27 Jun 2012

01. Consultant appointments

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Time’s up for ward rounds

Introduction

If someone was to devise a system that disrupted ward life, drained nurses’ time and provoked anxiety and anger among patients, it would be The Ward Round. Bad things happen when ward rounds are taking place – more incidents, more attempted suicide, more patients going missing. Groovy (and effective) wards have replaced time-demolishing, morale-sapping ward rounds with individual appointments with the patient’s consultant.

We asked Dr Hugh Griffiths, National Clinical Director for Mental Health, for his view on ward rounds and were heartened by what he told us:

“It seems to me that for most patients suffering with mental ill-health, it must be extremely difficult to be expected to participate in multidisciplinary meetings unless they do so by active and informed choice. This must be especially true for in-patients on acute wards at a time when, generally speaking, they will be acutely ill. Therefore it is anathema to me that some practice exists where there is an expectation that service users will attend a ward round, usually being interviewed in a meeting with many staff present. Most service users I speak to hate it.

Of course, multidisciplinary meetings are necessary but it should be perfectly possible to make it clear to any patient that he or she does not need to attend, but they can do so if they wish. Any professionals who need to see them can do so by separate arrangement and I can see no reason why their consultant psychiatrist should not meet with them individually before and/or after any Multidisciplinary Team (MDT) meeting and discuss the care plan and any decisions made. In my view, it’s straightforward and is fundamentally about treating people with dignity and respect.”

Patients often say that the number one most daunting and anxiety-provoking thing about being on the ward (apart from the reason they are there) is the weekly ward round. Patients work themselves up all week about having to face a room full of (mostly) strangers, being on the hot-seat and generally worrying about the outcome.

Ward rounds seem to take priority over other ward events. Everything else goes out of the window – escorts, ward groups and meaningful activities. A growing sense of anxiety can be felt on the ward as the ward round approaches. Staff seem more stressed out too. It’s simply a terrible way to achieve vital objectives for patients and staff.

For most patients, meeting their consultant is incredibly important (especially if issues of medication and/or leave are at stake) and unsurprisingly nerve-wracking. Very intimate and complex issues need to be discussed, so how can it be appropriate for the room to be full of strangers? It’s much too exposing for any sensitive, effective discussion to take place. Changing the name to ‘ward reviews’ does at least make it a bit less Carry on Matron, but the fundamental concept and structure is awful.

The common arguments for ward rounds are:

  • Help teach professionals – particularly doctors. (We feel there are much better ways to teach and to learn)
  • Give patients a single place where decisions are made
  • Mark the changes over the weeks for patients
  • Guaranteed appointment with consultant.

 

Ward examples

  • User groups have influenced ward rounds. Patients now have appointment times for seeing SHOs, rather than having to hang around for hours. This also means patients can take s17 leave on ward round days because they know what time they’re appointment is. Nurse, consultant and care co-ordinator are all at the meeting.
  • Groups running at same time as reviews are open so patients can come and go.
  • When consultants won’t have specified times for each appointment, staff keeping patients very very well informed about when they are likely to be called in.
  • Care Plans are developed on a Multi-Disciplinary basis and are implemented by all members of the team, with the Named Nurse taking responsibility to coordinate the plan.
  • “Ward rounds, appointments, and assessments can be stressful events for patients. There can be a big build up of tension, anxiety and worry before appointments. Why not get the gardening tools out and discuss any issues over the daffodils and pansies?” (Healthcare Support Worker)

Patient Examples

  • When ward rounds are on there’s less qualified staff on the ward. So I sat with other patients and made sure I didn’t isolate myself because that’s when bad things happened.
  • I felt really exposed in ward rounds at the start but over time I kept in my mind that staff actually cared and wanted the best for me.
  • I didn’t know what a ward round was so I asked my named nurse. She explained it very slowly and clearly, as I was feeling drowsy from my medication.
  • I asked a member of staff to give me an idea of what time my ward round would be as I was starting to felt anxious. Just being given some idea of when I would see my psychiatrist made such a difference to me.
  • Writing an agenda for ward rounds helped give me a focus and stopped me feeling so intimidated and overwhelmed.
  • I always attend appointments to see my psychiatrist. I have a good relationship with her and I am very knowledgeable about my diagnosis which helps me get the most from any treatment offered.
  • I am sent a copy of every consultation. It reminds me what has been discussed, my treatment plan and my next appointment date. It also helps me feel in control of my treatment and that what I said has been understood.
  • Sometimes I find it hard to say what I want or what I need. I have learnt in meetings to nod at a nominated member of staff as a way of letting them know I’d like to speak and then they find the space for me to talk.
  • It’s good having all the people who are caring for me in one room; like my social worker etc.
  • I felt part of the decision making process in ward rounds because I was listened to.
  • Most of the time the ward were able make and commit to appointments.
  • Working out my own ways of coping with ward rounds made them feel okay. You learn what works for you after a while.
  • Whilst under section an advocate came in with me to ward rounds and spoke on my behalf. It took the pressure off me to get across what I wanted.
  • I rest on my bed and do some relaxation techniques before and after seeing the doctor in ward rounds. It helps me feel calmer.
  • I make notes in ward rounds so I don’t forget things that are said.
  • The ward helpfully use a whiteboard which tells patients what time they will be seeing the consultant. This puts my mind at ease and helps me know how much time I’ve got to prepare for the appointment.
  • I didn’t really understand what ward rounds were. So I plucked up the courage to ask a member of staff. I felt a bit silly at first because all the other patients seemed to be clued up. But it was helpful to find out.
  • I used to use the ward doctor as a bit of a sounding board. He was very helpful and because he was slightly removed from the rest of the ward it felt really cathartic.
  • I met with my named nurse before each ward round to go over what I wanted to put across and what my needs were.
  • I only had one or two ward rounds. They were too much for me to handle so I asked if I could just see the consultant on his own which felt better.
  • I just told the staff that I didn’t like the ward round. I felt really paranoid and anxious with everyone looking at me. So they arrange for a one to one each week with my consultant.
  • Writing a list of things I wanted to put across in ward rounds helped me feel more confident and relaxed. Sometimes my named nurse read it out for me.
  • The more decisions I make about my treatment the more I feel like I have a chance at recovery.
  • My husband comes to the ward rounds. It’s helped me open up to him about how I’m feeling which I think is part of recovery.

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