IN THIS ARTICLE …
·
Why
ward rounds are necessary
·
Stages
of the ward round process
·
The
nurse’s role on a ward round
Liz Lees is consultant nurse and senior clinical research
fellow, Faculty of Education, Heart of England Foundation Trust, Birmingham.
Abstract
Lees L (2013) The nurse’s role in
hospital ward rounds. Nursing Times; 109: 12, 12-14.
Ward
rounds are a crucial aspect of acute care, but nurses’ involvement varies.
While their responsibilities on ward rounds may vary from
ward to ward, nurses have a vital role to play and should make it a
priority to attend. This article discusses key aspects of nurses’
responsibilities and the different stages in the ward-round process.
·
This article has been double-blind peer reviewed
·
Figures and tables can be seen in the attached print-friendly
PDF file of the complete article in the ‘Files’ section of this page
5 key points
1.
Ward rounds provide a
link between patients’ admission to hospital and their discharge or transfer
elsewhere
2.
Nurses have a vital
role in ward rounds and should make it a priority to attend
3.
Ensuring
patients/carers are fully involved in care decisions is a nursing
responsibility
4.
When patients are
transferred or discharged, nurses ensure information is communicated to the
next stage in the pathway
5.
A rushed round or one
with no nurse present will have a negative effect on the team
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week, is outdated.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 (Lambert,
2010). 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 (Hindmarsh and
Lees, 2012). 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.
Conclusion
Nurses and the multidisciplinary team are central to ward
rounds. Although this article has attempted to define the core nursing
activities involved in ward rounds, nurses will delegate and/or lead the
actions that arise. The energy created by a well-run ward round will resonate
across a whole ward team, while a rushed round or one that has no nurse
presence will have a negative effect, such that related actions maybe
fragmented.
In busy ward environments it is a constant balancing act to
prioritise the jobs that need to be done within the ward routine; if, however,
nurses lead by example and are present on ward rounds, it is likely that
discipline will be instilled in the entire team and an expected standard of
practice for this core activity created.
References:
Department of Health (2004) Assisting
Timely Discharge from Hospital: A Multi-disciplinary Toolkit. London: DH.
Hindmarsh D, Lees L (2012) Improving
the safety of patient transfer from AMU using a written checklist.Acute
Medicine; 11: 1, 13-17.
Jugessur T, Iles L (2009) Advocacy
in mental health nursing: an integrative review of the literature. Journal
of Psychiatric and Mental Health Nursing; 16: 187-195.
Lambert J (2010)
Chaperones: practice, policy and training. Practice
Nursing; 21: 7, 347-349.
Lees L et al (2006) Using
post-take ward rounds to facilitate simple discharge. Nursing
Times; 102: 18, 28-30.
