward rounds are an important and ubiquitous element of hospital care with a history extending well over a century. Although originally intended as a means of educating medical trainees and junior doctors, over time they have become focused on supporting clinical practice. Surprisingly, given their ubiquity and importance, they are under-researched and inadequately understood. This study aims to contribute knowledge in human reasoning within medical teams, meeting a pressing need for research concerning the reasoning occurring in rounds.

METHODS

The research reported here aimed to improve the understanding of ward round reasoning by conducting a critical realist case study exploring the collaborative group reasoning mechanisms in the ward rounds of two hospitals in Victoria, Australia. The data collection involved observing rounds, interviewing medical practitioners and holding focus group meetings.

RESULTS

Nine group reasoning mechanisms concerning sharing, agreeing and recording information in the categories of information accumulation, sense-making and decision-making were identified, together forming a program theory of ward round reasoning. In addition, themes spanning across mechanisms were identified, further explaining ward round reasoning and suggesting avenues for future exploration. Themes included the use of various criteria, tensions involving mechanisms, time factors, medical roles and hierarchies.

CONCLUSIONS

This paper contributes to the literature by representing rounds in a manner that strengthens understanding of the form of the group reasoning occurring within, thus supporting theory-based evaluation strategies, redesigned practices and training enhancements.

Co-Producing Interprofessional Round Work: Designing Spaces for Patient Partnership

Within wide-ranging quality improvement agendas, patient involvement in health care is widely accepted as crucial. Ward rounds that include patients' active participation are growing as an approach to involve patients, ensure safety, and improve quality. An emerging approach to studying quality improvement is to focus on “clinical microsystems,” where patients, professionals, and information systems interact. This provides an opportunity to study ward rounds more deeply. A new model of conducting ward rounds implemented through quality improvement work was studied, using the theory of practice architectures as an analytical tool. Practice architecture focuses on the cultural-discursive, social-political, and material-economic conditions that shape what people do in their work. Practice architecture is a sociomaterial theoretical perspective that has the potential to change how we understand relationships between practice, learning, and change. In this study, we examine how changes in practices are accomplished. The results show that practice architecture formed co-productive learning rounds, a possible model integrating quality improvement in daily work. This emerged in the interplay between patients through their “double participation” (as people and as information on screens), and groups of professionals in a ward round room. However, social interplay had to be renegotiated in order to accomplish the goals of all ward rounds.

Older hospitalized patients' experiences of dialogue with healthcare providers in hospitals: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective is to identify and synthesize findings from qualitative studies of older (over 65 years) hospitalized patients' experiences of the barriers and facilitators to their dialogues with healthcare providers (HCPs) concerning their health and well-being.Specifically, the review questions are.

Communication behaviors and patient autonomy in hospital care: A qualitative study

BACKGROUND

Little is known about how hospitalized patients share decisions with physicians.

METHODS

We conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before morning rounds and obtained consent. The RA audio recorded morning rounds, and then separately interviewed both patient and physician. Coding was done using integrated analysis.

RESULTS

Most patients were white (61%) and half were female. Most physicians were male (66%) and of Southeast Asian descent (66%). All physicians explained the plan of care to the patients; most believed that their patient understood. However, many patients did not. Physicians rarely asked the patient for their opinion. In all those cases, the decision had been made previously by the doctors. No decisions were made with the patient. Patients sometimes disagreed.

CONCLUSIONS

Shared decision-making may not be the norm in hospital care. Although physicians do explain treatment plans, many hospitalized patients do not understand enough to share in decisions. When patients do assert their opinion, it can result in conflict.

PRACTICE IMPLICATIONS

Some hospitalized patients are interested in discussing treatment. Improving hospital communication can foster patient autonomy.

An exploratory study of healthcare professionals' perceptions of interprofessional communication and collaboration

Interprofessional communication and collaboration during hospitalisation is critically important to provide safe and effective care. Clinical rounds are an essential interprofessional process in which the clinical problems of patients are discussed on a daily basis. The objective of this exploratory study was to identify healthcare professionals' perspectives on the "ideal" interprofessional round for patients in a university teaching hospital. Three focus groups with medical residents, registered nurses, medical specialists, and quality improvement officers were held. We used a descriptive method of content analysis. The findings indicate that it is important for professionals to consider how team members and patients are involved in the decision-making process during the clinical round and how current social and spatial structures can affect communication and collaboration between the healthcare team and the patient. Specific aspects of communication and collaboration are identified for improving effective interprofessional communication and collaboration during rounds.

Physicians' perceptions of physician-nurse interactions and information needs in China

BACKGROUND

Good communication between physicians and nurses is important for the understanding of disease status and treatment feedback; however, certain issues in Chinese hospitals could lead to suboptimal physician-nurse communication in clinical work.

METHODS

Convenience sampling was used to recruit participants. Questionnaires were sent to clinical physicians in three top tertiary Grade-A teaching hospitals in China and six hundred and seventeen physicians participated in the survey.

RESULTS

(1) Common physician-nurse interactions were shift-change reports and provisional reports when needed, and interactions expected by physicians included face-to-face reports and communication via a phone or mobile device. (2) Most respondents believed that the need for information in physician-nurse interactions was high, information was moderately accurate and timely, and feedback regarding interaction time and satisfaction indicated that they were only average and required improvement. (3) Information needs in physician-nurse interactions differed significantly according to hospital category, role, workplace, and educational background (p < .05).

CONCLUSIONS

There was a considerable need for information within physician-nurse interactions, and the level of satisfaction with the information obtained was average; requirements for the improvement of communication differed between physicians and nurses because of differences in their characteristics. Currently, the use of information technology in physician-nurse communication was less common but was highly expected by physicians.

Interprofessional collaboration in nursing homes (interprof): a grounded theory study of general practitioner experiences and strategies to perform nursing home visits

Background

Interprofessionalism, considered as collaboration between medical professionals, has gained prominence over recent decades and evidence for its impact has grown. The steadily increasing number of residents in nursing homes will challenge medical care and the interaction across professions, especially nurses and general practitioners (GPs). The nursing home visit, a key element of medical care, has been underrepresented in research. This study explores GP perspectives on interprofessional collaboration with a focus on their visits to nursing homes in order to understand their experiences and expectations. This research represents an aspect of the interprof study, which explores medical care needs as well as the perceived collaboration and communication by nursing home residents, their families, GPs and nurses. This paper focusses on GPs’ views, investigating in particular their visits to nursing homes in order to understand their experiences.

Methods

Open guideline-interviews covering interprofessional collaboration and the visit process were conducted with 30 GPs in three study centers and analyzed with grounded theory methodology. GPs were recruited via postal request and existing networks of the research partners.

Results

Four different types of nursing home visits were found: visits on demand, periodical visits, nursing home rounds and ad-hoc-decision based visits. We identified the core category “productive performance” of home visits in nursing homes which stands for the balance of GPs´ individual efforts and rewards. GPs used different strategies to perform a productive home visit: preparing strategies, on-site strategies and investing strategies.

Conclusion

We compiled a theory of GPs home visits in nursing homes in Germany. The findings will be useful for research, and scientific and management purposes to generate a deeper understanding of GP perspectives and thereby improve interprofessional collaboration to ensure a high quality of care.

Communication with physicians in hospital rounds: An interview with nurses

A hospital round is a long tradition in which nurses and physicians communicate to develop an integrated plan of care together with the patient. There is insufficient knowledge of care professionals’ experiences of communication during hospital rounds, particularly in surgical units, where the physician is frequently absent during daily care. Hence, the aim of this study was to describe nurses’ experiences of communication with physicians during hospital rounds in a surgical unit. Nine qualitative unstructured interviews with nurses were conducted and analysed using Burnard’s description of content analysis. ‘An encounter involving opportunities for and challenges to teamwork’ was found to be the predominant theme. The hospital round in a surgical unit is a short encounter that can be challenged by missing patient care goals, difficulties in transmitting messages and frustration over unshared information. Further studies are needed to overcome existing knowledge gaps about communication during hospital rounds.

Medical ward round competence in internal medicine - an interview study towards an interprofessional development of an Entrustable Professional Activity (EPA)

BACKGROUND

The medical ward round is a central but complex activity that is of relevance from the first day of work. However, difficulties for young doctors have been reported. Instruction of ward round competence in medical curricula is hampered by the lack of a standardized description of the procedure. This paper aims to identify and describe physicians' tasks and relevant competences for conducting a medical ward round on the first day of professional work.

METHODS

A review of recent literature revealed known important aspects of medical ward rounds. These were used for the development of a semi-structured interview schedule. Medical ward round experts working at different hospitals were interviewed. The sample consisted of 14 ward physicians (M = 8.82 years of work experience) and 12 nurses (M = 14.55 years of work experience) working in different specializations of internal medicine. All interviews were audiotaped, fully transcribed, and analyzed using an inductive-deductive coding scheme.

RESULTS

Nine fields of competences with 18 related sub-competences and 62 observable tasks were identified as relevant for conducting a medical ward round. Over 70 % of the experts named communication, collaborative clinical reasoning and organization as essential competences. Deeper analysis further unveiled the importance of self-management, management of difficult situations, error management and teamwork.

CONCLUSION

The study is the first to picture ward round competences and related tasks in detail and to define an EPA "Conducting an internal medicine ward round" based on systematic interprofessional expert interviews. It thus provides a basis for integration of ward round competences in the medical curricula in an evidence based manner and gives a framework for the development of instructional intervention studies and comparative studies in other medical fields.

The nurse-patient communication: voices from nursing students

BACKGROUND

Effective communication skills have been found to be one of the pivotal factors in building positive interpersonal relationships. Little is known about nursing undergraduates' perspectives on communicating with patients.

OBJECTIVE

This study aimed to explore nursing students' perspectives and experiences of nurse-patient communication in their clinical placement.

METHODS

The participants included 21 second-year undergraduates and 21 first-year master's students. Interviews were conducted in Cantonese and then transcribed in Chinese and translated into English. A content analysis approach was adopted to analyze the data.

RESULTS

Five themes emerged from the interview data. 'The necessity of nurse-patient communication' reveals why the students valued nurse-patient communication. 'The conversation contents' describes the content of the conversations that students typically had with patients. The third theme is 'self-reflection on the nurse-patient communication'. The last two themes, 'the communication pattern in different hospital settings' and 'the obstacles impeding nurse-patient communication', are about the students' communication styles in different hospitals and the barriers they encounter.

DISCUSSION

To improve students' communication skills, educators and clinical staff should listen to students, enhance students' reflective skills and strengthen their confidence.

CONCLUSION

Through understanding students' difficulties in the nurse-patient communication experience and the skills that they lack, educators can provide them with helpful recommendations to improve their communication skills in clinical practice.

PRACTICE IMPLICATIONS

The results of this study reveal that students' nurse-patient communication skills need to be improved.

Ward rounds, participants, roles and perceptions: literature review

Purpose

– The purpose of this paper is to classify and describe the purpose of ward rounds, who attends each round and their role, and participants’ perception of each other’s role during the respective ward rounds.

Design/methodology/approach

– A literature review of face-to-face ward rounds in medical wards was conducted. Peer reviewed journals and government publications published between 2000 and 2014 were searched. Articles were classified according to the type of round described in the study. Purposes were identified using keywords in the description of why the round was carried out. Descriptions of tasks and interactions with team members defined participant roles.

Findings

– Eight round classifications were identified. The most common were the generalised ward; multidisciplinary; and consultant rounds. Multidisciplinary rounds were the most collaborative round. Medical officers were the most likely discipline to attend any round. There was limited reference to allied health clinicians and patient involvement on rounds. Perceptions attendees held of each other reiterated the need to continue to investigate teamwork.

Practical implications

– A collaborative approach to care planning can occur by ensuring clinicians and patients are aware of different ward round processes and their role in them.

Originality/value

– Analysis fulfils a gap in the literature by identifying and analysing the different ward rounds being undertaken in acute medical wards. It identifies the complexities in the long established routine hospital processes of the ward round.

Collaboration Expertise in Medicine - No Evidence for Cross-Domain Application from a Memory Retrieval Study

Background

Is there evidence for expertise on collaboration and, if so, is there evidence for cross-domain application? Recall of stimuli was used to measure so-called internal collaboration scripts of novices and experts in two studies. Internal collaboration scripts refer to an individual’s knowledge about how to interact with others in a social situation.

Method—Study 1

Ten collaboration experts and ten novices of the content domain social science were presented with four pictures of people involved in collaborative activities. The recall texts were coded, distinguishing between superficial and collaboration script information.

Results—Study 1

Experts recalled significantly more collaboration script information (M = 25.20; SD = 5.88) than did novices (M = 13.80; SD = 4.47). Differences in superficial information were not found.

Study 2

Study 2 tested whether the differences found in Study 1 could be replicated. Furthermore, the cross-domain application of internal collaboration scripts was explored.

Method—Study 2

Twenty collaboration experts and 20 novices of the content domain medicine were presented with four pictures and four videos of their content domain and a video and picture of another content domain. All stimuli showed collaborative activities typical for the respective content domains.

Results—Study 2

As in Study 1, experts recalled significantly more collaboration script information of their content domain (M = 71.65; SD = 33.23) than did novices (M = 54.25; SD = 15.01). For the novices, no differences were found for the superficial information nor for the retrieval of collaboration script information recalled after the other content domain stimuli.

Discussion

There is evidence for expertise on collaboration in memory tasks. The results show that experts hold substantially more collaboration script information than did novices. Furthermore, the differences between collaboration novices and collaboration experts occurred only in their own content domain, indicating that internal collaboration scripts are not easily stored and retrieved in memory tasks other than in the own content domain.

Improving patient-centered communication: Results of a randomized controlled trial

OBJECTIVE

Patient-centered communication is a key element for improving the quality of care in terms of therapeutic relationship, patient participation, and treatment process. Postgraduate trainings provide an essential way of promoting patient centeredness on the job where learning opportunities are often limited by time, patient volume, and economic pressure. In the present study, changes in patient centeredness during clinical routines of postgraduate physicians (internal medicine) after a three-day communication training were assessed.

METHODS

A randomized controlled trial was conducted in a primary care clinic. The intervention consisted of a communication training that aimed to enhance patient centeredness in postgraduate physicians. The training was based on a need assessment and the principles of deliberate practice. Workplace-based assessment of physicians' communication behavior was obtained using the Roter Interaction Analysis System.

RESULTS

Three months after the intervention, trained physicians showed significantly increased patient centeredness (F=5.36, p=.04; d=0.42).

CONCLUSION

The communication training significantly improved patient centeredness during routine clinical practice. Thus, this training provides a structured and theory-based concept to foster patient centeredness.

PRACTICE IMPLICATIONS

The results support the implementation of communication trainings as a part of faculty development and medical specialization training.

Students' Perceptions on an Interprofessional Ward Round Training - A Qualitative Pilot Study

INTRODUCTION

Ward rounds are an essential activity for interprofessional teams in hospital settings and represent complex tasks requiring not only medical knowledge but also communication skills, clinical technical skills, patient management skills and team-work skills. The present study aimed to analyse final year students', nurses' as well as physiotherapists' views on a simulation-based interprofessional ward round training.

METHODS

In two successive passes a total number of 29 final year students, nursing students and physiotherapy students (16 in the first run, 13 in the second) volunteered to participate in two standardized patient ward round scenarios: (1) patient with myocardial infarction, and (2) patient with poorly controlled diabetes. Views on the interprofessional ward round training were assessed using focus groups.

RESULTS

Focus group based feedback contained two main categories (A) ward round training benefits and (B) difficulties. Positive aspects enfolded course preparation, setting of the training, the involvement of the participants during training and the positive learning atmosphere. Difficulties were seen in the flawed atmosphere and realization of ward rounds in the daily clinical setting with respect to inter-professional aspects, and course benefit for the different professional groups.

CONCLUSION

The presented inter-professional ward round training represents a well received and valuable model of interprofessional learning. Further research should assess its effectiveness, processes of interprofessional interplay and transfer into clinical practice.

Improving patient recall of information: Harnessing the power of structure

OBJECTIVE

Assess the amount of medical information laypeople recall, investigate the impact of structured presentation on recall.

METHODS

105 first-year psychology students (mean age 21.5±3.8 years; 85% female) were randomised to two information-presentation conditions: structured (S group) and nonstructured (NS group). Students watched a video of a physician discharging a patient from the emergency department. In the S Group, content (28 items of information) was divided into explicit "chapters" with "chapter headings" preceding new information. Afterwards, participants wrote down all information they recalled on an empty sheet of paper.

RESULTS

The S group (N=57) recalled significantly more items than NS group (N=41) (8.12±4.31 vs. 5.71±3.73; p=0.005), rated information as easier to understand (8.0±1.9 vs. 6.1±2.2; p<0.001) and better structured (8.5±1.5 vs. 5.5±2.7; p<0.001); they rather recommended the physician to friends (7.1±2.7 vs. 5.8±2.6; p<0.01).

CONCLUSION

University students recalled around 7/28 items of information presented. Explicit structure improved recall.

PRACTICE IMPLICATIONS

Practitioners must reduce the amount of information conveyed and structure information to improve recall.

The importance of existential dimensions in the context of the presence of older patients at team meetings—in the light of Heidegger and Merleau-Ponty's philosophy

The aim of the present study is to explore interpersonal dimensions of the presence of older patients at team meetings. The theoretical foundation of the study is grounded in caring science and lifeworld phenomenology. The results from two empirical studies, that indicated the need for a more in-depth examination of the interpersonal relationships when an older patient is present at a team meeting, were further explicated by philosophical examination in the light of Heidegger and Merleau-Ponty's philosophy. The empirical studies were performed in a hospital ward for older people, where the traditional rounds had been replaced by a team meeting, to which the patients were invited. The analysis of the general structure and philosophical examination followed the principles of reflective lifeworld research. The philosophical examination is presented in four meaning structures: mood as a force in existence; to exist in a world with others; loneliness in the presence of others; and the lived body as extending. In conclusion, professionals must consider patients' existential issues in the way they are expressed by the patients. Existence extends beyond the present situation. Accordingly, the team meeting must be seen in a larger context, including the patients' life as a whole, as well as the ontological and epistemological foundations on which healthcare is based.

Introduction of a new ward round approach in a cardiothoracic critical care unit

BACKGROUND

Francis (2013) described inconsistent ward rounds and failures to conduct ward rounds properly as contributing factors to the poor care seen at the Mid Staffordshire Foundation Trust. He suggested that the absence of a nurse at the bedside had clear consequences for communication, ward round efficiency and patient safety. He recommended that nurses should be actively involved in ward rounds and linked this to high quality patient care.

AIM

To share an experience of introducing a ward round checklist, a bedside nurse verbal summary and the development of standard operating procedure for Ward Rounds in cardiothoracic critical care unit to improve patient safety and care.

DESIGN AND METHODS

Semi structured interviews of six registered nurses. A questionnaire to 69 registered nurses. An electronic questionnaire sent to 23 members of the MDT. An observational audit of seven ward rounds reviewing 69 patients.

RESULTS

97% of nurses agreed that verbal summarizing had improved clarity and 90% felt that it had improved patient care. 87% of the MDT respondents stated that they had noticed an improvement in the attendance of the bedside nurse at the ward round review. The ward round checklist reduced omissions. Communication with patients during ward rounds was an area which needed to be improved.

CONCLUSIONS

The introduction of a new ward round approach and audit of its practice has enabled an improvement in the quality of patient care by: Giving more opportunity for the nurse to participate and feel part of the ward round. Reduction of omissions through the use of a ward round checklist. Improved clarity among the MDT by the use of bedside nurse verbal summarizing of the plan of care.

RELEVANCE TO CLINICAL PRACTICE

Nurses' full participation in ward rounds is essential to ensure effective communication and enhance patient safety.

Improving ward round skills

BACKGROUND

Ward rounds represent an important task in clinical settings. Despite their importance, students show substantial deficits in ward round competencies (e.g. physical examination, drug prescription, documentation). Previously reported teaching methods such as ward round training with standardized patients or educational wards, however, are time-consuming and expensive.

AIMS

To assess the effects of a structured on-ward supervision program for final-year students with specially trained supervising doctors focusing on ward round competencies.

METHOD

A total of 36 medical students were randomly assigned to an intervention group (IG) and a control group (CG). During an eight-week-long training course, the intervention group (IG; n = 18) received structured ward round training while the control group (CG; n = 18) received on-ward training regarding how to take patient histories and perform physical examinations. Ward round competencies were assessed using simulated ward round scenarios with objective checklist ratings and standardized patient ratings.

RESULTS

The IG achieved significantly more predefined learning goals compared to the CG. Standardized patient ratings did not differ significantly between groups.

CONCLUSIONS

RESULTS provide evidence that the presented program is a feasible and efficient tool for teaching ward round skills at the bedside. Further research should focus on cost effectiveness compared to alternative models.

Barriers to nurse-patient communication in cardiac surgery wards: a qualitative study

BACKGROUND

An appropriate and effective nurse-patient communication is of the most important aspect of caring. The formation and continuation of such a relationship depends on various factors such as the conditions and context of communication and a mutual understanding between the two. A review of the literature shows that little research is carried out on identification of such barriers in hospital wards between the patients and the healthcare staff.

OBJECTIVES

The present study was therefore conducted to explore the experiences of nurses and patients on communication barriers in hospital cardiac surgery wards.

DESIGN AND METHODS

This qualitative research was carried out using a content analysis method (Graneheim & Lundman, 2004). The participants were selected by a purposeful sampling and consist of 10 nurses and 11 patients from the cardiac surgery wards of three teaching hospitals in Tehran, Iran. Data was gathered by unstructured interviews. All interviews were audio-taped and transcribed verbatim.

RESULTS

Findings were emerged in three main themes including job dissatisfaction (with the sub-themes of workload tension and decreased motivation), routine-centered care (with the sub-themes of habitual interventions, routinized and technical interventions, and objective supervision), and distrust in competency of nurses (with the sub-themes of cultural contrast, less responsible nurses, and their apathy towards the patients).

CONCLUSION

Compared to other studies, our findings identified different types of communication barriers depending on the nursing settings. These findings can be used by the ward clinical nursing managers at cardiac surgery wards to improve the quality of nursing care.

Norwegian nursing and medical students' perception of interprofessional teamwork: a qualitative study

BACKGROUND

Little is known about the ways in which nursing and medical students perceive and understand their roles in interprofessional teamwork. A 2010 report by the World Health Organization highlights the importance of students' understanding of teamwork in healthcare, and their ability to be effective team players. This study aims at describing nursing and medical students' perceptions of interprofessional teamwork, focusing on experiences and recommendations that can be used to guide future educational efforts.

METHODS

The study uses a qualitative research design. Data were collected from four focus group interviews: two homogenous groups (one with medical students, one with nursing students) and two mixed groups (medical and nursing students).

RESULTS

The results show that traditional patterns of professional role perception still prevail and strongly influence students' professional attitudes about taking responsibility and sharing responsibility across disciplinary and professional boundaries. It was found that many students had experienced group cultures detrimental to team work. Focusing on clinical training, the study found a substantial variation in perception with regard to the different arenas for interprofessional teamwork, ranging from arenas with collaborative learning to arenas characterized by distrust, confrontation, disrespect and hierarchical structure.

CONCLUSIONS

This study underlines the importance of a stronger focus on interprofessional teamwork in health care education, particularly in clinical training. The study results suggest that the daily rounds and pre-visit "huddles," or alternatively psychiatric wards, offer arenas suitable for interprofessional training, in keeping with the students' assessments and criteria proposed in previous studies.

Older patients' participation in team meetings-a phenomenological study from the nurses' perspective

Although the importance of patient participation is acknowledged in today's healthcare, many challenges remain before patient participation can become an integral part of care provision. The ward round has traditionally been the forum for crucial decisions about patient care, but often with limited possibilities for patient participation. As part of the process of improving patient participation, the round in the present study has been replaced by a team meeting (TM) to which the patient has been invited. The aim of this study is to highlight nurses' experiences of older patients' participation in TMs. The research process was guided by the principles of phenomenological reflective life world research. Data were collected in a Swedish hospital, in a ward specializing in older patients. Nine nurses, who had invited and planned for a patient to participate in TMs and/or had experienced TMs in which patients participated, were interviewed. The essential meaning of patient participation in the TM, as experienced by the nurses, is that patient participation can be supported by a safe relationship in which the patient can make his or her voice heard. Participation is challenged by the patients' vulnerability and by the subordinated role assigned to the patient. The essential meaning is further described by its constituents: "the need for a guide," "patient participation challenged by structures," and "creating space for the whole human being." In conclusion, the nurse plays a core role in guiding the patient in an unfamiliar situation. The meaning of patient participation in the TM needs to be discussed by professionals so that the patient perspective is present.

"It made me feel human"-a phenomenological study of older patients' experiences of participating in a team meeting

This study focused on older patients participating in a team meeting (TM) in a hospital ward in Sweden. A process had taken place on the ward, in which the traditional round had developed into a TM and understanding what participating in a TM means for the older patient is necessary for the development of care that facilitates older patient's participation. The aim of this study was to describe the caring, as experienced by the older patients on a ward for older persons, with a specific focus on the team meeting. A reflective lifeworld research (RLR) design was used. Fifteen patients, 12 women and three men (mean age of 82 years) were interviewed while they were hospitalized in a hospital ward for older people. In the essential meaning of the phenomenon, the TM is described as being a part of a wider context of both caring and life. The need for hospitalization is an emotional struggle to overcome vulnerability and regain everyday freedom. The way in which the professionals are able to confirm vulnerability and create a caring relationship affects both the struggle for well-being and the possibilities for maintaining dignity. The essence is further explicated through its constituents; Vulnerability limits life; Life is left in the hands of someone else; Life is a whole and Space for existence. The result raises concern about how the care needs to be adjusted to older people's needs as lived bodies. The encounter between the carer and the patient needs to be developed in order to get away from the view of the patient as object. An expanded vision may open up for existential dimensions of what brings meaning to life. One way, as described by the patients, is via the patient's life stories, through which the patients can be seen as a whole human being.

Medication communication during ward rounds on medical wards: Power relations and spatial practices

Communication plays a crucial role in the management of medications. Ward rounds are sites where health professionals from different disciplines and patients come together to exchange medication information and make treatment decisions. This article examines power relations and spatial practices surrounding medication communication between patients and health professionals including doctors, nurses and pharmacists during ward rounds. Data were collected in two medical wards of a metropolitan teaching hospital in Melbourne, Australia. Data collection methods involved participant observations, field interviews, video-recordings, together with individual and group reflexive interviews. A critical discourse analysis was undertaken to identify the location sites where power relations were reproduced or challenged in ward rounds. Findings demonstrated that traditional medical hierarchies constructed the ways in which doctors communicated about medications during ward rounds. Nurses and pharmacists ventured into the ward round space by using the discourse of preparation and occupying a peripheral physical position. Doctors privileged the discourse of medication rationalization in their ward round discussions, competing with the discourse of inquiry taken up by patients and families. Ward rounds need to be restructured to provide opportunities for nurses and pharmacists to speak at dedicated times and in strategic locations. By critically reflecting upon the complex process of medication communication during ward rounds, greater opportunities exist for enhanced team communication among health professionals.

Family-centered rounds: views of families, nurses, trainees, and attending physicians

OBJECTIVE

To study the impact of family-centered rounds for general pediatrics inpatients.

METHODS

An observation tool and participant surveys was developed. The authors analyzed rounding time and rounds participants. Associations between family presence and participants' satisfaction were analyzed.

RESULTS

Data were collected on 295 patients and from 257 staff members. Average rounding time was reduced with increased family and nurse presence (8.7 minutes with both, 12.7 minutes without family, P = .0001). Families reported high satisfaction regardless of participants. Families present on rounds reported increased knowledge of team members' roles (54% vs 35%, P = .04). Attending physicians more often reported ease in managing rounds with families present. Senior residents perceived decreased autonomy with high family participation (11%) versus low family participation (70%; P = .02). Improved nurse satisfaction was associated with increased family and nurse participation.

CONCLUSION

Family participation may shorten inpatient rounds. Families and staff were satisfied with family-centered rounds, though senior resident autonomy requires attention.

Hospice nurse communication with patients with cancer and their family caregivers

BACKGROUND

Effective communication by hospice nurses enhances symptom management for the patient, reduces family caregiver burden and distress, and potentially improves bereavement adjustment. However, research has not kept pace with the rising use of hospice by patients with cancer and thus we know little about how hospice nurses communicate.

METHODS

The overriding objective of this pilot study was to provide insight into these in-home visits. Hospice nurses audiorecorded their interactions over time with family caregivers and patients with cancer. The communication within these tapes was coded using Roter Interaction Analysis System (RIAS) and analyzed.

RESULTS

We found that tape recording home hospice nurse visits was feasible. RIAS was suited to capture the general content and process of the home hospice encounter and the coded interactions show the range of topics and emotions that are evident in the dialogue. Implications and future directions for research are discussed.

'Are decisions about discharge of elderly hospital patients mainly about freeing blocked beds?' A qualitative observational study

OBJECTIVE

To explore the interactions concerning the frail and elderly patients having to do with discharge from acute hospital wards and their participation in medical decision-making. The views of the patients and the medical staff were both investigated.

DESIGN

A qualitative observational and interview study using the grounded theory.

SETTING AND PARTICIPANTS

The setting was three hospitals in rural and urban areas of two counties in Sweden of which one was a teaching hospital. The data comprised observations, healthcare staff interviews and patient interviews. The selected patients were all about to be informed that they were going to be discharged.

RESULTS

The patients were seldom invited to participate in the decision-making regarding discharge. Generally, most communications regarding discharge were between the doctor and the nurse, after which the patient was simply informed about the decision. It was observed that the discharge information was often given in an indirect way as if other, albeit absent, people were responsible for the decision. Interviews with the healthcare staff revealed their preoccupation with the need to free up beds: 'thinking about discharge planning all the time' was the core category. This focus not only failed to fulfil the complex needs of elderly patients, it also generated feelings of frustration and guilt in the staff, and made the patients feel unwelcome.

CONCLUSIONS

Frail elderly patients often did not participate in the medical decision-making regarding their discharge from hospital. The staff was highly focused on patients getting rapidly discharged, which made it difficult to fulfil the complex needs of these patients.