The benefits and barriers to nurses attending ward rounds

Medical ward rounds are a daily and longstanding practice in hospitals.

It is the process where health professionals visit patients on the wards for clinical decision-making. They provide a time to review the patient’s diagnosis, progress, treatment and discharge planning, as well as a time for communication between the patient and health professionals.^6,12 Ward rounds are also an opportunity for health professionals to collaborate together on a patient’s care plan.¹²

Ward rounds are traditionally led by a senior doctor and attended by junior doctors, medical students, and nurses.¹⁰

As student nurses on clinical placement we noticed that nurses in most wards did not attend ward rounds. One outcome we observed was poor communication. For instance, medication administration was delayed as it was revised during the ward round without the nurse’s knowledge. If nurses had been present then this information would have been shared, and the quality of care improved.

But even when nurses were present we noticed they were not actively contributing to the ward round team. As ward rounds are a chance for interprofessional decision-making, we thought it was important for nurses to participate; not just to be aware of the care plan but also to contribute the holistic nursing view.

Based on our clinical placement experience, we believe nurses not attending ward rounds contributes to a lack of collaboration between doctors and nurses. This can lead to communication breakdown and insufficient information being exchanged between the two professions. It is known that the lack of interdisciplinary collaboration can have adverse effects on the quality of care provided.²¹

The lack of nurses’ participation in ward rounds is evident in the literature. Miller et al. found that nurses’ attendance and contributions to ward rounds were minimal.⁷ This finding was reconfirmed by the study from Ndie, Ogwa, Oko & Emeh that discovered only 13% of nurses interviewed participated in ward rounds the previous day.⁹ Additionally, Royal College of Physicians & Royal College of Nursing suggest that even when nurses are part of the ward round team, they often remain invisible and do not actively participate in the process.¹² As demonstrated by Gonzalo, Kuperman, Lehman, & Haidet, less than 10% of ward round time is spent on nurse-doctor collaboration.¹

This is not a newly emerging issue or one that has improved over time. Indeed, studies dating back to the 1990s displayed the theme of nurses’ lack of contribution to the ward rounds.¹³

Literature review to find out why?

To explore the issue in more depth, a review was carried out using EBSCOhost, Google Scholar, CINAHL, and Cochrane Library databases. Literature from 2007-2017 was included. Search terms used were “nurses” “ward rounds” and “nurse-physician ward rounds”. The literature search focused on the role of nurses in ward rounds, their perceptions, the barriers to participation and the importance of collaboration. Only articles written in English were included and literature referring to nurse-led intentional rounding was excluded. A number of themes were identified and are discussed below.

Role of nurses in ward rounds

Ward rounds are an ideal opportunity for the members of the multidisciplinary team to share information and collaborate.⁹ The knowledge and insight gained through nurses’ daily interactions with their patients are incomparable to any other healthcare professionals. This places great importance of nurses being present in multidisciplinary discussions, like ward rounds, as it leads to improved collaboration.⁴

Swenne & Skytt suggest it is imperative that nurses support the patient and advocate for them during ward rounds.¹⁴ They say nurses “have a great responsibility to teach and support patients’ experience of participation in care, thus giving them the courage to ask questions and participate in their own care”.^{14 (p 298)} Patients are better connected with nurses compared to doctors, and they appreciate nurses translating information for them into a language they can easily understand.¹⁸ Hence, in ward rounds, nurses have the role of advocating for their patients as well as effectively contributing to interdisciplinary collaboration.

Benefits of nurses involved in ward rounds

There are numerous benefits of nurses being involved in ward rounds. Interdisciplinary collaboration improves patient care. as demonstrated by Gonzalo et al, who showed that communication between nurses and doctors improves awareness of clinical issues and teamwork, thus enhancing the care of the patient.¹ Effective communication between the doctor, nurse, and the patient can reinforce patient-centred care and improve patient outcomes.¹¹ It was found that the collaborative ward rounds resulted in statistically significant improvement in bed turnover rates, shortened patient stays, and higher patient, nurses and doctors’ satisfaction.²⁰ The inclusion of nurses in the ward rounds resulted in a greater degree of interprofessional teamwork, which is linked to higher satisfaction and better patient outcomes.²

Gonzalo mentions that nurses value collaboration in healthcare planning more than the doctors.¹ Nurses recognise the benefit of ward rounds for collaborative communication. Umesh & Klocke demonstrated that collaborative ward rounds increased the nurses’ job satisfaction as they felt more valued as a team member.¹⁷ Nursing involvement in ward rounds also improved professional relationships and working environment, resulting in lower staff turnover.⁸ Overall, collaborative ward rounds improve the quality of patient care and fosters a team oriented working environment.

Barriers to ward round participation

Some obstacles result in nurses’ lack of participation in ward rounds.

Common themes include traditional interprofessional hierarchies, time restraints and bed space limitations.^1,13 There is a strong historical hierarchical influence on the way ward rounds are conducted, where the domination of the medical staff contributes to a lack of confidence for nurses to participate.¹³ Consequently, this fosters a sense of submissiveness in nurses, leaving them feeling disempowered and undervalued by the medical team.¹⁸

Consultants usually lead the ward rounds as they are perceived as the dominant figure in the medical hierarchy. Shaughnessy & Jackson stated that nurses found it difficult to tell the consultants what needed to be done as it seemed inappropriate due to the power imbalance.¹³ O’Hare found that nurses are usually excluded from executive decision making as they are perceived to be on the lower end of the interprofessional hierarchy.¹⁰

Nurses have noted that in some situations, the attitude of consultants towards them can be demeaning.¹⁵ The behaviour of the consultants towards the nurses significantly affects their participation in ward rounds where their contribution increases when consultants actively involve them.^13,15  Some nurses also believe that their contributions to the ward rounds are insignificant and overlooked by the medical team.¹⁹

Time is another critical barrier to nurses being present at ward rounds.

Nurses are often unable to attend the rounds due to increased amounts of competing priorities such as medications and wound dressings.⁵ A study conducted by Ndie et al. showed that 91% of the interviewed nurses would participate in ward rounds if they had time.⁹ This idea is confirmed by Gonzalo who found that time was the leading cause for non-attendance of nurses in ward rounds.¹ Nurses usually have several patients under their care at one time, which means that there are various tasks and responsibilities needed to be carried out to provide efficient care for each patient.¹ Participation in the ward rounds would mean that these tasks would have to be delayed, which may affect the timeliness of these responsibilities.

Bed space is another contributing factor as to why nurses do not participate in ward rounds.^13,18

Ward rounds are attended by numerous doctors of varying levels, and priority of space are usually allocated to them. This can be attributed to the historical professional hierarchy. Although some doctors have noted the importance of nurse’s presence at ward rounds, they are usually seen as the lowest priority.¹⁸

Overall, the effects of the interprofessional hierarchy, time restraints and bed space limitations are significant barriers that influence the nurse’s attendance to ward rounds.

Promoting Participation

It is evident that nurses have an important role in contributing to ward rounds.

Therefore, strategies should be used to encourage nurses to attend and actively participate. Firstly, the timing of the ward rounds must be considered. Gonzalo suggests that group consensus and the schedules of nurses and doctors should be considered when agreeing the time for ward rounds.¹ Nurses should also make it a priority in their care plan to participate in ward rounds.⁹ Triggle recommends organising morning ward rounds, to ensure that the tasks discussed can be completed following the round.¹⁶

Structured participation of nurses in ward rounds can also be enhanced when the role of the nurse is clearly defined to the multidisciplinary team.¹³ The use of checklists and guidelines in ward rounds have shown to improve collaboration as it becomes mandatory for nurses to be present.^3,13 Shaughnessy & Jackson improved the ward round model by using checklists, which required the bedside nurse to provide a summary of the care plan.¹³ This resulted in increased participation of nurses, reduced miscommunication errors, and improved collaboration within the team.¹³

Efforts should be made by nurses to overcome interpersonal barriers that hinder their attendance to ward rounds, particularly the implications of the medical hierarchy. Communication and input between health professionals in ward rounds requires leadership and responsibility.¹² Nurses should take on their leadership roles in the ward rounds, and purposefully position themselves within the circle of doctors. This can help nurses to establish their roles within ward rounds. As student nurses moving into the workforce, we can have an impact by taking on this important role during ward rounds and to change the current culture on non-attendance.

Conclusion

Collaborative care in ward rounds is essential because it is a common place for all health professionals to provide input for the patient’s well-being.

Yet, non-involvement of nurses in ward rounds remains an issue. Non-attendance can result in ineffective communication between nurses and doctors ultimately affecting patient outcomes.

Nurses should know their value and how their contribution can improve collaborative and patient-centred care. Interprofessional hierarchy, time restraints and limited bed spaces are barriers that nurses experience. Limiting these barriers can promote participation. Practical strategies such as mutually agreed ward round times, checklists and ward round guides can promote participation. It is recommended that further studies should investigate the lack of nursing involvement and evaluate strategies that promote participation. If these are found to be successful, a call for wider implementation should be made.

University of Auckland nursing students Rebecca Amann, Natasha Chua, Tanvi James & Regina Sanga wrote and contributed this article for an assignment as 2^nd year students in 2017.