Patients’ views of the ward round: a survey

AIMS AND METHOD As part of the total experience of hospital admission, it is important to 
ensure that ward rounds are efficient and acceptable to patients. 
Self-completed questionnaires relating to the conduct of the ward round were 
given to a consecutive series of 100 in-patients admitted to four psychiatric 
wards serving one half of the population of Cornwall. RESULTS Twenty-two patients disliked being seen in their own bedrooms, 54 disliked 
large ward rounds and three-quarters liked having an exact appointment time. 
There was a group of patients who felt particularly anxious before or during 
the ward round. CLINICAL IMPLICATIONS It is important to reconsider the conduct of the ward round, and in so 
doing to balance the preferences of the patient with the needs of the 
multidisciplinary team.

Twenty-two patients disliked being seen in their own bedrooms, 54 disliked large ward rounds and threequarters liked having an exact appointment time. There was a group of patients who felt particularly anxious before or during the ward round.

CLINICAL IMPLICATIONS
It is important to reconsider the conduct of the ward round, and in so doing to balance the preferences of the patient with the needs of the multidisciplinary team.
For many patients being admitted to psychiatric hospital is a difficult and frightening experience (Sainsbury Centre, 1988). Although the ward round is a small part of that experience, it is one of the most important, as many of the decisions regarding patients' care take place then. The way the ward round is conducted probably owes much to posterity and to institutional traditions that serve to reinforce unequal power relations between doctor and patient. It is therefore in need of revision in order to be both more efficient and more acceptable to patients.
There is little systematic research in this area, although there have been more general studies of patients' total experience of hospital admission (e.g. Sainsbury Centre, 1988;Goodwin, 1999;Ballard & McDowell, 1990). McBride (1988), reviewing his own experience of psychiatric ward rounds, described the complexity of functions that the ward round serves. Foster et al (1991) carried out a survey of patients' subjective experiences of ward rounds, based on a similar study by Armond & Armond (1985). They found a large number of patients preferred a smaller ward round (i.e. fewer professionals present) and those from minority ethnic groups found the ward round less helpful. Neither study set out to explore patient preferences as to the actual conduct of the ward round, which was the main focus of our study.

Method
The study was initiated as part of a data-gathering exercise for audit purposes. A self-completion questionnaire was given to a consecutive series of in-patients on four psychiatric wards covering the east of Cornwall. This included a locked ward and a care of the elderly ward. Ward rounds, of a largely traditional kind, are carried out by ten different consultants on at least a weekly basis on these wards.
Recruitment continued until 100 valid questionnaires were returned. Patients were told they were not obliged to complete the questionnaire and help was offered by staff to those who appeared to need it. The questionnaire, which was drawn up in consultation with nursing and medical staff, was in two parts. The first part comprised seven questions relating to the conduct of the ward rounds and the second part comprised three questions related to the patient's own subjective experience of ward rounds. There was also an open-ended question: 'My experience of ward rounds could be improved by . . .'. The patient's age and gender were also recorded.
The data were analysed variable by variable. Associations by individual consultants were not explored because of insufficient statistical power.

Results
There were 4 outright refusals to complete questionnaires and 3 questionnaires were illegible. The final sample comprised exactly 50 men and 50 women. Of these, 72 were from the two general acute wards, although one of these wards included some elderly patients (over 65 years), 29 were 34 years of age or less, 37 were 35^49 years, and 34 were 50 years or over. Table 1 shows patient preferences regarding ward rounds. Patients appeared to have strong views regarding whether they were seen in their own bedspace. Although twice as many patients liked it as disliked it (41 v. 22), the number who disliked it was still quite high, and subsequent analysis suggested that this was more likely to be the youngest group of women. Overall 16 women of all ages said they did not like it as opposed to only 6 men (w 2 P=0.017). The patients were relatively indifferent regarding being seen elsewhere.
Knowing approximately when they would be seen was liked by almost all patients, as was having an exact appointment time. There was no association with gender, but the middle age-band were most likely to say they liked it (w 2 P=0.008).
Ward rounds in which four or more people are present were disliked by the majority of patients (n=54). This was more apparent for women, 36 of whom disliked it (w 2 P=0.003). The women who disliked it tended to be in the two younger age-bands.
A total of 37 patients said they did not like family or friends being present during the ward round. There were no particular associations with this variable. Table 2 shows patients' feelings regarding the ward rounds. The majority of patients (n=58) said they felt sometimes, rarely or never able to express their feelings in the ward round. There was an association with age, with the youngest age-band feeling least able to express their feelings (P=0.03). There was also a trend for women to say that they were rarely or never able to express their feelings. Forty-six of the patients always or usually felt anxious before a ward round (32 of the women v. only 14 of the men (w 2 P=0.007)). This was more apparent in the older age-groups.
There were no clear associations with ward, which may have been a type 2 error, however patients on the locked ward were less likely to feel involved in treatment decisions.
The open-ended question 'my experience of ward rounds could be improved by . . .' was completed by only 54 of the sample. The answers, for the most part, did not add to the information in the questionnaire. However, 5 patients asked to have more time alone with the consultant.

Discussion
Many patients both felt anxious before the ward round and had difficulty expressing their feelings during it. Feeling anxious beforehand correlated with not liking large ward rounds (r=70.35, P50.001) and being unable to express feelings during the ward round (r=0.27, P=0.008). This suggests that there is a particular group of patients who find large ward rounds problematic, and who would benefit from a less threatening approach.
A surprisingly large number said they did not like friends or family attending the ward round. Unfortunately it is difficult to interpret this finding, although it may simply reflect the fact that many patients do not have social support structures that they value or can rely upon. Appointment times are liked by patients, but our data suggest that there is little additional benefit in having exact times. One workable solution is to see patients in a predetermined order (e.g. by alphabetical order of surname) and for a predetermined length of time. Both staff and patients will then have a good idea of when they will be seen.
Interestingly, large ward rounds do not appear to be so strongly disliked on surgical wards, where it is suggested the patient finds the presence of many professionals reassuring (Seo et al, 2000). In psychiatry, where the opposite appears to apply, it is necessary to balance patient preferences with the needs of the multidisciplinary team. Large ward rounds are not the optimal environment for assessing a psychiatric patient's mental state or for sharing information with them (see McBride, 1988). We would agree with Wolf (1997) and Wagstaff & Solts (2003) that such ward rounds should be avoided unless absolutely necessary (e.g. at discharge) and that less formal procedures, which emphasise patient choice where possible, and more intimate interviews with the consultant are adopted. Patient bedrooms are suitable for these interviews, but although being seen in their own bedspaces was liked by a large number of patients, this may be less acceptable to some, particularly younger females.
White & Karim Patients' views of the ward round original papers