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Ward
Rounds - |
During informal discussions with members of HUG the subject of ward rounds is often raised, usually in very negative terms, by those people who have experienced them. In responding to these experiences we decided to describe what users thought of ward rounds, explore ways in which they could be made into a better experience for users and examine whether there is any justification for holding ward rounds in the first place. A series of meetings were held in December 1997 to consider this subject. These meetings involved 59 members of HUG and 6 of the branches of HUG.
The following is the result of an interview with a representative of Highland Communities NHS Trust working in Craig Dunain and routinely involved in ward rounds. It is very difficult to generalise about a ward round as their nature and purpose are generally determined by the consultant involved. Common to all ward rounds is that it is conducted in a multidisciplinary setting generally with the user present. Ward rounds are generally conducted once a week with the progress of the user for the previous week reviewed and the various inputs of the professionals concerned put into the meeting. Anticipated contributions from all those concerned with the users care for the next week are then discussed and agreed upon. A ward round can vary from the involvement of the nurse, consultant and user to a large group of people. The grouping of professionals involved in a ward round varies from consultant to consultant. If a user is anxious about a ward round they are sometimes invited in after most of the professionals have left, or the nurse may act as their advocate / representative and sometimes, especially if the user has been unable to attend the ward round, the consultant and nurse will meet with the user to debrief them on what has happened on a ward round on the same day. Sometimes a consultant
will see the user outside of the ward round on a one to one basis to
discuss the user`s concerns. Although on other occasions (a situation
that occurred more frequently in the past) the only contact some consultants
have with the user is during ward rounds. This is sometimes attributed
to their activities in the community taking away from the time they
could spend in the hospital.
The Collective Views Of HUG On Ward Rounds The Good Elements of A Ward Round One person had had an enjoyable experience with ward rounds and had found the opportunity to discuss his health and care with the people responsible for it to be very rewarding. If ward rounds are carried out in a decent manner they can raise the person`s confidence and well being. They become particularly important when people are close to being discharged from hospital, when prospects and arrangements for returning to the community can be set with the user`s participation.
The great majority of people involved in the HUG discussion described ward rounds as a negative experience. Once people are told that they are going onto a ward round it is easy to become anxious. During the often considerable wait to be asked in, they go over and over their feelings and the possible questions you may be asked. This can make them feel more ill. On entering the room it is often crowded with people, many of whom they don't know. This is embarrassing and makes people tense and anxious - they withdraw from the situation, They wonder
Some people have entered the room expecting to just see their doctor only to find a room full of people which they found very surprising. One person on being confronted by a room full of people found himself completely unable to speak and was accordingly sent away. Once the ward round started people tried to concentrate on the doctor and to block out other people in the room but often they couldn't get away from the feeling that they were being interrogated. People sometimes deliberately said little or nothing about themselves because they resented their private lives being talked about in a room full of comparative strangers. This also made some users worried about how far their personal details would spread when revealed in the room. When trying to ask their own questions some users felt that they weren't given enough time and were given vague, uninformative answers which they did not find satisfactory. For instance a member wanted to know how long they were likely to be in hospital and the response was "How long is a piece of string?"
A User`s View The Past One of the members of HUG recounted their experience of the nearest equivalent to a ward round when in hospital many years ago. All the patients and staff lined up in a big room in the hospital and the main psychiatrist walked round the circle of patients. When she reached the patient they had to stand up and answer her questions in front of everyone and then be told what they must and mustn't do.
Carer's View
A Nurse's View
In view of the many negative comments about ward rounds it was felt important to discuss whether they had any worthwhile function that would justify their continuation. The majority of members thought that given work to change them, they could perform a useful function. However there were two groups who thought ideally they shouldn't exist. All the groups thought that there should be less people involved in a ward round with the majority of groups saying that most discussions about their care in hospital could be adequately carried out with just the psychiatrist and key nurse present. It was said that ward rounds become more important the closer to discharge from hospital a person gets with one group saying that ideally, this should be the only time for ward rounds.
Information about the Ward Rounds Patients should
be prepared for a ward round with someone explaining its purpose, when
it will happen and what it entails. This should be done in advance of
any attendance at a ward round. Preparation for the Ward Round People should have a good idea of the topics that are going to be covered in the ward round, who will be attending the ward round, and a general idea of what questions are going to be asked. However some users
were of the impression that many of the professionals at the ward round
were equally ignorant about what was going to be covered and that therefore
it would be difficult to prepare the patient for the subjects to be
raised. When a professional
is going to attend a ward round and she/he has not previously met the
patient they should take the time to meet them informally beforehand
to explain who they are and why they are attending. It was said that
the people on a ward round should be directly concerned with your case
and known to you. Ideally students would not attend a ward round although
there was an acknowledgement that they had to learn somehow. This decision should
be made jointly and the patient should have a say in who attends along
with the doctor. One group said that the decision should rest solely
with the patient. It was also said that some people do not speak if
they are uncomfortable with particular people in the room. Although it was said that it is important for professionals to gain information about the user it was also said that it should be made absolutely clear to the user that they have a choice about attending a ward round and that if they refuse there should be no adverse consequences. At present many
users feel that they don't have a say in whether they attend a ward
round or not and that pressure is put on them to attend. It is important that all people realise that the patient is a person not a set of problems. There should be respect, trust and honesty with the patient. Some groups thought that the emphasis on the relative importance of the people in the room should change with the patient becoming acknowledged as the most important person. Other groups were more inclined to a move towards equality for all people present. Although it was accepted that users were given the opportunity to ask questions, people felt that there needs to be an effort made so that they genuinely feel this, which could be partly achieved by giving more power and control to the user whilst not overburdening them if they don't feel up to it. Some people felt that they were under pressure to give snap answers to the questions they were asked. It should be made clear to them that they could take their time over answering or refuse to answer. All the groups were agreed that there should be a person of your choice (who could be an advocate) to help support, explain things and represent you if you feel that you need it. This option should always be offered to the person attending the ward round and should be an option that it is possible to achieve. With the exception of one group it was agreed that there should be a written record of the meeting (in plain English) which is made accessible to the user on request. It was frequently said that people choose what they say to different people in a way that often depends upon the trust and the relationship that they have built up with that person. Many people felt very uneasy that a group over which they had no control had access and knowledge of feelings of distress and embarrassment that they might not normally have chosen to share with them. There was a feeling that if a group of relative strangers had access to this information then it could be equally possible that other people would find out about it. There was a call for more discussion about this and the view that at a minimum the user should know how far information they gave to a professional could possibly travel.
Acknowledgments With thanks to all the members of HUG, and other mental health service users, who contributed to this report. |
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